Why am I Bleeding During Pregnancy? My Experience with SCH

My story: Week 13 of Pregnancy #2

Early Morning

My husband and I have sex before he leaves for work. That's always fun. And, hey, we're already knocked up, so we don't need to worry about birth control!

Mid-morning

Well, leave it to an insurance company to take away any good feelings leftover from a morning roll in the hay. I'm angry, on the phone with a completely unhelpful CSR who refuses to do anything useful about reimbursement of our home birth expenses with our first child.

I feel a small gush of fluid in my underwear. I assume it's, uhm, residual fluid from the morning sex, making its way back out. Now thoroughly annoyed, I disconnect my call and head downstairs to the bathroom. 

Horror

What seems like an excessive amount of bright red blood is dripping into the toilet. If you've ever been pregnant, you know that is one of those "call your provider immediately" type situations. 

A huge flood of emotions passes through me, along with a ton of questions. Basically, a big, dreadful stream-of-consciousness experience.

What if this is a miscarriage? 1 in 4 women experience a miscarriage. Will I be one of them? What does a miscarried baby look like? Do I want to see that? Is 13 weeks too early to see anything anyway? Did it already happen and I just flushed a little embryo down the toilet and didn't even look for it? 

If it is a miscarriage, what if I can't get pregnant again? Am I ok with just one baby? Would I want to have more kids after this? Oh, what if I have to get a D&C or something? I don't want that. Maybe there are natural things to help. Maybe I am ok with just one baby. Maybe the time wasn't right for us to have two kids anyway. I think one baby could be ok. I need to call Katie. I need to call John. I want to call my mom.

I give my midwife, Katie, a call, and of course she is compassionate, understanding, and helps me feel better. We schedule a time for her to come over later that day to check me out. In the meantime, I'm advised to rest and avoid any pelvic activity like stairs, sex, or excessive squatting or walking. And to call if anything changes.

Afternoon

After napping in the morning, and resting all day, the bleeding has not subsided. It's still as bright red as before, and I'm preparing myself for a miscarriage.

Katie is not able to find the heartbeat using her hand held doppler. This is not unusual at this stage of pregnancy, but is not very comforting, either. She has me take a urine pregnancy test. If that comes out negative, she says, it'd be a sign the pregnancy was terminating itself. The pregnancy test shows positive, so we're still in the "inconclusive" category. We schedule an ultrasound. 

The Ultrasound

The folks at RCI understand this might not be a happy ultrasound. When the tech puts the wand down, the first thing she says is "Oh! There is the heartbeat, good and strong!"

Another mix of emotions, now! I was thoroughly resigned to losing this pregnancy and this baby. I was preparing myself for the worst. Hearing that everything, in fact, seems to be proceeding as normal is almost hard to take in.

The eventual conclusion of this bleeding is a subchorionic hemorrhage, or subchorionic hematoma.

What the Heck is a Subchorionic Hematoma?

Definition

Good old Wikipedia says: "Chorionic hematoma (also chorionic hemorrhage) is the pooling of blood (hematoma) between the chorion, a membrane surrounding the embryo, and the uterine wall.[1] With an incidence of 3.1% of all pregnancies,[1] it is the most common sonographic abnormality and the most common cause of first trimester bleeding.[2]"

What's that mean?

It's easiest for me to visualize the subchorionic hematoma (SCH) as a giant bruise or open scab in between the uterus and amniotic sac.

In my mind, I saw something like this: the uterus is its own entity, somewhat hollow. It's like a circle, filled with other layers - the chorion and amnion (which together make the amniotic sac), the placenta is an additional layer between part of the uterus and the amniotic sac. 

Uterus, placenta, chorion, amnion, and amniotic fluid.

The baby, of course, is floating around in the middle somewhere!

Where Does the SCH Fit In?

There are three main kinds of chorionic hematomas (again, from Wikipedia):

  • Subchorionic hematomas, the most common type, are between the chorion and endometrium.
  • Retroplacental hematomas are entirely behind the placenta and not touching the gestational sac.
  • Subamniotic or preplacental hematomas are contained within amnion and chorion. Rare.

Since the SCH is most common, and the one I have experience with, we'll discuss that one here. Here's my visual of what that sort of looks like:

A Subchorionic Hematoma occurs between the uterus and the chorion. It may or may not be near the placenta and could be located anywhere in the uterus (top, bottom, middle, front, back).

Of course, the placenta can be in a different location. So can the SCH. You don't have to use this visual with "top at the top" and "bottom at the bottom." This really could be rotated any direction and still be accurate. The SCH itself could be near the placenta, or it could be on the other side of the uterus. It happened to fit nicely in my image where I put it, but that is by no means the only place it could be.

So, Basically, an SCH is a Big Bruise or Pool of Blood Between the Amniotic Sac and the Uterus?

Yep.

The bright red bleeding I was experiencing was the result of the hematoma bleeding. Because it was not bleeding contained within the amniotic sac, it either had to be absorbed back into my body, or come out. For me, that looked like vaginal bleeding, frightening and worrying me and causing a lot of stress over the next few months.

What Causes a Subchorionic Hemorrhage?

Unfortunately, there is no known cause, so there is nothing you can specifically do to avoid having one. 

Potential Outcomes of SCH

While having a diagnosis is nice, a diagnosis of SCH is not particularly actionable.

There are a handful of studies readily available doing a quick search in Google Scholar, but unfortunately, they tend to all say the same thing: it's still very much a waiting game to see how your particular case turns out. 

The following factors potentially play into how much your SCH will affect your pregnancy. Keep in mind that NONE of these factors is a tried-and-true indicator of either a positive or negative outcome related to SCH:

  • How big or small is the hematoma? This is measured by volume. The larger it is, the more cause for concern.
  • Where is the hematoma located within your uterus? Is it right next to, or partially under your placenta? Generally, the further from the placenta, the better. If the SCH is next to or partially under the placenta, there is concern of it causing the placenta to detach, causing a true emergency for you and your baby.
  • Is the hematoma getting larger or smaller in size? Obviously, we'd prefer for it to disappear completely!
  • When was the SCH discovered? Earlier in your pregnancy could mean that you have more time for it to resolve itself, or it could just mean that you have that much longer to worry about it. 

My SCH was butting up next to the placenta, so I ended up boiling down my possible outcomes like this:

1. SCH gets bigger and/or placenta moves over it, resulting in placental abruption and loss of pregnancy, and possibly excessive bleeding for the pregnant woman. This would typically be the worst case scenario.

2. SCH remains as-is, not causing any issues during pregnancy, but causing an issue during labor/delivery, or causing pre-term labor. Another worst-case type scenario, just... later.

3. SCH remains as-is, not causing any issues during pregnancy, and also not causing any issues during labor/delivery. This one would be ok with me, though the continued bleeding is annoying.

4. SCH gets smaller and/or goes away completely, causing no issues during the remainder of the pregnancy or during labor/delivery. The best-case scenario! 

I am very, VERY happy to say that I ended up in scenario 4, and that baby is now almost 4 years old. 

I experienced bleeding throughout the pregnancy, which was frustrating (who wants to have to wear a pad when you're pregnant and not supposed to have to worry about all that?!) But the SCH was gone completely by mid-pregnancy. 

I have had students and friends who did not experience such a positive outcome, and my heart goes out to them. If you are in this situation, please know that I am always willing to lend an ear.

What Can You Do if You Have an SCH?

My midwife continued to recommend pelvic rest, and to avoid any heavy lifting or other high exertion activities.

Some sources recommend bed rest for as long as the bleeding continues. This seems impractical for many people for a variety of reasons, and there is no conclusive evidence that it prevents adverse outcomes. However, if you are able to do it, and it makes you feel better to do so, then go for it!

Hypnosis or other deep relaxation combined with positive affirmations can be incredibly helpful. Not only will the act of relaxation help you feel physically more calm, the affirmations can help with the mental and emotional stress of handling an SCH.

Talk to others who have been in your shoes. I cannot stress enough that having an SCH is incredibly taxing. Being able to talk with others who have experienced the bleeding and the diagnosis can help you gain perspective of your situation. Also, you will be able to lean on your support group in the event of a miscarriage. They'll be able to understand so much better what you're going through, and be able to help you as you seek comfort.

TL;DR

If you are diagnosed with SCH, I sympathize and empathize with you! You may be told it's an uncommon occurrence. That may technically be the case, but you will find lots of support in online groups and forums. I'm always a few clicks away, too!

The SCH may or may not resolve itself and it may or may not cause issues for your pregnancy and labor and baby.

Regardless, it is likely stressful to deal with, and you should feel free to express your concerns and your fears. 

Do you have experience with bleeding during pregnancy?

Did it turn out to be a subchorionic hematoma?

What advice or words of wisdom would you share with other readers?