BLEEDING IN EARLY PREGNANCY (MISCARRIAGE)

Bleeding in early pregnancy is a common problem and very worrying for the women concerned. It may settle with no further problem or it may herald a miscarriage or other pregnancy complications or it may be due to a problem unrelated to the pregnancy.
Sympathetic counselling is of the utmost importance whatever the diagnosis.

Miscarriage/Abortion

These words are synonymous, but the word miscarriage should be used when possible for a spontaneous miscarriage as to many women ‘abortion’ implies criminal induced abortion.
Spontaneous miscarriage occurs in about 15% of clinically confirmed pregnancies. It usually occurs in the first 3 months.
Many more miscarriages occur before pregnancy is confirmed.
The commonest cause of first trimester miscarriage is abnormality of the embryo which is severe enough to cause death of the embryo. Embryonic chromosomal abnormalities have been found in up to 50% of first trimester miscarriage. Second trimester miscarriages are less common, and more likely to have an identifiable cause such as cervical incompetence, fetal abnormality, multiple pregnancy, placental abruption, uterine anomaly, maternal infection, diabetes, hypertension etc.

Threatened Miscarriage

In threatened miscarriage, there is bleeding from the uterus usually in the first 3 months. It is a common problem.
Sometimes there is lower abdominal discomfort but no actual pain. The cervical os is usually closed. The fetal heart is seen on the ultrasound scan, the risk of miscarriage is less than 5%.
If the fetus is alive, advise bed rest and no intercourse for 2 weeks. Reassurance of patients that the bleeding does not increase the likelihood of fetal abnormality if miscarriage does not ensue. If bleeding becomes heavier and painful contractions occur, miscarriage is likely.

Complete Abortion/Miscarriage

Complete abortion implies that all the product of conception has been expelled on examination, the bleeding is not heavy the cervix is closed and an ultrasound scan will show an empty uterine cavity.

Incomplete Miscarriage

Many spontaneous miscarriages are incomplete particularly between 8 and 14 weeks gestation retention of placental tissue leads to continued bleeding and risk of infection.
If the diagnosis is uncertain ultrasound scan will show whether the uterus is empty or not.
Definitive treatment is the evacuation of the retained products of conception.

Missed Abortion

Missed abortion implies that the fetus has died but that the miscarriage has not occurred.
The woman will notice cessation of pregnancy symptoms, the uterus will be small for date, a brown vaginal loss will occur and the pregnancy test will eventually become negative. This might take several days.
The diagnosis is confirmed by ultrasound scan. This will show no fetal heart activity and a collapsed, usually empty sac. If one is in doubt, it is better to err on the side of caution and repeat the ultrasound scan 1 week later.
Once the diagnosis is certain, many women will prefer an-elective evacuation of the uterus rather than spontaneous miscarriage.

Septic Abortion

Septic abortion means incomplete abortion with intra uterine infection. It is uncommon in developed countries with proper abortion laws. It is very common in Nigeria where many criminal and unregulated termination of abortion occurs and are performed by quack. The woman presents with an incomplete abortion and fever. She may be shocked due to severe blood infection (septicaemia). There will be abdominal pain, purulent vaginal discharge.
Resuscitation and antibiotic therapy should precede surgical evacuation of the uterus.
Antibiotic therapy should be continued for at least a week after temperature settles to minimize chance of blocked tubes and subsequent infertility.

Emotional Effects of Miscarriage

The loss of even a very early pregnancy is usually a deeply distressing event for the woman and her partner.
Many emotions will come to the surface at different times in the days and weeks following miscarriage. These include: fear of the process of miscarriage and about the future.
Profound disappointment, grief, anger, self pity, feeling of inadequacy, failure and helplessness, guilt, jealousy of those who have got children, overwhelming sadness and sometimes prolonged depression. It is important to help the woman and her partner to realize that these feelings are normal and that they should be expressed and not repressed.
It is important for the woman to receive an appropriate and sympathetic explanation of what is happening at the time of miscarriage and about what is likely to happen in the future from the doctors and nurses looking after her. For someone to just say “better luck next time” is not appropriate.

Advice Following a Miscarriage

To minimize the risk of infection, tampons should not be used for the bleeding that occurs.
There should be no intercourse for two weeks.
It is advisable to wait 2 or 3 months before trying for another pregnancy to allow emotional and physical adjustment.
The woman’s questions must be fully and sympathetically answered. She must be reassured that the miscarriage was not her fault and that it is normal to experience a variety of emotions for a prolonged period of time after a miscarriage.
Following your first trimester miscarriage the chance of the next pregnancy being successful is about 80%, following 2 miscarriages at least 70% and following 3 consecutive miscarriages at least 50% without any treatment.

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