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BLEEDING IN EARLY PREGNANCY ABORTION/MISCARRIAGE The term 'early pregnancy' refers to the duration of pregnancy in the 1st trimester according to some researchers. Others however describe 'early pregnancy' to mean the duration of pregnancy from the implantation of the fertilized ovum to the 20th week of pregnancy. For the sake of convenience, here, early pregnancy means pregnancy up to and including the 20th week of pregnancy. Late pregnancy describes the period from the end of the 20th week to term, that is to the end of the 40th week (the total duration of pregnancy being 40 weeks). Bleeding in Early Pregnancy can be due to : Abortion Threatened abortion Incomplete abortion Inevitable abortion Missed Abortion Habitual Abortion Septic Abortion Implantation Bleeding Ectopic Pregnancy Molar Pregnancy Cervical Erosion Cervical Polyp ABORTION / MISCARRIAGE Abortion or miscarriage is defined as the expulsion or extraction from its mother of a foetus or embryo weighing less than 500 grams (20-22 completed weeks of gestation) whether that abortion was spontaneous or induced. About 20% of all pregnancies end in abortion. Since many pregnancies end at or around the time of implantation, i.e. before the first missed menstrual period, they go unnoticed. About 80% of all recognized abortions occur during the 2nd or 3rd months of pregnancy. The others occur during the remaining months up to 22 weeks. Causes of Abortion / miscarriage: Abortions may be spontaneous or induced. Spontaneous abortion / miscarriage: can be due to: Fault in the embryo: Embryos with chromosomal defects are seen in about two-thirds of all early abortions. There may also be a defect in the placenta causing death of the foetus. Fault in the maternal environment: maternal diseases causing high fever. Infections by toxoplasma (common) or by Listeria monocytogenes. Hormonal deficiencies as in progesterone deficiency in corpus luteum defect, or in hyperthyroidism or hypothyroidism. Cervical Incompetence Rh-ve pregnancy ABO incompatibility Uterine fibroid causing improper implantation of the placenta Physical trauma, e.g. a blow on the abdomen or that caused by a fall. Surgical trauma due to any operation. Congenital malformations of the uterus like hypoplastic uterus, unicornuate, bicornuate uterus, septate uterus etc. Signs and Symptoms of Abortion / Miscarriage: Abortions can occur in two ways: Death of the embryo: Death of the embryo or the fetus can be the first event to occur followed by its expulsion from the uterus. This is usually seen in very early pregnancies. Abnormal uterine activity In these type of abortions, the main event is abnormal uterine activity, causing the uterus to expel a healthy foetus. This is usually a feature of abortions in the second trimester (after 13 completed weeks of pregnancy). Signs and Symptoms: The chief symptoms of abortion are pain and bleeding. Whether pain occurs first or bleeding will depend on whether the abortion is due to death of the foetus or abnormal uterine bleeding. If the death of the foetus occurs first, the woman will notice bleeding as her first symptom. Death causes separation of the product of gestation (embryo + early placenta and membranes) from the uterine wall. This causes bleeding which is slight at first but later increases. The woman may complain of passage of blood clots per vagina. Pain occurs when the uterus starts to contract to expel the now unwanted product of gestation. It is usually intermittent and is often described as ‘colicky’. Pain continues to increase until the product is expelled from the uterus. If the product is expelled completely, pain may cease completely. But if any amount of the product is retained, the woman may continue to feel pain or at least some discomfort till the uterus is completely empty, whether spontaneously or by surgical intervention. If the abortion is due to abnormal uterine activity, pain is the first symptom followed by bleeding. If the pregnancy is in the second trimster, the pain may be severe enough to resemble labour pains. Bleeding is also heavy and there may be passage of large clots of blood. If the fetus is around 18-20 weeks of gestation, it may even be born alive at the time of the abortion. A mild haemorrhagic discharge, somewhat similar to the lochia seen after childbirth continues for a few days, then gradually ceases. CLINICAL TYPES OF ABORTION / MISCARRIAGE There are different clinical types of abortions: Threatened Abortion: This type of abortion starts with pain that occurs as a result of abnormal uterine activity. The embryo is usually alive. The woman will have a crampy pain that gradually increases in severity. A mild bleeding or blood stained vaginal discharge can occur. The cervix of the uterus however remains closed. There is a possibility of continuation of the pregnancy on proper and timely management. Treatment : The aim of treatment is to try and conserve the pregnancy by decreasing the uterine contractions. Complete bed rest, uterine relaxants like isoxsuprine hydrochloride or ritodrine and sedating the patient are various methods used to prevent uterine contraction. Progesterone supplements are given if progesterone deficiency is suspected to be the cause of the threatened abortion. Human Chorionic Gonatrophin(HCG) injections can also be prescribed to support the pregnancy. But the main and most effective treatment is complete bed rest of the patient. Inevitable abortion: If the treatment of threatened abortion is not adequate or timely, the abortion may become inevitable. In this type of abortion, besides pain and bleeding there is also dilation of the cervix of the uterus and the process of expulsion of the fetus cannot be stopped. Treatment: The aim of treatment is to prevent further pain and bleeding by emptying the uterus as early as possible. Further dilation of the cervix and curettage (D&C) of the uterine cavity have to be carried out. If bleeding is already severe, supportive treatment like IV fluids and blood transfusion may also become necessary. Incomplete Abortion: Occasionally, some part of the gestational tissue (embryo+early placenta+membranes) may be retained within the uterus during the process of abortion while other parts may be expelled. This is then called an incomplete abortion. Treatment: To evacuate the uterus completely by D&E (dilation and evacuation), and to prevent infection. Complete Abortion: When the embryonic and placental components have been expelled completely, it is called a complete abortion. Normally, once complete abortion occurs, there is complete cessation of pain and bleeding. An ultrasonography becomes necessary to confirm that the uterus is indeed empty. Treatment: Supportive, with antibiotics, pain-relieving tablets etc. Missed Abortion: This is a type of abortion where the product is dead but retained inside the uterus. The patient usually comes with a complaint of missed menstrual periods for a month or two. There may mild brown or dirty vaginal discharge. Frank bleeding is rare. On further questioning, she may reveal that there had been some episodes of pain or even blood stained discharge earlier that disappeared spontaneously. But sometimes there may not be any pain or bleeding at any time. On examination, the size of the uterus will be found to be smaller than the duration of pregnancy suggested by the number of missed periods. An USG is necessary to confirm the diagnosis. Treatment: To remove the dead product as early as possible. Habitual Abortion: When three or more abortions have occurred consecutively and spontaneously, the process is termed habitual abortion or recurrent abortion. Causes of Habitual Abortion: Cervical Incompetence: The most important cause of recurrent abortion is cervical incompetence i.e. inability of the cervix to retain the embryo. The cervix may be weak congenitally, or may become weak later due to lacerations or injury due to any cause, most commonly childbirth. Hormonal deficiency. Uterine fibroids. Malformations of the uterus Infections like toxoplasmosis or syphilis Diseases like diabetes mellitus and essential hypertension. Rh-ve Pregnancy Idiopathic: Where no cause can be identified, it is termed idiopathic – but this is usually due to an underlying hormonal weakness that is difficult to identify. Treatment: Treatment of habitual abortion should be started when the woman is in a non-pregnant state. Thorough investigations to identify the cause is carried out – blood tests for hormonal levels and for infections, blood glucose level, USG for uterine causes, HSG to identify cervical incompetence and for uterine causes etc. Once a new pregnancy has started, treatment is as per the identified cause. If cervical incompetence is the cause, the cervical opening is sutured (tied up) until the 37th week of gestation. Hormonal deficiencies and infections are treated by medicines and bed rest. Septic abortion: This is a type of abortion where there is sepsis or infection of the uterus and its contents. The underlying abortion is usually incomplete, but sometimes, inevitable or threatened. The patient suffers from high fever and looks toxic. There is foul-smelling vaginal discharge which may or may not be blood stained. Extra-uterine spread of infection can occur. It is more commonly seen in criminal abortions. Treatment: Active support with high-grade antibiotics and anti-inflammatory drugs are given. An IV line may be necessary to provide fluids and nutrition to the patient. If the infection is restricted to the uterus, careful evacuation of the products are carried out. If there is evidence of spread of infection outside the uterus, evacuation is carried out only after the infection has been controlled. However if it is deemed that the infection cannot be controlled unless the source of infection, i.e. the products are removed, then careful evacuation of the uterus may be carried out, sometimes under anaesthesia. Medical termination of Pregnancy: (Syn: therapeutic abortion) The deliberate induction of abortion on grounds of safety for the maternal life and health is termed Medical termination of Pregnancy. Bookmark this page Digg it! Stumbleupon Facebook del.icio.us OTHER TOPICS IN COMPLICATED PREGNANCY: Bleeding in early pregnancy (Abortion, Implantation Bleeding, Ectopic Pregnancy, Molar Pregnancy, Cervical Erosion, Cervical Polyp). Placenta Previa Placental Abruption Multiple Pregnancies (twins, triplets etc.) Pre-eclamptic toxemia Rh-ve (Rh Negative) Pregnancy Anemia in Pregnancy Diabetes in Pregnancy Web www.gynaeonline.com Go Top

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