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Introduction

Bleeding in early pregnancy is most commonly caused by miscarriage but can denote one of four situations:

  • Miscarriage
    • 1 in 5 pregnancies
  • Ectopic pregnancy
    • 1 in 100 pregnancies
  • Benign cause
    • Threatened miscarriage
    • “Implantation bleed” – typically small amount of spotting that occurs around the time that the missed period would be due
  • Other causes
    • Cervical polyp
    • Cervical ectropion
    • Cervicitis
    • Hydatiform mole
    • Neoplasm

It is particularly important to exclude ectopic pregnancy, which – if left untreated – can be fatal.

Many hospitals have an Early Pregnancy Assessment Unit (EPAU) to assess and manage bleeding in early pregnancy. This typically is a clinic run by midwives and obstetricians, which provides rapid access to USS and blood tests (particularly for blood type for rhesus incompatibility) to ensure ectopic pregnancy is ruled out, and assess that the any miscarriage has been complete (as well as detect any other disorders). Typically referral from your GP or from the emergency department is required to access these services.

In this article, we will look at differentiating the causes of bleeding in early pregnancy with history, examination and investigations, and then in more detail at miscarriage.

Presentation

  • Vaginal bleeding
    • May include large clots or other tissue – the products of conception
  • Pain – typically worse than normal period pain

Indications for immediate referral to emergency department for assessment for ectopic pregnancy:

  • Severe pelvic pain
  • Marked lower abdominal tenderness
  • Hypotension
  • Syncope
  • Tachycardia

If any signs of shock, then speculum examination is indicated:

  • Remove any products of conception from the cervical canal
  • Check if os is open
  • Are cervical lesions visible? Are they the cause of the bleeding?
  • Isuterine size appropriate for dates?

Investigations

If EPAU (early pregnancy assessment unit) is available – refer to your local service.

ALL women with bleeding in early pregnancy should have USS and B-HCG tests performed.

  • USS
    • Ectopic pregnancy can usually be diagnosed via USS
      • If the location cannot be determined, then serial B-hCG and serial USS may be required to ensure the pregnancy is not ectopic
    • 98% of miscarriage can be diagnosed with transvaginal ultrasound
    • I usually pre-warn patients that the USS will be transvaginal!
    • Trans abdominal USS is less accurate but may be performed based on patient preference
    • If no fetal heartbeat is detected, then scan can be repeated in 7-14 days
  • B-hCG
    • Two tests are typically taken 48 hours apart
    • In a normal pregnancy, the result should increase by at least 63%
    • If rising, but at a slower rate – suggests >50% of pregnancy not likely to continue, or may represent ectopic pregnancy
      • These patients require EPAU follow-up within 24 hours
    • If falling – suggests miscarriage
  •  Progesterone
    • Low progesterone in early pregnancy suggests non-viable pregnancy
    • Can be a normal variation and thus this alone cannot be used to diagnose miscarriage

Miscarriage

Epidemiology and Aetiology

  • 1 in 5 pregnancies ends in miscarriage
    • Miscarriage is not considered abnormal unless a women has more than three miscarriages in succession (without a successful pregnancy)
    • True rate may be higher, as many are missed as they occur before the woman knows that she is pregnant
  • 80% of miscarriages occur before 13 weeks
    • Late miscarriage is defined as miscarriage between 13 and 24 weeks
    • Bleeding in pregnancy after 24 weeks typically has different causes, and is called Antepartum Haemorrhage
  • Most miscarriages are thought to be due to chromosomal abnormalities
  • Risk factors for miscarriage
    • Increased maternal age (particularly >35)
    • Paternal age >45 (irrespective of maternal age)
    • Smoker
    • High alcohol intake
    • Illicit drug use
    • Poorly controlled diabetes
    • Infectious diseases – particularly listeria and rubella
    • PCOS
    • Poorly controlled thyroid disease
    • Fertility problems
    • Connective tissue disorders (SLE, antiphospholipid syndrome)
  • Usually no cause is found

Management

Conservative management

  • “Watch and wait” – for nature to take its course
  • Suitable for women with confirmed first-trimester miscarriage on USS
  • Confirm pregnancy has ended with serum or urine B-hCG in 7-14 days
    • If negative, no further management required
    • If positive, repeat USS – if any retained products, then consider medical or surgical management (below)
  • If bleeding or pain persist more than 7 days – repeat USS
  • In most cases, there is minimal bleeding as most fetal tissue is reabsorbed
  • Compared to medical management there is a higher risk of blood transfusion and incomplete miscarriage, but similar risk of infection

Medical management

  • Usually – vaginal misoprostol
    • Oral misoprostol is also appropriate
    • Mifepristone should NOT be used as it has been proven to be ineffective
  • Typically offered alongside a watch and wait approach, as well as for those women who have failed the watch and wait approach
  • May cause more pain than surgical management
  • Advise patients that bleeding can continue for up to three weeks
  • Repeat serum or urine B-hCG at three weeks to ensure the end of the pregnancy
  • It is equally as effective as the “watch and wait” approach

Surgical management

  • Offered for:
    • Persistent excessive bleeding
    • Haemodynamically unstable patients
    • Evidence of infection
  • Options include:
    • Manual vacuum aspiration under local anaesthetic
    • General anaesthetic with D&C
  • Complications can include:
    • Perforation, cervical tear, intra-abdominal trauma, intrauterine adhesions, haemorrhage
  • Tissue removed during surgery should be sent for histology to confirm pregnancy and rule out trophoblastic disease and malignancy

Rhesus status

  • 250IU of anti-D should be offered to all rhesus negative women
    • May not be required if no surgical intervention is given

Patient reassurance

  • Myths abound as to the causes of miscarriage
  • Reassure affected women that it is almost definitely nothing that they have done (e.g. straining, lifting, full-time employment, constipation, sex or diet are NOT associated with miscarriage)
  • Offer information leaflets and referral to helplines to discuss psychological impact

Threatened miscarriage

  • Defined as bleeding in the first 12 weeks of pregnancy, without evidence of miscarriage or ectopic pregnancy
  • Usually painless
  • Cervical os remains closed

 

References

  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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