BLEEDING IN EARLY PREGNANCY382 Obstetric and Gynaecological Emergencies
2 Inevitable miscarriage
(i) This represents a spontaneous miscarriage that cannot be arrested.
(ii) The bleeding is heavier, followed by lower abdominal cramps
that are more persistent.
(iii) The external cervical os is open 0.5 cm or more
(a) products of conception may be found in the vagina, or
protruding from the cervical canal in which case there will be
ongoing pain, bleeding and bradycardia (‘cervical shock’).
(iv) Symptoms and signs of pregnancy such as amenorrhoea, nausea,
vomiting, breast enlargement, tenderness, tingling, areolar
pigmentation and frequency of micturition will disappear.
3 Incomplete miscarriage
(i) Parts of the fetus or placental material are retained in the uterus.
(ii) The bleeding remains heavy and the cramps persist, even
following the passage of clots and the products of conception.
4 Complete miscarriage
(i) All the fetal and placental material has been expelled from the uterus.
(ii) The bleeding and cramps stop after the conceptus has been
passed and the signs of pregnancy disappear.
(iii) The cervical os is closed.
5 Silent miscarriage (missed abortion)
(i) An early pregnancy fetal demise in which all the products of
conception are retained.
(ii) Cramps and bleeding are replaced by an asymptomatic brownish
vaginal discharge.
(iii) The uterus is small and irregular, and ultrasound fails to detect
fetal heart motion.
(iv) Infection and disseminated intravascular coagulation (DIC) may
occur.
6 Gain i.v. access and send blood for FBC and G&S if the bleeding is heavy.
Note the rhesus antibody status.
7 Perform a quantitative serum -hCG to confirm the pregnancy, and as a
baseline for subsequent serial testing to monitor for a continued pregnancy
or fetal demise.
8 Arrange a pelvic ultrasound to assess fetal size and viability, and to rule out
an ectopic pregnancy.MANAGEMENT
1 Commence an inf usion of norma l sa line.
2 Remove the products of conception with sponge forceps if they are blocking
the cervical canal, to relieve the pain, bradycardia and hypotension.
(i) Send them for histology to exclude a hydatidiform mole.