Emergency Medicine

Bleeding in Early Pregnancy

Obstetric and Gynaecological Emergencies 381

Endometriosis

DIAGNOSIS AND MANAGEMENT

1 There is a preceding history of recurrent abdominal and f lank pain, worse at
the time of menstruation and immediately pre-menstrually. Other common
symptoms include acquired dysmenorrhoea, dyspareunia, painful defeca-
tion (tenesmus) and infertility.

2 Examination is often normal, or may show adnexal or rectovaginal tender-
ness on internal examination.

3 Send blood for FBC, collect an MSU, and exclude pregnancy with a
pregnancy test.

4 Arrange a pelvic ultrasound, and refer the patient to the gynaecology team.
(i) This is a difficult diagnosis that requires review by the
gynaecology team. A laparoscopy may be indicated, but there is
poor correlation between symptoms and laparoscopic findings.

BLEEDING IN EARLY PREGNANCY

Two important causes are ectopic pregnancy (see p. 377) and spontaneous
miscarriage.

The old term ‘spontaneous abortion’ has now been replaced by the more appropri-
ate terminolog y ‘spontaneous miscarriage’ to diminish negative self-perceptions of
women experiencing early pregnancy fetal demise.

Spontaneous miscarriage

Spontaneous miscarriage (failed pregnancy) is the expulsion of the products of
conception before the 24th week of pregnancy. It is most common in the first
trimester and occurs in 10–20% of all early pregnancies. There are five recog-
nized stages of spontaneous miscarriage.

DIAGNOSIS

1 Threatened miscarriage
(i) This is most common up to 14 weeks gestation, causing mild
cramps and transient vaginal bleeding. These symptoms indicate
a possible miscarriage.
(ii) The uterine size is compatible with the duration of pregnancy. As
a guide, the expected size of the uterus is approximately:
(a) abdominal palpation: the fundus reaches the symphysis pubis
at 12 weeks and the umbilicus at 24 weeks
(b) bimanual examination: the uterus is the size of a hen’s egg at
7 weeks, an orange at 10 weeks, and a grapefruit at 12 weeks.
(iii) The external cervical os is closed on speculum examination.