Chapter 11 Abnormalities of Early Pregnancy

Bleeding in pregnancy

Vaginal bleeding during pregnancy is abnormal. If the woman presents with a history of bleeding in the current pregnancy, it is important to establish when it occurred. How much blood was lost, the colour of the loss and whether it was associated with any pain should be noted. If the symptoms have subsided, it is important to advise the mother to report any recurrence.

Assessment of fetal condition will depend on gestation. Ultrasound scanning can confirm viability of the pregnancy before heart sounds are audible or movements felt. In the second trimester the use of ultrasound equipment can elicit the heart sounds, and note of fetal movements may also be made.

Implantation bleeding

As the trophoblast erodes the endometrial epithelium and the blastocyst implants, a small vaginal blood loss may be apparent to the woman. It occurs around the time of expected menstruation and may be mistaken for a period, although lighter. It is of significance if the estimated date of delivery is to be calculated from menstrual history.

Cervical ectropion

This condition is commonly and erroneously known as a cervical erosion. High levels of oestrogen cause proliferation of columnar epithelial cells, found in the cervical canal. These occupy a wider area, including the vaginal aspect of the cervix, encroaching on the squamous epithelial cells (metaplasia). The junction between is everted into the vagina. This ectropion is a physiological response to the hormonal changes in pregnancy. As the cells are vascular it may cause intermittent blood-stained loss, or spontaneous bleeding particularly following sexual intercourse. Normally, treatment is not required in pregnancy and the ectropion will usually disappear during the puerperium.

Cervical polyps

Small, vascular pedunculated growths attached to the cervix may bleed during pregnancy. They can be visualised on speculum examination and no treatment is required during pregnancy, unless bleeding is profuse or a cervical smear suggests malignancy.

Carcinoma of the cervix

Carcinoma of the cervix is the most frequently diagnosed cancer in pregnancy. It is a treatable condition if detected early.

Cervical intraepithelial neoplasia (CIN) is the precursor to invasive cancer of the cervix. If the condition is detected at this stage, treatment can be given and the cytology reverts to normal. The principal screening test used is the Papanicolaou smear (Pap smear).

Types

There are two main types of cervical cancer:

squamous cell carcinoma

adenocarcinoma.

The latter is less common.

Clinical presentation

Bleeding is the most common symptom.

Vaginal discharge is the next most common.

As symptoms may be mistakenly diagnosed as symptoms of pregnancy, there may be delay in diagnosis.

Investigation

A Papanicolaou smear test will detect atypical cells on the surface of the cervix, or within the endocervix.

When changes are detected, a repeat smear test, followed by colposcopy, is indicated.

Biopsies can be taken to reveal the extent of the lesion.

The mother and her partner should be fully informed about any tests and treatments that are offered and when and from whom results will be available. A positive test result following a smear test will cause anxiety to the mother and her family and it is important that accurate information is available, along with supportive counselling.

Treatment

Treatment depends on the stage of the disease and gestation. Laser treatment or cryotherapy following colposcopy can be carried out on an outpatient basis and will result in the destruction of the abnormal area of cells.

Cone biopsy under general anaesthesia involves excision of cervical tissue and is both a diagnostic tool and a treatment, but it may increase the risk to the mother. The cervix is highly vascular in pregnancy and the risk of haemorrhage is high, as is the possibility of causing the mother to miscarry. Delaying treatment until the end of pregnancy is an option for women who are found to have early changes in cervical cytology.

If the changes to the cervix are advanced and diagnosis is made in the first or second trimester, the mother may have to make a choice as to whether to terminate the pregnancy in order to undergo treatment. If diagnosis is made later in pregnancy, a decision to deliver the fetus may be taken to allow the mother to commence treatment.

Spontaneous miscarriage

Spontaneous miscarriage is defined as the involuntary loss of the products of conception prior to 24 weeks’ gestation.

Incidence

Fifteen per cent of all confirmed pregnancies are said to result in miscarriages, the majority of which happen in the first trimester. The different outcomes of potential miscarriage (abortion) have varying signs and symptoms (Fig. 11.1 and Table 11.1).

Fig. 11.1 Possible outcomes of potential miscarriage (abortion).

Table 11.1 Signs of miscarriage

Sequelae to early pregnancy loss

Language should be appropriate, avoiding terms such as ‘products’ or ‘scrape’, recognising that most women will be grieving for the lost baby.

Regardless of gestation, the parents may want to see and hold the baby. Some parents may want to see the loss when there is no body.

Creation of memories is important for the grieving process, and midwives can assist by taking photographs of the baby for the parents, and by providing a letter or certificate to confirm the loss.

Parents need information on how the remains will be disposed of. Under 24 weeks’ gestation the baby is not registrable in the UK; it is therefore not a legal requirement for the baby to be buried or cremated but nevertheless respectful disposal is paramount. At no time should any fetal remains be included with hospital clinical waste. Parents may wish to take the remains home; burial in a garden is not precluded in this instance. If cremation is considered, then midwives should be aware that the size of the fetus may result in few ashes, if any.

Full written consent must be given by the mother for postmortem or any other investigations involving fetal tissue. Follow-up after miscarriage is needed, with parents being given the opportunity to receive further information about their loss and be offered advice regarding future pregnancies.

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Related

Related posts:

1. The Placenta
2. Trauma During Birth, Haemorrhage and Convulsions
3. Obstetric Emergencies
4. Problems of Pregnancy

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