in pregnancy

Chapter 54 Bleeding in pregnancy

Bleeding before the 24th week of pregnancy

Bleeding from the genital tract in early pregnancy – that is, before the 24th week – may be caused by:


A pregnancy that ends before 24 completed weeks of gestation, and where the fetus is not alive, is termed an abortion. The classification is shown in Figure 54.1.

Spontaneous abortion

Approximately 15–20% of confirmed pregnancies end in spontaneous abortion, most of these occurring before the 12th week of pregnancy. Midwives should be aware that the term ‘abortion’ may cause confusion. Many women who have lost a wanted pregnancy find the word offensive and it should not, therefore, be used when talking to women about a pregnancy ending from natural causes. In these circumstances, the use of the word ‘miscarriage’ is more appropriate.


Despite detailed investigations, no cause can be found in the majority of cases.

Inevitable abortion

The key feature of inevitable abortion is cervical dilatation with an outcome of unavoidable pregnancy loss. The gestation sac separates from the uterine wall and the uterus contracts to expel the conceptus. This uterine activity causes discomfort similar to that of labour contractions. Speculum examination reveals a dilating cervix, possibly with products of conception protruding through. The gestation sac may be expelled complete (complete abortion), or in part, usually with placental tissue retained (incomplete abortion).

The midwife who is called by a woman with signs of inevitable abortion should arrange immediate care. The woman’s vital signs should be recorded and an estimate of blood loss made. If the fetus has been expelled and the woman is bleeding, local policies for the management of the third stage of labour and control of postpartum bleeding should be followed. Any products of conception passed should be saved for inspection. The midwife should refer the woman for medical care either by her GP or by a gynaecologist at her local hospital. If the bleeding is severe or the woman is showing signs of shock, a paramedic team from the local ambulance service should be requested. They will resuscitate the woman and stabilize her condition before transfer to hospital. In hospital, evacuation of retained products of conception (ERPC) from the uterus may be carried out and a blood transfusion may be given if blood loss has been severe.

Medical management of inevitable or incomplete abortion is possible, using prostaglandin analogues such as misoprostol or gemeprost. Once the uterus is empty, vulval hygiene is important for comfort and to reduce the likelihood of infection: the woman should be advised to change her sanitary towels frequently and keep the vulva clean, using a bidet or shower if possible. All women who have required surgical evacuation should be screened for chlamydial infection (RCOG 2006).

If the breasts begin to secrete, the woman should be advised to wear a well-fitting brassiere in order to minimize discomfort. Cabergoline 1 mg may be prescribed by a medical practitioner or qualified midwife prescriber to suppress lactation. If the woman is rhesus negative, anti-D gammaglobulin is given within 60 hours of abortion to prevent isoimmunization and potential rhesus problems in subsequent pregnancies. Women who are non-immune to rubella may be given rubella vaccination at this time and advised to avoid the risk of pregnancy for the next 3 months.

Psychological effects

Many women experience a marked grief reaction following abortion and may require considerable counselling and support. Psychological distress may be severe and some women become clinically depressed. The grief experienced by the partner may be as intense as that of the woman, though he is less likely to receive support (Conway & Russell 2000). Staff should treat the parents with sensitivity. The couple may wish to see their baby and staff should take account of their wishes. The guidelines written by the Stillbirth and Neonatal Death Society are useful (SANDS 2009).

After the end of the 24th week of pregnancy, the infant must be registered as a stillbirth (Home Office 2008). Many maternity hospitals offer a funeral or memorial service for pre-viable fetuses and all must offer respectful disposal. In this situation, the hospital chaplain may be a valuable source of support and advice. Antenatal Results and Choices (ARC) can provide non-directive support and counselling for parents who have received high-risk antenatal screening results or diagnosis of a fetal abnormality (ARC 2009).

Induced abortion

This term refers to the deliberate termination of a pregnancy. Induced abortions are classified as therapeutic or criminal.

Criminal abortion

This is the termination of a pregnancy outside the terms of the Abortion Act, possibly by unauthorized and untrained persons, and is an offence punishable by law. The incidence has fallen sharply since the introduction of the 1967 Abortion Act. However, cases still occur: four such offences were detected in the year 2000–2001 (Home Department 2001) and seven in 2004–2005 (Home Office 2009). The abortion may be induced either by the woman herself or by some other person, by use of drugs or instruments. Whether successful or not, the action is illegal. The methods used may cause sudden death from haemorrhage, air embolus or vagal inhibition. Because of lack of asepsis, infection readily occurs and may lead to chronic ill-health or salpingitis and sterility (see website).

Gestational trophoblastic disease (hydatidiform mole and choriocarcinoma)

Hydatidiform mole

This condition occurs as a result of degeneration of the chorionic villi at an early stage of pregnancy (Fig. 54.4). Usually, the embryo is absent; occasionally, a hydatidiform mole may be found in a twin pregnancy alongside a viable fetus (Kauffman et al 1999). Molar pregnancy may be complete, with an intrauterine multivesicular mass composed of hydropic chorionic villi, or partial, where vesicular tissue is present, but less well developed, along with a fetus. Vesicle formation may occur within the placenta of an apparently normal pregnancy.


Once the diagnosis of molar pregnancy is confirmed, the uterus must be completely evacuated at once. This is achieved by careful suction curettage (see Fig. 54.3). Uterine contractions may cause molar tissue to enter the circulation via the sinuses of the placental bed. These emboli may set up metastatic disease in other sites, commonly the lungs. Medical termination should therefore be avoided. Unless the woman is haemorrhaging, oxytocic drugs are withheld until the uterus has been surgically emptied. A Syntocinon infusion may then be used to maintain uterine contraction and haemostasis. The woman should be registered at a specialist follow-up centre in London, Sheffield or Dundee (RCOG 2004a).

After treatment for hydatidiform mole, careful observation is required as approximately 3% of these women will develop malignant trophoblastic disease (choriocarcinoma). Partial moles are less likely to become malignant but still require follow-up (Seckl et al 2000). Serum beta-hCG levels are monitored fortnightly until the values fall to within the normal range. Urine samples are then normally tested every 4 weeks until 1 year after evacuation. In the second year of follow-up, urinary hCG testing is carried out every 3 months.

If any molar tissue remains in the uterus, it will continue to grow and may invade the myometrium. Perforation of the uterine wall is then likely and this will cause major internal haemorrhage. Signs that the mole is continuing to grow are indicated by the persistence of high hCG levels 24 hours after uterine evacuation and high levels 1 month after treatment. If the serum or urinary hCG fails to return to normal levels within 6 months or begins to rise again, the woman is at risk of malignant trophoblastic disease.

The woman must avoid another pregnancy until she has been discharged from the follow-up programme. Use of the oral contraceptive pill increases the risk of the development of invasive disease and should therefore be avoided until hCG levels have been normal for three successive months.

Ectopic or extrauterine gestation

Ectopic pregnancy occurs when the fertilized ovum implants outside the uterine cavity. In 95% of cases the site of implantation is the uterine tube and these are known as tubal pregnancies. Occasionally, the site may be the ovary, the abdominal cavity or the cervical canal, but these are rare. The incidence of ectopic pregnancy is 1 : 150 pregnancies (Baker 2006). Ectopic pregnancy is the major cause of maternal death before 20 weeks’ gestation in the industrialized world (Benrubi 2005, Lewis 2007).

Tubal pregnancy

This is the commonest type of ectopic pregnancy and the incidence has increased two- to threefold in the last 30 years (Wiznitzer & Shener 2007). Tubal pregnancy occurs when there is a delay in the transport of the zygote along the fallopian tube. This may be due to a congenital malformation of the uterine tubes or more commonly to tubal scarring following pelvic infection. The ovum implants and begins to develop in the lining of the tube. The ampulla is the most common site (Fig. 54.5).

Although tubal pregnancy may occur in the absence of any significant history, there are certain risk factors (Lemus 2000, Wiznitzer & Shener 2007):

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Jun 18, 2016 | Posted by in MIDWIFERY | Comments Off on in pregnancy

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