8: Emergencies in early pregnancy (up to 20 weeks)

CHAPTER 8
Emergencies in early pregnancy (up to 20 weeks)


Any vaginal bleeding during early pregnancy is abnormal and is a concern to the woman and her partner, especially if there is a history of pregnancy loss; 15–20% of pregnancies result in miscarriage and can cause considerable distress (NICE, 2014). Reassurance and empathy are important elements of caring for the woman; sensitivity to the situation is paramount. There are many causes of vaginal bleeding in early pregnancy, some of which may occasionally lead to life‐threatening situations (Marshall and Rayner, 2014). Early pregnancy loss accounts for 50 000 hospital admissions annually in the UK (NICE, 2012).


8.1 Miscarriage


Definition


Miscarriage is the loss of a pregnancy before 24 completed weeks. It can occur in either the first or second trimester. Miscarriage is more common in the first 12 weeks. The further advanced the pregnancy, the more bleeding can occur.


There are different types of spontaneous miscarriage, all of which are associated with vaginal bleeding but may or may not have abdominal pain:



  • Inevitable: the cervix opens and all products of conception are passed. Bleeding can be heavy or light. If some of the products of conception remain in the uterus, this is classed as an incomplete miscarriage and there is increased risk of infection (Marshall and Raynor, 2014)
  • Complete: all the placental/fetal tissue has passed and the cervix will be closed or closing and bleeding will be settling
  • Threatened: there has been some bleeding but no tissue has been passed, the cervix remains closed and on ultrasound assessment the fetus is thought to still be viable. It may or may not be accompanied by abdominal pain (Marshall and Raynor, 2014)
  • Missed: there has been very little or no bleeding but on ultrasound assessment the fetus is either dead or has not developed properly. Products of conception may not be passed spontaneously. This – and incomplete miscarriage – may be managed medically in hospital with between 600 and 800 micrograms of misoprostol (pessary or oral)

Risk factors



  • Previous history of miscarriage
  • Previously identified potential miscarriage at scan
  • Smoking
  • Obesity
  • Drug misuse in pregnancy
  • Increasing age (rate of miscarriage is 1:10 in women <30 years and 1:2 for women >45 years)
  • Alcohol use (more than 2 units per week) (NHS Choices, 2015a)


Diagnosis


Take a clinical history:



  • Bleeding can be light or very heavy
  • There may be a history of passing clots or jelly‐like tissue. Any tissue that has been passed and collected should be brought to hospital. Pregnancy remains are regarded as tissues of the woman and as such the woman has a right to decide how the remains of pregnancy are disposed of and should be involved in any decisions regarding this (HTA, 2015)
  • Pain – central, period‐like cramps, can radiate to the back or down the legs
  • Symptoms of pregnancy may be subsiding such as nausea or breast tenderness

To make an accurate diagnosis of the type of miscarriage, vaginal examination and ultrasound are required; neither is appropriate in the pre‐obstetric setting. In the acute situation, management depends on the clinical situation rather than the absolute diagnosis.


Be aware that infection may follow any miscarriage. It can be associated with incomplete miscarriage, post‐surgical evacuation or following termination of pregnancy.


Pre‐hospital management


If there is light bleeding or bleeding that has resolved, with no associated pain, consideration may be given to arranging an appointment in either an outpatient or early pregnancy assessment unit.


In the event of life‐threatening bleeding with evidence of confirmed miscarriage (e.g. a patient has been discharged home following medical management and starts to bleed heavily), an oxytocic drug such as ergometrine or syntometrine can be given. Alternatively, misoprostol 800 micrograms PR can be given. (See Chapter 7 for management of shock.) For heavy or life‐threatening bleeding, referral to a hospital emergency department with appropriate surgical facilities is required.


8.2 Cervical shock


This occurs when some products of conception partially pass through the cervix and become ‘trapped’, causing stimulation of the vagus nerve and subsequent symptomatic bradycardia and hypotension. The level of shock is often out of proportion to the amount of blood loss (JRCALC, 2016).

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Mar 9, 2019 | Posted by in EMERGENCY MEDICINE | Comments Off on 8: Emergencies in early pregnancy (up to 20 weeks)

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