9 Early pregnancy loss
Spontaneous Miscarriage
Women may present with abdominal pain and bleeding of varying severity. The GP has several roles:
Generally women and their partners are hesitant to disclose a newly diagnosed pregnancy to family and friends until 12–14 weeks have passed. This is not without reason, given that 12–16% of all clinically recognised pregnancies end in miscarriage.1 In fact the rate of pregnancies lost is probably even higher, since many miscarriages occur before pregnancy is even diagnosed.
About one quarter of all pregnant women experience spotting or bleeding in the first few weeks of pregnancy, and one half of those who bleed will miscarry.What should a GP do?
After a history is taken (Box 9.1), an examination needs to be performed. It is important first to take note of the vital signs of the patient. A temperature may indicate sepsis, while rapid pulse and postural drop, or lowered blood pressure point to loss of a large amount of blood and the need for urgent attention and stabilisation.
Key features of the general examination of a woman bleeding in early pregnancy are her vital signs, postural drop, abdominal tenderness and/or guarding.Once these parameters are established, the GP should examine the abdomen, looking for signs of tenderness and guarding in either iliac fossa, as this may be indicative of a ruptured ectopic pregnancy. The next step is to carry out a pelvic examination. After positioning the speculum accurately, the blood loss present in the vagina should be noted and the cervix carefully examined. It is often handy to wipe away any blood or mucus covering the os so as to enable inspection and to confirm this with digital examination, as its shape may be the key to diagnosis. A closed os in a pregnant woman during the first trimester can mean that the presentation is one of a threatened miscarriage or a missed miscarriage (i.e. the pregnancy has been lost and the process is complete). An open os indicates an inevitable or incomplete miscarriage.
When a woman presents with bleeding in early pregnancy, a GP should assess vital signs, do a urinary pregnancy test (unless pregnancy is already confirmed), establish gestation based on the last menstrual period, palpate the abdomen, and undertake a speculum and bimanual assessment.If the patient is stable the usual course of action is to obtain a transvaginal ultrasound. There are two ways in which an ultrasound can assist patient management. First, it will confirm whether or not the pregnancy is intrauterine or ectopic. Second, if the pregnancy is intrauterine the sonographer may be able to confirm whether or not a fetal heart is present and, if not, whether or not products of conception remain in the uterus. Sometimes it is difficult to assess the contents of the uterus or indeed whether or not it is an ectopic pregnancy. Success is dependent on gestational age and the skill of the ultrasonographer. If cardiac activity is detected by ultrasound early in the pregnancy, the chance of miscarriage is reduced to 5.5%.3
The routine early use of ultrasound may, however, lead to a diagnosis of incomplete miscarriage, blighted ovum or missed miscarriage (Box 9.2), when the natural outcome may be spontaneous complete miscarriage; the ultrasound may therefore encourage unnecessary intervention.4,5
BOX 9.2 Ultrasound criteria for types of miscarriage
| Complete miscarriage | Incomplete miscarriage | Missed miscarriage |
|---|---|---|
What are the causes of early fetal loss?
It can be reassuring for patients to be told that if a pregnancy ends in early miscarriage, ‘the pregnancy would not have continued’ and ‘it is nature’s way of dealing with problems in a fetus’. While historically, 50% of spontaneously expelled fetuses have been thought to be chromosomally abnormal,6 this figure is probably an underestimate.
The major cause of miscarriage is genetic abnormalities in the fetus.How should the GP assist with the emotional consequences of spontaneous miscarriage?
When pregnancies are planned, and even when unplanned but wanted, an early miscarriage is very traumatic. Expectations, plans and hopes are dashed and patients can and do present very emotionally.
Current management of these situations often fails to provide adequate support for women and their partners,7 who often feel that they might have contributed to the miscarriage in some way. It is therefore important to offer patients follow-up after a miscarriage, to ensure that they are not becoming depressed and that they have an opportunity to talk about their experiences and how the miscarriage has affected their personal lives and relationships (Box 9.3).
BOX 9.3 The role of the GP in managing the psychological consequences of spontaneous miscarriage
In dealing with women and their partners who are facing these difficult circumstances, it is also important not to use language that may cause additional distress. For this reason, ‘miscarriage’ is the preferred term, rather than abortion. Definitions of terms commonly used in relation to first-trimester bleeding are given in Table 9.1.
TABLE 9.1 Definitions of terms related to first-trimester bleeding
| Term | Definition |
|---|---|
| Anembryonic pregnancy | Presence of a gestational sac larger than 18 mm without evidence of embryonic tissues (yolk sac or embryo); this term is preferable to the older and less accurate term ‘blighted ovum’ |
| Ectopic pregnancy | Pregnancy outside the uterine cavity (most commonly in the fallopian tube, but may occur in the broad ligament, ovary, cervix, or elsewhere in the abdomen) |
| Embryonic demise | An embryo larger than 5 mm without cardiac activity; this replaces the term ‘missed abortion’ |
| Gestational trophoblastic disease or hydatidiform mole | Complete mole: placental proliferation in the absence of a fetus; most have a 46,XX chromosomal composition; all derived from paternal source |
| Recurrent pregnancy loss | More than two consecutive pregnancy losses; ‘habitual aborter’ has also been used but is no longer appropriate |
| Spontaneous miscarriage | Spontaneous loss of a pregnancy before 20 weeks’ gestation |
| Complete miscarriage | Complete passage of all products of conception |
| Incomplete miscarriage | Occurs when some, but not all, of the products of conception have passed |
| Inevitable miscarriage | Bleeding in the presence of a dilated cervix; indicates that passage of the conceptus is unavoidable |
| Septic miscarriage | Incomplete miscarriage associated with ascending infection of the endometrium, parametrium, adnexa, or peritoneum |
| Threatened miscarriage | Bleeding before 20 weeks’ gestation in the presence of an embryo with cardiac activity and closed cervix |
Do all women suffering from a spontaneous miscarriage require a D&C?
More than 80% of women with a first-trimester spontaneous miscarriage have complete natural passage of tissue within 2 to 6 weeks, with no higher complication rate than that from surgical intervention.8 However, for the last 50 years, women experiencing an early miscarriage have been managed by surgical evacuation of the uterus through a D&C. While this procedure is a common one, it is not without some risks. Apart from anaesthetic risks, there are also the risks of early complications such as infection, bleeding and, less frequently, injury to the cervix or uterine perforation and later on Asherman syndrome (intrauterine scars resulting in adhesions that can obliterate the uterine cavity to varying degrees).
Before ultrasound was available, it was clinically difficult to determine whether or not a spontaneous miscarriage was complete at the time of presentation. The reasons for recommending a D&C therefore seemed quite reasonable: the sooner products of conception are evacuated from the uterus, the smaller the risk of heavy bleeding or infection. With the growing momentum of the evidence-based movement, however, the routine use of D&C in situations of early miscarriage has come into question and two other approaches can be utilised: expectant management or medical management with agents such as misoprostol.
Both expectant and medical management of spontaneous miscarriage may be appealing to some women, as both methods obviate the need for surgery and an anaesthetic and may be perceived as more natural. Both are highly successful (expectant management 86% and medical management 100%), but expectant management is more likely to fail where there is embryonic demise or anembryonic pregnancy.9
Expectant management is successful within 2–6 weeks without increased complications in 80–90% of women with first-trimester incomplete spontaneous miscarriage and in 65–75% of women with first-trimester missed miscarriage or anembryonic gestation (presenting with spotting or bleeding and ultrasound evidence of fetal demise).8
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