Case 45: Pain and bleeding in early pregnancy

 

Case 45: Pain and bleeding in early pregnancy

CASE 45: PAIN AND BLEEDING IN EARLY PREGNANCY

History

A 30-year-old woman is referred from her GP. She is 11 weeks and 2 days’ gestation and has

noticed dark spotting and mild period-like pains for the last 4 days. Her last period was

4 months ago but she has a history of polycystic ovarian syndrome and has an irregular

cycle bleeding for 4–7 days every 5–6 weeks. She had a positive home pregnancy test after

she noticed breast tenderness, and came for a dating ultrasound scan 4 weeks ago that confirmed a viable single intrauterine pregnancy. Since then she has had a booking visit with the

midwife and all routine blood tests are normal. She is gravida 2 para 0. Her last pregnancy

9 months ago ended in a complete miscarriage at 7 weeks. There is no other medical or gynaecological history of significance.

Examination

She is apyrexial with normal heart rate and blood pressure. The abdomen is soft and nontender. Speculum examination shows a small cervical ectropion but this is not bleeding. The

cervix is closed and no blood or abnormal discharge is seen. Bimanual examination reveals

an 8–10-week-sized anteverted mobile uterus with no cervical motion tenderness, adnexal

masses or tenderness.

INVESTIGATIONS

Transvaginal ultrasound scan report (Fig. 45.1): the uterus contains a gestational sac measuring 49×48×36 mm. A single fetus of crown–rump length 47 mm is visible. Fetal heartbeat is absent. The uterus is anteverted. Both ovaries appear normal with no adnexal

masses visible.

Questions

• What is the diagnosis?

• How would you investigate and manage this patient?

Figure 45.1 Transvaginal ultrasound scan showing the midsagittal view through the uterus.100 Cases in Obstetrics and Gynaecology

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ANSWER 45

The diagnosis is of a missed miscarriage. The alternative terminology for this condition is

delayed miscarriage, silent miscarriage or early fetal demise.

The diagnosis can be made for two reasons. First, the fetal heartbeat has been seen previously

and is no longer visible. Second, where the crown–rump length exceeds 7 mm, a fetal heartbeat should be visible on transvaginal ultrasound in all cases of a viable pregnancy. Thus the

diagnosis could have been made even if the previous scan result was not known.

The term ‘empty sac’ (blighted ovum or anembyonic pregnancy) is used where the pregnancy

has failed at a much earlier stage, such that the embryo did not become large enough to be

visualized, but a sac is still seen. The diagnosis of an empty gestational sac can be made when

the mean sac diameter exceeds 25 mm with no visible fetal pole (fetus). This is illustrated in

Fig. 45.2. The management of missed miscarriage and empty sac is the same.

Management

The woman needs to discuss how to proceed now and also what has happened and what she

might expect for future pregnancies. The management of miscarriage is expectant, medical or

surgical. The choice should be given with the potential advantages and disadvantages of each:

• Expectant (‘wait and see’) approach:

• avoids medical intervention and can be managed completely at home

• may involve significant pain and bleeding

• unpredictable time frame – miscarriage may even take several weeks

• more successful for incomplete miscarriage than for missed miscarriage

• Medical (intravaginal or oral misoprostol tablets):

• avoids surgical intervention and general anaesthetic

• the woman may retain some feeling of being in control

• equivalent infection and bleeding rate as for surgical management (2–3 per cent)

• surgical evacuation may be indicated if medical management fails

• Surgical (evacuation of retained products of conception):

• can be arranged within a few days and avoids prolonged follow-up

• very low rate of failure (retained products of conception)

• small risk of uterine perforation or anaesthetic complication.

Success rates for missed miscarriage are generally greater for medical or surgical management, whereas expectant management is very successful for incomplete miscarriage.

Figure 45.2 Transvaginal ultrasound image

demonstrating an empty gestational sac

with mean sac diameter greater than 25 mm,

confirming the diagnosis of miscarriage.Case 45: Pain and bleeding in early pregnancy

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! Important counselling points after miscarriage

• Express sympathy – this is a very significant event for the couple and they may

perceive the pregnancy loss as strongly as they would the loss of a full-term baby.

• Offer further counselling if needed and give written advice sheets/leaflets.

• Reassure that the miscarriage would not have been a result of anything she has

done, such as lifting heavy objects, having a glass of alcohol or having sexual intercourse (all common reasons for women to feel they are responsible for the loss).

• Explain that over 60 per cent of fetal losses are due to sporadic chromosomal

abnormalities such as trisomies.

• Explain that although she has had two consecutive fetal losses there is still a high

chance (>70 per cent) that she will have a normal pregnancy in the future.

Further investigation into recurrent miscarriage is usually reserved for those with three or

more consecutive losses, because miscarriage is extremely common and those couples with

two miscarriages are extremely unlikely to have any underlying cause of miscarriage.

KEY POINTS

• Most miscarriages are due to sporadic fetal chromosomal abnormalities.

• A ‘missed’ miscarriage may be managed expectantly, medically or surgically.

• Never forget that a miscarriage may be a significant life event for a woman/couple,

regardless of whether or not the pregnancy was planned.