Case 48: Bleeding in early pregnancy

 

Case 48: Bleeding in early pregnancy

CASE 48: BLEEDING IN EARLY PREGNANCY

History

A 41-year-old woman is seen in the early pregnancy unit because of vaginal bleeding. She

is gravida 4 para 2 having had two previous normal vaginal deliveries followed by a miscarriage. She has a regular 28-day menstrual cycle and her last period started 9 weeks ago.

She had slight vaginal bleeding 2 weeks ago and on ultrasound scan an early intrauterine

pregnancy had been visualized with gestational sac of 18 × 12 × 22 mm diameter and a yolk

sac visualized of 4 × 5 × 5 mm. No fetus was visualized. She was given an appointment for a

repeat ultrasound.

Four days ago her bleeding became very heavy and she passed large clots which she described

as ‘like liver’. She developed severe abdominal pain which lasted for about 4 h, and since then

the bleeding has become very light and she is now pain-free.

She has normal appetite and no nausea or vomiting. She has no urinary or bowel symptoms.

Examination

She appears well and is apyrexial. There are no signs of anaemia. The heart rate is 82/min

and blood pressure is 132/78 mmHg. The abdomen is soft and mildly tender suprapubically.

Speculum shows the cervix is closed with a small amount of old blood in the vagina. There is

slight uterine tenderness on bimanual palpation and the uterus feels normal size, anteverted

and mobile, with no adnexal tenderness or cervical motion tenderness.

INVESTIGATIONS

A transvaginal ultrasound scan is shown in Fig. 48.1.

Questions

• What is the diagnosis?

• What further management is indicated?

Figure 48.1 Transvaginal ultrasound scan showing a midsagittal view through the uterus.100 Cases in Obstetrics and Gynaecology

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ANSWER 48

The ultrasound image shows a longitudinal view of the uterus with a thin homogenous

endometrium and no evidence of a gestation sac or retained products of conception. As we

know from the previous report that there was previously an intrauterine pregnancy, we can

conclude that this is a complete miscarriage. If a previous ultrasound had not been available we would need to treat the case as a pregnancy of unknown location and monitor serial

serum hCG.

No further management is needed as the miscarriage is complete and there are no signs of

retained products of conception, or any suggestion of sepsis. Anti-D is not needed even if the

woman is rhesus negative as the pregnancy is less than 12 weeks’ gestation.

Counselling is the most important part of this consultation, as explained in case 45.

There is no clear evidence that a longer interpregnancy interval improves the outcome in

future pregnancies, and the couple should be informed that they may try and conceive whenever they choose. However it may be advisable to wait until after the next menstrual period

(usually 4–6 weeks after a miscarriage) in order to date the pregnancy.

Reassurance scans are helpful in future pregnancies and may improve outcome. In view of

the two consecutive losses, reassurance ultrasound at 7 weeks and then at intervals until the

11–14-week scan would be ideal.

KEY POINTS

• Clinical suspicion alone is not sufficient to make a diagnosis of miscarriage.

• If the uterus is empty and an intrauterine gestation has not been previously confirmed then a case should be treated as a pregnancy of unknown location, with

serial hCG follow-up.

• Appropriate counselling is vital in the management of couples with early pregnancy

loss.