Each year in Australia around 55,000 couples will experience early pregnancy loss.
Many women will present to our emergency departments with symptoms of early pregnancy loss and it is important that they receive appropriate assessment and clinical management.
Of equal importance is the consideration of offering psychological counselling/support and referral to appropriate follow-up services.
Causes of early pregnancy loss include:
- Abnormalities of the embryo of foetus.
- Problems with the embryo implanting in the wall of the uterus.
- Problems with placenta formation.
- Inability of the cervix to stay closed.
Bleeding in early pregnancy is very common affecting 1 in 4 women. Sometimes there is some bleeding around the pregnancy sac (identified on ultrasound) that is referred to as implantation bleeding.
Often a cause will not be found and the pregnancy will continue normally.
Most miscarriages occur within the first 10 weeks of gestation. The likelihood of them occurring increases with the following risk factors:
- Women > 30 yrs of age. By age 40, the rate of miscarriage increases to one in two pregnancies.
- Previous miscarriages.
- Use of alcohol, drugs or cigarettes.
More than 3 alcoholic drinks per week in first 12 weeks of pregnancy. More than 3–5 cups of coffee per day.
- Multiple previous pregnancies.
- Previous surgery of the uterus.
- Poorly controlled diabetes.
- Disorders of blood coagulation.
- Trauma to the uterus.
Here is a list of some of the preferred terminology that is used to describe early pregnancy loss whilst minimising negative emotions, or feelings of guilt or failure that some of the older descriptions (in brackets) may trigger.
- Miscarriage [ not spontaneous abortion]. Pregnancy loss occurring before 20 weeks gestation.
- Threatened miscarriage [ not threatened abortion]. Vaginal bleeding (other than spotting) before 20 weeks gestation.
- Inevitable miscarriage [ not inevitable abortion]. Miscarriage is imminent or in the process of happening.
- Incomplete miscarriage [ not incomplete abortion] Miscarriage where some of the foetus or placenta are unable to be expelled by the mother.
- Missed miscarriage [not missed abortion]. Non-viable pregnancy confirmed on ultrasound with no bleeding.
- Miscarriage with infection [not septic abortion]. A miscarriage complicated by pelvic infection.
- Ectopic pregnancy. Foetus developing in Fallopian tube instead of uterus.
- Anembryonic pregnancy [not blighted ovum]. Absence of foetal development despite fertilised egg implanting into the wall of the uterus.
- Gestation viability: Gestation expressed as weeks/40.
- Obstetric and Gynaecological Hx
Gravity: No. times pt has been pregnant regardless of outcome.
Parity: No. of deliveries of viable foetus.
- Menstrual history including last menstrual period (LMP).
- Pain: position, intensity, character, duration
- Vaginal Loss: type / colour
Bleeding: colour (dark, bright, brown), consistency, volume. preceding factors
- Any clots or tissue?
- No of pads used and over what time?
- Observations: Temp ,Pulse, BP, O2 Sats
- Complications of previous pregnancies/deliver
- Blood group.
- Confirmation of pregnancy: All women of reproductive age presenting with abdominal/pelvic pain or PV bleeding should have serum pregnancy test performed.
Serum B-hCG first becomes positive at 9 days post conception ( greater than 5 IU/L confirms pregnancy).
- Internal examination: to examine source and amount of bleeding as well as to look for evidence of products of conception (POC) in the cervical os.
- Ultrasound: Allows clinician to find location and viability of early pregnancy. Foetal heartbeat can be seen after 6 weeks gestation.
Transvaginal scanning (TVS) is the gold standard.
Ectopic pregnancy is a potential medical emergency (rupture) and accounts for up to 10% of all pregnancy related maternal deaths.
95% of ectopic pregnancies occur in the fallopian tube (may occur in ovary, cervix or abdomen).
The clinical presentation may include:
- Irregular vaginal bleeding.
- Shoulder tip pain (in 10–20% of women with ruptured ectopic).
- Tachycardia and hypotension.
- Abdominal pain/tenderness.
- Absence of intrauterine pregnancy on ultrasound with positive B-hCG.
Treatments for early pregnancy loss:
- No treatment: Allowing products of conception to pass naturally. Usually occurs within a few days but may take up to 4 weeks.
Approximately 10% will require subsequent surgical treatment.
- Medication: Misoprostol (a prostaglandin) stimulates uterine contractions and is the drug of choice. May cause heavy vaginal bleeding and cramping pain for up to 3 weeks.
Misoprostol is contraindicated with ectopic pregnancy, presence of an intrauterine device or haemodynamic instability.
- Surgical treatment (dilatation and curettage): The cervix is gently opened and pregnancy tissue is removed.
Asherman’s Syndrome: a uterine disorder where adhesions form within the uterine cavity and/or cervical canal. Complications may include infertility, recurrent miscarriage and intrauterine growth restriction.
It is thought to occur due to a combination of genetic disposition, inflammatory process and response to surgical instrumentation.
Asherman’s Syndrome is thought to effect 5-39% of women who have repeated miscarriage and up to 40% of women who undergo repeated dilatation and curettage.
Women and their partners may experience a wide range of emotions and reactions following and early pregnancy loss.
These feelings must be acknowledged and supported by nurses and allied health services from the outset of our care.
It is useful to have access to quality information sheets to give to the parents as they may not take in much of what is given to them at the time (see bottom of page for some examples).
There are early pregnancy loss support groups in all states and territories that are available to provide ongoing support and healing.
It is important to emphasise:
- that a miscarriage is almost never caused by anything that the parents did or did not do.
- that grief is a normal and valid reaction, even if it is intense and prolonged.
- that grief may be experienced as feelings of emptiness, failure, anger, guilt, disbelief, sadness or loss.
- Usually products of conception are initially sent to pathology for examination. After this the parents may choose to have their baby buried or cremated if they wish.
If not the hospital will manage them in a respectful way (for example in my own hospital, the baby is placed in a small coffin donated by a local funeral provider, cremated and the ashes are place in a special children’s Memorial Garden in a local cemetery).
- that in most cases, the following pregnancy will be successful.
The following patient handout fact sheets are available from the Royal Womens Hospital, Victoria:
- Early Pregnancy Loss. Queensland Government. 2011 [Internet]. [cited 2013 Nov 17]. Available from: http://www.health.qld.gov.au/qcg/documents/g_epl5–0.pdf
- Miscarriage [Internet]. [cited 2013 Nov 17]. Available from: http://www.thewomens.org.au/MiscarriageFactSheet.
- Misoprostol for Treatment of Incomplete Abortion and Miscarriage [Internet]. [cited 2013 Nov 17]. Available from: http://www.reproductiveaccess.org/m_m/misoprostol.htm
Asherman’s syndrome: A rare infertility disorder – 12 April 2013 | Jean Hailes for Women’s Health [Internet]. [cited 2013 Nov 17]. Available from: http://www.jeanhailes.org.au/health-professionals/medical-observer/1535-ashermans-syndrome-a-rare-infertility-disorder-12-april-2013