First Trimester Bleeding

and
Abortion

VAGINAL BLEEDING
Vaginal bleeding during pregnancy is
always a deviation from the normal,
may occur at any point during
pregnancy, and is always frightening.
It must always be carefully investigated
because if it occurs in sufficient amount
or for sufficient cause, it can impair
both the outcome of the pregnancy and
a womans life or health.

First Trimester Bleeding

Type

Cause

Assessment

Threatened
miscarriage
(earlyunder 16
weeks; late16 to
24 weeks)

Unknown;
possibly
chromosomal,
uterine
abnormalities

Vaginal spotting,
perhaps slight
cramping

Imminent
(inevitable)
miscarriage
Missed miscarriage

Cautions

Vaginal spotting,
cramping,
cervical dilatation
Vaginal spotting,
perhaps slight
cramping; no
apparent loss of
pregnancy

Disseminated
intravascular
coagulation
associated
with missed
Miscarriage

First Trimester Bleeding

Type

Cause

Incomplete
miscarriage

Cautions

Vaginal spotting,
cramping,
cervical
dilatation, but
incomplete
expulsion of
uterine contents.

Complete
miscarriage

Ectopic (tubal)
pregnancy

Assessment

Implantation of
zygote at site
other than in
uterus; tubal
constricture,
adhesions
associated

Vaginal spotting,
cramping,
cervical
dilatation, and
complete
expulsion of
uterine contents.
Sudden unilateral
lower abdominal
quadrant pain;
minimal vaginal

May have repeat

ectopic
pregnancy in
future if tubal
scarring is
bilateral

VAGINAL BLEEDING
Although vaginal bleeding may be innocent,
any degree of this during pregnancy is
potentially serious because it may mean that
the placenta has loosened, cutting off
nourishment to the fetus.
Also, the amount visualized may be only a
fraction of the blood actually being lost.
This happens because an undilated cervix and
intact membranes can contain blood within the
uterus.
A woman with any degree of bleeding,
therefore, needs to be evaluated for the
possibility that she is experiencing a significant
blood loss or is developing hypovolemic shock.

The process of shock

because of blood loss
(hypovolemia)

 Signs of hypovolemic shock occur

when 10% of blood volume, or
approximately 2 units of blood, have
been lost; fetal distress occurs when
25% of blood volume is lost.
Because normal blood pressure
varies from woman to woman, it is
important to know the baseline blood
pressure for a pregnant woman when
evaluating for shock.

 Inform women of their blood pressure

at prenatal visits; for example, Your
blood pressure is 110 over 70
thats normal, not just Your
pressure is normal.
Then if blood loss should occur, a
woman can supply her baseline
pressure.

Signs and Symptoms of

Hypovolemic Shock

Spontaneous Miscarriage
Abortion is the medical term for any
interruption of a pregnancy before a
fetus is viable (able to survive outside the
uterus if born at that time).
A viable fetus is usually defined as a fetus
of more than 20 to 24 weeks of gestation
or one that weighs at least 500 g.
A fetus born before this point is considered
a miscarriage or premature or immature
birth.

Spontaneous Miscarriage
(Contd)
Spontaneous miscarriage occurs in 15% to 30% of all
pregnancies and arises from natural causes.
A spontaneous miscarriage is an early miscarriage if it
occurs before week 16 of pregnancy and a late
miscarriage if it occurs between weeks 16 and 24.
For the first 6 weeks of pregnancy, the developing
placenta is tentatively attached to the decidua of the
uterus; during weeks 6 to 12, a moderate degree of
attachment to the myometrium is present.
After week 12, the attachment is penetrating and deep.
Because of the degrees of attachment achieved at
different weeks of pregnancy, it is important to attempt
to establish the week of the pregnancy at which
bleeding has become apparent.

Spontaneous Miscarriage
(Contd)
Bleeding before week 6 is rarely severe; bleeding
after week 12 can be profuse because the placenta
is implanted so deeply.
Fortunately, at this time, with such deep placental
implantation, the fetus tends to be expelled as in
natural childbirth before the placenta separates.
Uterine contractions then help to control placental
bleeding as it does postpartally.
For some women, then, the stage of attachment
between weeks 6 and 12 can lead to the most
severe, even life-threatening, bleeding.

Causes of Spontaneous
Miscarriage
The most frequent cause of miscarriage in
the first trimester of pregnancy is abnormal
fetal development, due either to a
teratogenic factor or to a chromosomal
aberration.
Between 50% and 80% of fetuses aborted
early have structural abnormalities.
In other miscarriages, immunologic factors
may be present or rejection of the embryo
through an immune response may occur.

Causes of Spontaneous Miscarriage

Contd
Another common cause of early miscarriage involves
implantation abnormalities, as up to 50% of zygotes
probably never implant securely because of
inadequate endometrial formation or from an
inappropriate site of implantation.
With inadequate implantation, the placental
circulation does not develop adequately, leading to
poor fetal nutrition.
Miscarriage may also occur if the corpus luteum on
the ovary fails to produce enough progesterone to
maintain the decidua basalis.
Progesterone therapy may be attempted to prevent
this if this cause is documented.

Therapeutic Management
Depending on the symptoms and the
description of the bleeding a woman
gives, the physician or nurse-midwife
will decide whether she needs to be
seen by a health care provider and, if
so, whether she should be seen in an
ambulatory setting or the hospital.

Threatened Miscarriage
Symptoms of a threatened miscarriage begin as vaginal
bleeding, initially only scant and usually bright red.
A woman may notice slight cramping, but no cervical
dilatation is present on vaginal examination.
A woman with an apparent threatened miscarriage may
be asked to come to the clinic or office to have fetal heart
sounds assessed or an ultrasound performed to evaluate
the viability of the fetus.
Blood for human chorionic gonadotropin hormone (hCG)
may be drawn at the start of bleeding and again in 48
hours (if the placenta is still intact, the level in the
bloodstream should double in this time).
If it does not double, poor placental function is suspected.

Threatened Miscarriage
Contd
Avoidance of strenuous activity for 24 to 48
hours is the key intervention, assuming the
threatened miscarriage involves a live fetus
and presumed placental bleeding.
Complete bed rest is usually not necessary.
Bed rest may stop the vaginal bleeding but
only because blood is pooling vaginally.
When a woman does ambulate again, the
vaginal blood collection will drain and
bleeding will recur.

Imminent (Inevitable)
Miscarriage
A threatened miscarriage becomes an imminent
(inevitable) miscarriage if uterine contractions and
cervical dilation occur.
With cervical dilation, the loss of the products of
conception cannot be halted.
A woman who reports cramping or uterine contractions is
usually asked to come to the hospital or office, where she
is examined.
She should save any tissue fragments she has passed and
bring them with her so they can be examined.
If no fetal heart sounds are detected and an ultrasound
reveals an empty uterus or nonviable fetus, a physician
may perform a vacuum extraction (dilation and evacuation
[D&E]) to ensure that all the products of conception are
removed.

Imminent (Inevitable) Miscarriage

Contd
Be certain the woman has been told that the pregnancy
was already lost and that all procedures, such as suction
curettage, are to clean the uterus and prevent further
complications such as infection, not to end the pregnancy.
Save any tissue fragments passed in the labor room, along
with any brought from home, so they can be examined for
an abnormality such as gestational trophoblastic disease or
for assurance that all the products of conception have been
removed from the uterus.
After a woman is discharged following the D&E, a woman
should assess vaginal bleeding by recording the number of
pads she uses.
Saturating more than one pad per hour is abnormally
heavy bleeding.

Complete Miscarriage
In a complete miscarriage, the entire
products of conception (fetus,
membranes, and placenta) are
expelled spontaneously without any
assistance.
The bleeding usually slows within 2
hours and then ceases within a few
days after passage of the products of
conception.

Incomplete Miscarriage
In an incomplete miscarriage, part of the
conceptus (usually the fetus) is expelled, but
the membrane or placenta is retained in the
uterus.
The term incomplete can be confusing for
women.
They may interpret it to mean that because
the miscarriage is incomplete, the pregnancy
will continue.
Be careful not to encourage false hopes by
also misinterpreting this term.

Incomplete Miscarriage
Contd
In an incomplete miscarriage, there is a danger of
maternal hemorrhage as long as part of the
conceptus is retained in the uterus because the
uterus cannot contract effectively under this
condition.
The physician will usually perform a dilation and
curettage (D&C) or suction curettage to evacuate
the remainder of the pregnancy from the uterus.
Be certain a woman knows that the pregnancy is
already lost and that this procedure is being done
only to protect her from hemorrhage and
infection, not to end the pregnancy.

Missed Miscarriage
In a missed miscarriage, also commonly referred to as
early pregnancy failure, the fetus dies in utero
but is not expelled.
Women may also find this term misleading because it
suggests that if a miscarriage is missed, then the
pregnancy can continue.
A missed miscarriage is usually discovered at a prenatal
examination when the fundal height is measured and
no increase in size can be demonstrated or when
previously heard fetal heart sounds cannot be heard.
A woman may have had symptoms of a threatened
miscarriage (painless vaginal bleeding), or she may
have had no prior clinical symptoms.

Missed Miscarriage Contd

An ultrasound can establish the fetus
has died.
Often the embryo actually died 4 to 6
weeks before the onset of
miscarriage symptoms or failure of
growth was noted.
After the ultrasound, most commonly
a D&E will be done.

Missed Miscarriage Contd

If the pregnancy is over 14 weeks, labor may be
induced by a prostaglandin suppository or misoprostol
(Cytotec) to dilate the cervix, followed by oxytocin
stimulation or administration of mifepristone
techniques used for elective termination of pregnancy.
If the pregnancy is not actively terminated, miscarriage
usually occurs spontaneously within 2 weeks.
There is a danger of allowing this normal course to
happen, however, because disseminated intravascular
coagulation (DIC), a coagulation defect, may develop if
the dead (and possibly toxic) fetus remains too long in
utero .

Complications of
Miscarriage
As with full-term childbirth,
hemorrhage and infection are two of
the most likely complications after
miscarriage.
The risk for Rh isoimmunization and
a womans psychological state also
need to be considered.

Hemorrhage
With a complete spontaneous miscarriage,
serious or fatal hemorrhage is rare.
With an incomplete miscarriage or in a woman
who develops an accompanying coagulation
defect (usually DIC), major hemorrhage is a
possibility.
Monitor vital signs for changes to detect
possible hypovolemic shock.
If excessive vaginal bleeding is occurring,
immediately position a woman flat and massage
the uterine fundus to try to aid contraction.

Hemorrhage Contd
This may be impossible with an early pregnancy
because the small uterus is not palpable above
the symphysis pubis.
A woman may need a D&C or suction curettage
to empty the uterus of the material that is
preventing it from contracting and achieving
hemostasis.
A transfusion may be necessary to replace blood
loss.
Direct replacement of fibrinogen or another
clotting factor may be used to increase
coagulation ability.

Infection
The possibility of infection is minimal when
pregnancy loss occurs over a short time,
bleeding is self-limiting, and instrumentation
is limited.
However, there is always a possibility it may
occur.
Infection tends to develop in women who
have lost appreciable amounts of blood.
Such women need especially close
observation to rule out this second and
possibly fatal complication.

Septic Abortion
A septic abortion is an abortion that is
complicated by infection.
Infection can occur after a spontaneous
miscarriage, but more frequently it occurs in
women who have tried to self-abort or were
aborted illegally using a nonsterile instrument
such as a knitting needle.
Because the uterus is a warm, moist, dark
cavity, infectious organisms, once introduced,
grow rapidly in this environment, particularly if
products of conception such as necrotic
membranes are still present.

Isoimmunization
Whenever a placenta is dislodged, either by
spontaneous birth or by a D&C at any point in
pregnancy, some blood from the placental villi (the
fetal blood) may enter the maternal circulation.
If the fetus was Rh positive and the woman is Rh
negative, enough Rh-positive fetal blood may enter
the maternal circulation to cause isoimmunization
the production of antibodies against Rhpositive blood.
If the womans next child should have Rh-positive
blood, these antibodies would attempt to destroy
the red blood cells of this infant during the months
that infant is in utero.

Powerlessness or
Anxiety
As with pregnancy loss for any reason,
assess a womans adjustment to a
spontaneous miscarriage.
Sadness and grief over the loss or a
feeling that a woman has lost control of
her life is to be expected.
Do not forget to assess a partners
feelings as well, or that persons grief
over the pregnancy loss can be missed.

Ectopic Pregnancy
An ectopic pregnancy is one in which
implantation occurs outside the uterine
cavity.
The implantation may occur on the surface of
the ovary or in the cervix.
The most common site (in approximately 95%
of such pregnancies) is in a fallopian tube.
Of these fallopian tube sites, approximately
80% occur in the ampullar portion, 12% occur
in the isthmus, and 8% are interstitial or
fimbrial.

Therapeutic Management
Some ectopic pregnancies spontaneously end before
they rupture and are reabsorbed over the next few days,
requiring no treatment.
It is difficult to predict when this will happen, so when an
ectopic pregnancy is revealed by an early ultrasound,
some action is taken.
An unruptured ectopic pregnancy can be treated
medically by the oral administration of methotrexate
followed by leucovorin.
Methotrexate, a folic acid antagonist chemotherapeutic
agent, attacks and destroys fast-growing cells.
Because trophoblast and zygote growth is so rapid, the
drug is drawn to the site of the ectopic pregnancy.

Therapeutic Management
Contd
Women are treated until a negative hCG titer is
achieved.
A hysterosalpingogram or ultrasound is usually
performed after the chemotherapy to assess
whether the tube is fully patent.
Mifepristone, an abortifacient, is also effective
at causing sloughing of the tubal implantation
site.
The advantage of these therapies is that the
tube is left intact, with no surgical scarring that
could cause a second ectopic implantation.