Case Study Reports: Pain and Bleeding in Early Pregnancy

PAIN AND BLEEDING IN EARLY PREGNANCY

History

A 30-year-old woman is referred from her general practitioner. 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 because 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 non- tender. 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 excitation, adnexal masses or tenderness.

Questions

·             What is the diagnosis?

·              How would you investigate and manage this patient?

ANSWER

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 heart beat has been seen previously and is no longer visible. Second, where the crown–rump length exceeds 6 mm, a fetal heart beat 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 20 mm with no visible fetal pole (fetus). This is illus- trated 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 disad- vantages 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 (oral mifepristone followed 48h later by misoprostol intravaginal 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 manage- ment, whereas expectant management is very successful for incomplete miscarriage.

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.