Early pregnancy problems

Many women experience pain or bleeding in early pregnancy. Approximately 50% of these women go on to have a live birth; the others experience a pregnancy loss or miscarriage. If you have bleeding or pain in early pregnancy it is very important that you see your GP or obstetrician to make a plan to investigate this.

What does bleeding in early pregnancy mean?

Many different things could be occurring – you may have bleeding from the lower genitals or cervix which is not related to the pregnancy. You could have an ectopic pregnancy, which is a pregnancy that has implanted outside the uterus, most commonly in the fallopian tube. This is a very important problem, as it can be life threatening for the mother, so we always need to work out if this is the cause of your bleeding.

You could have bleeding from the pregnancy itself – this is either an implantation bleed or a threatened miscarriage. With time we can work out if you are having a miscarriage and how best to manage that problem.

If your blood group is Rh (D) factor negative then it is important that you see your GP or obstetrician to assess whether you need to have some anti–D to protect your pregnancy from Rhesus isoimmunisation.

What happens if I have an ectopic pregnancy?

If you are diagnosed with an ectopic pregnancy you have two main options for management.

  1. Methotrexate
    Only a specific group of ectopic pregnancies are eligible for methotrexate treatment and your obstetrician or gynaecologist will let you know if this is an option for you. Methotrexate is a medical treatment where you are given an injection of medication that stops the pregnancy cells dividing and the pregnancy tissue is reabsorbed by your body over time. You shouldn’t conceive for at least 3 months after receiving a dose of methotrexate and will require review by your doctor and blood tests to ensure the pregnancy isn’t still growing.
  2. Laparoscopy
    A laparoscopy may be required to treat your ectopic pregnancy. This is a key-hole surgery where the pregnancy tissue is removed, usually with the damaged fallopian tube. If you have a laparoscopy and would like to conceive again, it is safe to do so as soon as you are ready. Removal of a fallopian tube can reduce your fertility slightly, but most couples can conceive naturally with one fallopian tube.
  3. Expectant management
    This is very rarely used as an option for ectopic pregnancy, but under certain special circumstances you and your doctor may agree that it is safe to watch and wait. You will need to have lots of follow up with blood tests if this occurs.

What is a threatened miscarriage?

This is a term used to describe any bleeding in early pregnancy. If you have a threatened miscarriage your doctor may recommend blood tests and ultrasounds to assess the progress of your pregnancy. This can be a stressful time whilst we work out what is happening to your pregnancy. Normal work, exercise and childcare routines can be followed as there is no evidence to say that your daily activities will change the outcome.

What is a miscarriage?

A miscarriage is the term used to describe any pregnancy which stops growing before 20 weeks gestation. It can be a devastating thing to experience, but it is extremely common, and most couples who experience a miscarriage go on to have a healthy pregnancy in the future. It is thought that about 20 – 25% of pregnancies end in miscarriage.

Miscarriages are classified according to when the pregnancy stopped growing – terms you may encounter include:

Evidence suggests that it doesn’t matter when the pregnancy is lost – most people still grieve for the loss of a loved one and feeling sad is very normal.

What causes a miscarriage?

Most miscarriages occur due to abnormal genetic material or chromosomes in the developing pregnancy tissue. This is a common error of reproduction, and does not mean there is anything wrong with you or your partner.

There is no evidence to suggest that work, stress, intercourse, exercise or most drugs or medications have any impact on your change of having a miscarriage. It’s just bad luck.

For women who have had three miscarriages in a row (or two if you are over 35) some investigations may be warranted to assess if there is something we can do to improve your chances of a successful pregnancy next time. For most couples nothing is found on these tests.

What happens if I have a miscarriage?

Three options exist for the management of a miscarriage.

  1. Expectant management
    Most people who have experienced a miscarriage will eventually start bleeding and pass the pregnancy tissue. This may be accompanied by crampy abdominal pain, and may require painkillers and hot packs to manage the pain. If you soak more than one pad an hour for more than 3 hours in a row or have pain that can’t be controlled with paracetamol, ibuprofen (with or without codeine) you should seek medical care.
  2. Medical management
    The administration of a medication called misoprostol can speed up the process of having a miscarriage. This is often done under medical supervision. Your experience is very similar to having a normal miscarriage, as outlined above. This method is 85% successful over three days, so a small group of women will still require a dilation and curettage after taking misoprostol.
  3. Dilation and curettage
    This is a procedure performed under anaesthetic. It is not a surgery as there is no cutting involved. You are given a dose of misoprostol 3 hours prior to your procedure to soften the cervix, then a series of small diameter rods are used to gently dilate the cervix. A suction catheter is then inserted through the cervix into the uterus to remove the pregnancy tissue. The procedure takes between 5 – 15 minutes to perform and is usually uncomplicated. A small group of people can have complications such as heavy bleeding, damage to the uterus and cervix (very rare), and scarring of the uterine cavity called Asherman’s syndrome (5%). About 1:2000 women need the procedure repeated for retained products of conception.

This is a procedure performed under anaesthetic. It is not a surgery as there is no cutting involved. You are given a dose of misoprostol 3 hours prior to your procedure to soften the cervix, then a series of small diameter rods are used to gently dilate the cervix. A suction catheter is then inserted through the cervix into the uterus to remove the pregnancy tissue. The procedure takes between 5 – 15 minutes to perform and is usually uncomplicated. A small group of people can have complications such as heavy bleeding, damage to the uterus and cervix (very rare), and scarring of the uterine cavity called Asherman’s syndrome (5%). About 1:2000 women need the procedure repeated for retained products of conception.

What happens after a miscarriage?

It is common to have bleeding for 2–6 weeks after a miscarriage. We recommend you avoid sex, swimming and tampons until the bleeding is complete to reduce the risk of infection inside the uterus. You will then experience a period sometime in the next couple of months – the timing of this period is very variable and difficult to predict for each woman. Most women recover physically quite quickly after a miscarriage. Some families find it takes longer to recover their emotional wellbeing.

It is safe to conceive again whenever you feel ready. Some literature recommends you wait until after you have had a period, but there is no evidence that the pregnancies conceived immediately after a miscarriage have any increased risk of problems.

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