Dr Ahmed Ismail

Consultant Gynaecologist & Fertility Expert

 

Bleeding in early pregnancy

Miscarriage
Unfortunately, miscarriage in early pregnancy is a very common event, occurring in around 1 in 5 pregnancies. The most common explanation for a miscarriage is a severe chromosomal problem, which means the pregnancy cannot survive. In the vast majority of cases, having a miscarriage has no bearing on future pregnancies, and the majority of women will go on to have a successful pregnancy.

A threatened miscarriage is where there is some bleeding, but the pregnancy remains viable.  This can be confirmed on ultrasound scanning.  If the bleeding resolves, then the pregnancy is likely to continue as normal. If the bleeding continues, then it may lead to a complete miscarriage (all pregnancy tissue is expelled naturally) or an incomplete miscarriage  (some tissue remains inside the womb).  An incomplete miscarriage can be managed conservatively, if there is little tissue remaining inside the womb, and bleeding is not excessive, or alternatively with a short procedure under anaesthetic, an ERPC, or Evacuation of Retained Products of Conception.

Recurrent miscarriage

Although miscarriage occurs in around 20% of all pregnancies, recurrent miscarriage, where 3 miscarriages occur in consecutive pregnancies, only affects 1% of women.
Women who experience these sad events are thoroughly investigated at Queensway Clinic, to try to identify an underlying cause, which in many cases can be successfully treated.
Recurrent miscarriage can be due to Antiphospholipid antibody Syndrome, a condition where autoantibodies lead to thrombosis in the vessels of the developing placenta, which can lead to early pregnancy loss, or complications in later pregnancy such as poor growth of the baby, pre eclampsia and even stillbirth.  Without treatment, women with this condition are at risk of having further miscarriages, but treatment from early pregnancy with blood thinning agents dramatically improves the chances of a successful outcome.
Other causes of recurrent miscarriage are uterine anomalies, chromosomal factors, and cervical insufficiency. The latter of these is due to a weakness of the cervix, or neck of the womb, which opens prematurely, in the second or early third trimester. There may be an inherent weakness, or sometimes the cervix has been weakened by previous surgery. If there is an increased risk of this occurring, we will perform serial scans of the cervix in the second trimester, to monitor for this, and in some cases a cervical cerclage, or stitch, is inserted to strengthen the cervix.

Bleeding in later Pregnancy

 

The term Antepartum Haemorrhage refers to vaginal bleeding after 24 weeks of pregnancy, up until delivery of the baby.  A small bleed is unlikely to have any serious implications, but heavy bleeding can be potentially life threatening to baby and mother.

The main causes of antepartum haemorrhage are:

  • Placental Abruption - Premature separation of the placenta from the wall of the uterus. 
  • Placenta Praevia - Bleeding from separation of a placenta lying over or near the cervix.

Placental abruption

The placenta should remain firmly attached to the wall of the uterus until after the baby is delivered. The placenta, or afterbirth, then separates (the third stage of labour).

Complete or partial separation before delivery of the baby is called a placental abruption.
This occurs in around 1% of all pregnancies, and accounts for a third of cases of antepartum haemorrhage.

This can lead to complications for the baby, such as premature delivery, lack of oxygen to the brain with resulting injury, or in extreme cases, death.

Risk factors for placental abruption

There are many potential risk factors which can be identified:

  • Hypertension/preeclampsia
  • Chorioamnionitis (infection in the membranes surrounding the baby)
  • Pre labour rupture of membranes
  • Previous history of abruption
  • Previous Caesarean section
  • Smoking
  • Alcohol excess
  • Cocaine use

The condition usually presents with obvious painful bleeding, but with pain alone, if the blood is trapped behind the placenta.

Treatment

Minor cases will be managed conservatively, with close observation in hospital, as sometimes a small bleed my herald a more significant haemorrhage.

More serious bleeding will necessitate delivery of the baby, often by Caesarean section, and with replacement of fluids and blood for the mother.

Placenta Praevia

Normally, the placenta will be implanted in the wall of the uterus in a position well away from the cervix.

A Placenta Praevia refers to when the placental is implanted in the lower segment of the uterus, close to, or covering the cervix.  It occurs in around 5 in every 1000 pregnancies.
This condition has the potential to cause life-threatening haemorrhage, either before, or immediately after delivery of the baby.

Again, certain risk factors make this condition more likely to occur:

Previous Caesarean section, or other operations on the uterus
Grand multiparity (having had 5 or more previous children)
Older mothers

Unlike abruption, bleeding from a placenta Praevia is often painless. The bleeding can sometimes be extremely heavy.

At Queensway Clinic, all patients have a detailed scan at 20 weeks. Part of the assessment is to localise the placenta. 
If the placenta is seen to be low at this time, it is important to note that as the lower part of the uterus expands during the pregnancy, in many cases, by 36 weeks, the placenta will no longer be low-lying.  Therefore a repeat scan will be done at 34-36 weeks to check.
If the placenta remains within 2cm of the cervix, it is necessary to deliver the baby by Caesarean section before labour, as labour will lead to inevitable bleeding.

Unless indicated sooner, we would plan to deliver your baby at 38 weeks if you have placenta praevia.

 
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