Bleeding in early pregnancy

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Definition

Vaginal bleeding in the first half pregnancy before the age of viability. Currently considered less than 24 weeks gestation (or 500g) but subject to review in light of recent medical progress[1]

Medically, the terms "abortion" and "miscarriage" are synonyms. In lay terms, the word abortion is mainly used as a contraction of therapeutic abortion, commonly referred to by doctors as termination of pregnancy.

Incidence

  • 15-20% pregnancies
  • 80% within 12 weeks
  • 50% continue to viability

Increase risk of pre-term delivery by 1.57x[2]

Aetiology

  • foetal factors
    • commonest cause of miscarriage
    • occurs early (<8 weeks)
    • usually chromosomal abnormalities (up to 50%)
    • autosomal trisomies - 50%
  • paternal factors
    • balanced translocation
    • carrier state
    • ? increased abnormalities with ageing sperm
  • idiopathic
  • maternal factors
    • Failure of the active processes involved in maternal-fetal tolerance to paternal alloantigens[3]
      • These active processes may explain why filgrasim in early pregnancy reduces rate of miscarriage
    • endocrine disorders
    • anti-phospholipid syndrome
    • chronic renal disease
    • chronic cardiovascular disease
    • anatomical abnormalities
      • submucous fibroids
      • congenital uterine abnormalities
        • septate / bicournate / unicournate uterus
      • cervical incompetence
      • intra-uterine adhesions (Asherman's syndrome)
    • infections
      • listeria
      • toxoplasmosis
      • Mycoplasma
      • Syphilis
    • environmental
      • toxins
      • radiation
      • drugs
      • smoking
      • alcohol

Management

LogoKeyPointsBox.pngMedical management of miscarriage
  • there is more than one regime
  • mifepristone orally
  • about 48 hours later misoprostol PV
  • 100mg diclofenac PR at same time as the misoprostol
  • expect miscarriage to occur in next 6 hours
  • analgesia - co-codamol as required
  • supportive - physically and emotionally
  • treatment of known causes between pregnancies
  • non-viable pregnancies
LogoKeyPointsBox.pngConservative management of missed miscarriage
  • about 50% will miscarry within 1 month from diagnosis

Differential diagnosis

References

This article is a work in progress. Please feel free to contribute to it.

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