PREGNANCY: WHAT CAN GO WRONG?
Miscarriage. The other medical term for this is ‘abortion’ but this can sometimes be misleading because the word abortion has been taken generally to mean a surgical termination of pregnancy.
Miscarriage means that the products of conception (embryo/foetus, placenta and sac) are spontaneously passed from the uterus before twenty weeks gestation. (After twenty weeks the same process is known as stillbirth.)
This happens fairly often. The ‘background’ rate of miscarriage in our society is about one in four to five pregnancies. Some of these happen so early that they may not actually be recognised as pregnancies, but rather as slightly late, heavier periods. Most miscarriages occur before twelve weeks gestation.
If a woman experiences bleeding in pregnancy, she should see a doctor, who can assess the state of her pregnancy. She can tell the doctor the history of what has been happening, and be examined. A pelvic examination will be performed to check the state of the cervix (whether it is open or closed), and the size of the uterus (whether it is correct for her dates).
If the bleeding has followed intercourse, it is called post-coital bleeding. In most cases of post-coital bleeding the blood has come not from the uterus, but from cervical ‘erosion’, as this is usually more prominent during pregnancy, and may bleed a little with examinations, pap smears and sex. Even if the bleeding is obviously post-coital, it is worth having it checked out.
If the woman’s cervix is closed, and her uterus is not smaller than her dates would suggest, her doctor may tell her that she has a ‘threatened’ miscarriage or ‘threatened’ abortion. An ultrasound will usually be organised to assess the viability of the pregnancy, as about 50 per cent of threatened miscarriages will not continue (but 50 per cent will!). If the pregnancy is not continuing a curette (D and C, see appendix 1) would be arranged to empty the uterus. If the pregnancy is viable, then most women will be told they should take it easy for a few days (although the benefits of rest in threatened miscarriage have not been thoroughly proven), and to avoid intercourse until at least two weeks after the last evidence of bleeding.
If she has already passed a large amount of blood, and some ’tissue’ (stuff that is firmer and different in texture to a blood clot), it is likely that her cervix will be open a little. She may still have some blood and contents in her uterus, and her doctor will tell her that she has had an ‘incomplete’ or ‘inevitable’ abortion or miscarriage. This means that the pregnancy is not continuing. The next step is usually to organise a curette, to more effectively empty the remnants from the uterus. This helps prevent further bleeding and potential infection.
It may be that the pregnancy has been passed, when it would be called a ‘complete’ miscarriage or abortion. Depending on the circumstances, and the gestation of the pregnancy, a curette is still often performed in case there are any pregnancy remnants which could form a focus for infection. If an ultrasound shows an empty uterus and the bleeding settles, a D and C may not be performed.
If the woman’s cervix is closed, but her uterus is smaller than her dates would suggest, an ultrasound may show that she has had a ‘missed’ miscarriage or abortion. This is when the embryo has stopped growing, but the uterus has not yet expelled the products of conception. Again, a curette would be arranged to remove the failed pregnancy.
The term ‘blighted ovum’ is given to a pregnancy which starts developing, and fails, and no actual embryo/foetus is identified (usually by ultrasound). It is treated in the same way as a missed miscarriage.
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