Medical emergencies in pregnancy

Most women carry their babies to term without any problems or emergencies. It's a good idea, though, to be aware of the danger signs just in case, so you know when to call for medical help.

Vaginal bleeding

About one-quarter of all pregnant woman suffer some vaginal bleeding in the first trimester. More than half of these women go on to give birth to a healthy baby at term. If you have any bleeding, call your doctor or midwife, who will probably refer you to the Early Pregnancy Unit at your local hospital. These are walk-in clinics, where you can be scanned quickly to check for your baby's heartbeat.

If it's confirmed, there's a very good chance (more than 90 per cent) that all will be well. Women with a history of repeated miscarriage may go to these units regularly to boost their confidence. Studies show that reassurance alone has a very positive effect.

If you start to bleed at any time during the second or third trimester, call your maternity unit and go there as soon as you can. There may be serious problems with your placenta, or you could be going into premature labour, but there are other less serious causes. It's important to be seen right away just in case.

Miscarriage

Spontaneous miscarriage is when a baby dies or is expelled from the womb before the 24th week. After the 24th week, this is called a stillbirth or premature delivery. About one-third of all pregnancies end in miscarriage in the first few weeks, but one-quarter of these happen before a woman even knows or suspects she is pregnant.

Miscarriages are more likely the older you are and the more pregnancies you've had. They are most common in the first trimester and the usual symptom is bleeding, which happens in 95 per cent of cases. If you notice bleeding at any time in your pregnancy, call your doctor.

Many early miscarriages are due to a seriously abnormal fetus failing to implant in the wall of the uterus, while 70 per cent are due to chromosomal abnormalities. In some, the baby itself never develops at all, just the amniotic sac and placenta. Causes linked to the mother include abnormalities in her uterus, such as large fibroids, and hormonal imbalances. Some miscarriages are also caused by bacterial and viral infections. Cervical incompetence accounts for only one per cent of spontaneous miscarriages. Factors linked to the father include abnormal sperm.

Whatever the cause, at some point in the first three months the body starts to reject the pregnancy, and bleeding then pain occurs. Doctors divide spontaneous miscarriages into several categories, as described below:

• Threatened miscarriage: A mother suffers vaginal bleeding and sometimes pain; miscarriage is possible, but not inevitable. This happens in about ten per cent of all pregnancies and may be confused with the slight bleeding that can come at the time of the first “missed” period.

• Inevitable miscarriage in pregnancy: A woman has vaginal bleeding and pain because her uterus is contracting. Unfortunately if her cervix also dilates, she is bound to lose the pregnancy.

• Complete miscarriage: Heavy bleeding means the fetus and placenta are expelled from the uterus, and the uterus goes back to its previous size. Ultrasound examination can confirm this.

• Missed miscarriage in pregnancy: The fetus fails to develop, or dies, but the placenta keeps functioning. Eventually a miscarriage would result, but an ultrasound scan will confirm that there is no ongoing pregnancy. Different ways of treating this will be offered.

• Incomplete miscarriage: There's a miscarriage, but some of the products of conception, such as the amniotic sac or the placenta, remain in place.

• Recurrent miscarriage: A woman suffers a miscarriage on three or more occasions. This may happen at the same stage of pregnancy or at different stages and the reasons may be the same or differ each time.

Treatment for a miscarriage

If you're bleeding in the second or third trimester, call the hospital and go there as soon as you can. If you bleed in the first trimester, call your doctor and stop any physical activities such as strenuous exercise and sexual intercourse. If the bleeding and pain stop, you're likely to go on to deliver a healthy baby.

If a miscarriage seems inevitable, there's little that doctors can do to prevent it. You will have a scan to confirm that the pregnancy has failed and will then be offered either a natural approach in which you wait until the body expels all of the placenta, or a surgical option. If you're bleeding heavily, or have lost a lot of blood, you may need to have an emergency operation, an evacuation of retained products of conception (ERPC). This is similar to a dilatation and curettage (D and C) and is the procedure for clearing out the uterus. A general anaesthetic is usually given, along with painkillers. A blood transfusion may be necessary if the woman has lost more than 1 litre (1 ¾ pts) of blood. There's no urgency in treating a missed miscarriage, but if, after a time, a spontaneous miscarriage hasn't taken place, a ERPC will be carried out.

If a baby dies later in pregnancy, prostaglandin pessaries or an oxytocin injection are given to stimulate delivery.

After suffering a miscarriage because of cervical incompetence, some women can be treated by stitching the cervix shut at the beginning of the next pregnancy, though this is not always successful.

Other possible reasons for recurrent miscarriage are genetic or hormonal disorders or problems with blood clotting. Long-term infections, such as listeria, may sometimes cause repeated miscarriages, but these can be difficult to diagnose and treat.

Other contributing factors to miscarriage can be poor nutrition; chronic disease, such as renal disease; or tumours in the uterus (particularly fibroids).

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Dr Miriam Stoppard

Posted 16.11.2010

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