The common presentation of miscarriage is bleeding from the vagina. This usually happen during the first three months of pregnancy. When this symptom is associated with lower abdominal pain/contraction, the implication is serious. As the bleeding and cramps become more severe, the conceptus is then expelled. Missed abortion is associated with brownish spotting couple with cessation of pregnancy symptoms. Threatened miscarriage, a ‘milder’ variant miscarriage presents with vaginal bleeding minus the uterine cramps. There is no change in the symptoms of pregnancy.
Pregnant mothers with vagina bleeding/ spotting must consult the obstetrician to exclude the above complications. There are also other causes of vaginal bleeding in early pregnancy. This includes cervical polyp, cervical erosion, vaginal laceration and infections.
What to expect from your doctor?
The doctor will obtain history of the vaginal bleeding, followed by a physical examination including pelvic assessment. A speculum is introduced into the vagina to visualize the cervix. This helps to exclude some of the cervical lesions. A pelvic ultrasound scan is performed to demonstrate the gestational sac and fetal heartbeat.
What are the possible findings anticipated on a pelvic scan?
1. Threatened miscarriage
There is a regular gestation sac with fetal heartbeat activity. There maybe blood clot around the gestational sac (perigestational hemorrhage).
2. Missed abortion
The gestational sac is crumpled/irregular and there is no fetal heartbeat.
Sometimes, there is an abnormally large sac without any fetal mass (anembryonic pregnancy).
What are the treatment options?
There is no specific treatment that is effective for threatened miscarriage. Most doctors advocate bedrest and restriction of physical activity. Others prescribe progestogen (hormone) or even HCG injection, to ‘support’ the pregnancy although the efficacy of such treatment is not proven. This probably helps to reduce the anxiety in the pregnant mother. An earlier appointment together with a repeat ultrasound scan is given.
In this condition, the conceptus has stop growing and needed to be removed. The uterus can naturally expelled the conceptus or this can be accomplished by medical intervention.
– Natural expulsion of conceptus
This option has the advantage of avoiding hospitalization. However, this process is unpredictable and vaginal bleeding may continue for days. The bleeding can be excessive, followed by severe cramp during expulsion. Some patients find this experience rather distressful. Admission to hospital is necessary when the expulsion of conceptus is incomplete and this warrants surgical intervention (D&C).
– Surgical intervention
Nowadays, most patients prefer intervention for removal of the conceptus. This is a short procedure (10-15minutes) whereby a curette is introduced into the uterine cavity, to accomplish the process. This D&C procedure can be done in a Day Surgery setting, without having to be hospitalized.
This procedure allows a complete removal of the conceptus, shorten the period of vagina bleeding and reduce complications of retained tissue. It also hastens patient’s emotional recovery and enables her to ‘move on’.
– Use of cytotec, a more recent option
Recently, misoprostol (cytotec) has been used to induce a medical D&C, avoiding the traditional surgical procedure. This tablet is either taken orally or inserted into the vaginal to facilitate the uterine contraction and expulsion of the conceptus. The vaginal mode is preferred due to fewer side effects.
I have conducted a study using Cytotec in women with miscarriage in early pregnancy, in my previous institution. The main objective is to compare the effectiveness of Cytotec to D&C (gold standard of treatment) in achieving a complete evacuation. The result shows an acceptable rate of 80% complete expulsion using Cytotec as compare to D&C. The other 20% of women need surgical intervention for failure to response.
I conclude that the above method provide an additional option to women. However, those who opted for this method must be aware that there is a one in five chance of requiring surgical D&C later. There are also reported side-effects associated with Cytotec including diarrhea, vomiting, severe cramps and fever,