What causes bleeding in the late stages of pregnancy?
Bleeding is a sign that cannot be ignored. If a woman bleeds at any time during pregnancy she should tell her doctor or midwife straight away. The bleeding can be caused by quite harmless changes in the cervix (neck of the womb) called an ectropion. This is the commonest cause of vaginal bleeding in the second half of pregnancy.
It can also be the type of bleeding that occurs immediately before labour and looks like bloody mucus (a 'show'). But bleeding in the late stages of pregnancy can also be caused by one of two potentially serious complications.
If the placenta, which nourishes the baby, is coming away from its attachment to the inside of the wall of the womb (a condition called placental abruption), bleeding will occur.
Abdominal pains and a tense, sore uterus are other symptoms of this problem.The bleeding may originate from a low placenta that is actually blocking the opening to the cervix (a condition known as placenta praevia).
What should a woman do if she starts bleeding in the late stages of pregnancy?
If bleeding starts suddenly, the woman should lie down and arrange to be taken to hospital immediately.
What will the doctors do?
The woman will be examined and looked after on the maternity ward. If she is close to the expected date of birth the doctors will decide whether it is best for her and the baby if the baby is delivered immediately.
If the placenta is breaking away, the doctor or midwife, will break the baby's waters and induce the labour. If, on the other hand, the placenta is blocking the opening to the vagina, the mother will probably need delivery by Caesarean section.
If the symptoms are less severe or the expected date of birth is a long way off, doing nothing other than monitoring the mother and baby's condition may be more appropriate. This will enable the pregnancy to continue and allow the development of the baby to proceed further.
Bleeding should never be ignored. If in doubt please contact a doctor - or the maternity ward at your local hospital immediately. A woman bleeding in the late stages of pregnancy should never have a vaginal examination outside a hospital as such an examination may cause further brisk bleeding.
DILATION & CURETTAGE
Curettage of the uterus (womb) is the scraping of the lining of the uterus (the endometrium). The procedure is commonly known as dilation and curettage or D&C.
When is D&C carried out?
There are two main reasons for performing a D&C:
an evacuation D&C is performed in a recently pregnant woman to remove tissue remaining in the womb.
a gynaecological D&C is part of the investigation of a woman who is experiencing heavy or irregular periods or vaginal bleeding after the menopause.
When is an evacuation performed in a recently pregnant woman?
After, or sometimes during, a miscarriage, the gynaecologist will examine you to see if there is any tissue from the pregnancy remaining in the womb. An ultrasound scan is the most reliable way to determine this. An evacuation is usually advised to avoid heavy bleeding and prevent a possible infection of the uterus.
An alternative to surgery is a medical evacuation that uses tablets to cause the womb to contract and empty itself. The success rate of a medical evacuation in completely emptying the uterus is slightly less than the surgical approach, but is an option for some women.
If you miscarried at an early stage in pregnancy, or if the amount of remaining tissue is small, a D&C may not be necessary since the remaining tissue will be passed as part of the next period.
What happens during a D&C?
First you will be given a general anaesthetic by an anaesthetist. The gynaecologist opens (dilates) the cervix with instruments called dilators, and then inserts a hollow tube through the cervix. Suction is applied to remove the retained tissue. The procedure usually takes less than five minutes.
How soon can you return to work after a D&C?
Most women will take the following day off work, but, physically, you recover quickly. Most women experience psychological effects after a miscarriage, because the pregnancy might have been anticipated with much joy. It is helpful to talk through thoughts and feelings with friends and relatives or with your midwife or doctor.
It is normal to experience irregular bleeding in the days following the D&C.
Why are gynaecological curettages performed?
Sometimes, the character or amount of a woman's period can change. Or there may be breakthrough bleeding or spotting in between periods or during sexual intercourse. Such changes can be caused by hormonal disturbances or may be due to a disease of the cervix or uterus.
Older women, especially those who experience postmenopausal bleeding, receive a gynaecological D&C. A gynaecologist will scrape (curette) the lining of the womb to make a diagnosis and find out which treatment is best.
Few women under the age of 40 require this procedure because disease in the uterus is rarely seen in young women.
How is a gynaecological curettage performed?
Gynaecological curettage is often an outpatient investigation that is performed in hospital by a gynaecologist. The gynaecologist will perform a pelvic examination. After this, a small tube (the width of a very thin straw) is inserted in the uterus. A biopsy of the lining of the womb can be obtained.
A woman usually experiences discomfort similar to a painful period, but this passes within seconds. The sample is sent to a pathologist for examination and results are ready within a week. However, this kind of D&C provides a limited amount of information.
Most gynaecologists recommend a hysteroscopy (telescopic examination of the inside of the womb) as well as the biopsy procedure. Most hysteroscopy examinations can be performed without general anaesthesia.
Sometimes a D&C (with or without a hysteroscopy) is performed under general anaesthesia. This is usually done if the gynaecologist anticipates that the neck of the womb will be difficult to dilate or if the woman is very anxious or requests a general anaesthetic.
Rarely, a woman may need an emergency D&C if she has heavy bleeding that can't be stopped with tablet treatment. In such cases, the D&C is used to treat the problem. However a D&C is usually used to make a diagnosis, and is not used as part of treating the bleeding problem.
How soon can you return to work after a gynaecological curettage?
After a curettage, it is a good idea to relax for the rest of the day, but recovery is quick. It is normal to have a small amount of vaginal bleeding for a few days afterwards. Contact your doctor if heavy bleeding occurs (similar to a heavy period) or if you have severe lower abdominal pain or a high temperature.
Are there any risks with a D&C?
Almost none: the medical or surgical procedure is virtually risk free, and complications following a D&C are rare. Possible complications include:
in recently pregnant women there is the small risk of making a hole in the uterus (uterine perforation) because the wall of the recently pregnant womb is very soft.
sometimes tissue may be left behind (incomplete evacuation). This tissue is usually passed without complication, but increased bleeding or infection may require a repeat procedure.
the risks of a D&C in non-pregnant women is much lower, although there is still the small risk of the uterus being perforated.
What is an ectopic pregnancy?
An ectopic pregnancy occurs when the fertilised egg attaches itself outside the cavity of the uterus (womb).
The majority of ectopic pregnancies are found in the Fallopian tubes. In rare cases, the egg attaches itself in one of the ovaries, the cervix (neck of the womb) or another organ within the pelvis. An ectopic pregnancy is not usually capable of surviving and in most instances an embryo is not developed. An ectopic pregnancy will spontaneously miscarry.
The majority of women diagnosed will have to be operated on or treated with medication.
What are the symptoms of an ectopic pregnancy?
The most common symptoms and findings of ectopic pregnancy are:
At first an ectopic pregnancy develops like a normal pregnancy and the same symptoms such as nausea and tender breasts will be present. However, some women do not have these symptoms and do not suspect that they might be pregnant.
The vaginal bleeding can vary from being slight or brown vaginal discharge to being like a normal period.
If you are pregnant and have a long-lasting throbbing in one side of your lower abdomen or if you experience sudden pain you should contact your doctor. This is important because an ectopic pregnancy can be life-threatening if it ruptures and causes internal bleeding.
Why does an ectopic pregnancy occur?
In a normal pregnancy, the egg is fertilised by the man's sperm in the Fallopian tube and is then transported into the cavity of the womb where it attaches itself. This is called implantation. This transportation is made possible by the tiny cilia (finger-like projections) in the delicate inner lining of the Fallopian tubes that push the fertilised egg along.
Risk factors may be present that increase the likelihood of a woman experiencing an ectopic pregnancy. These are:
previous surgery to the Fallopian tubes or previous inflammation of the Fallopian tubes (pelvic inflammatory disease). Because the lining of the Fallopian tubes is so delicate, inflammation or trauma can cause the cilia to beat in an abnormal fashion so that the fertilized egg implants in the wrong place.
previous ectopic pregnancy. If you have previously had an ectopic pregnancy, the chances of another one in the same Fallopian tube and in the other tube are increased.
becoming pregnant while using a contraceptive coil or the progestogen-only contraceptive pill (mini-Pill).
becoming pregnant with in vitro fertilisation (test-tube methods). When using the test-tube method to overcome infertility one or more eggs are inserted into the woman's uterus. Despite being placed within the womb, the fertilised egg may still attach itself to the wrong area outside the cavity of the uterus.
However, many women experiencing an ectopic pregnancy do not have any of these risk factors.
How is an ectopic pregnancy diagnosed?
A urine test for pregnancy will nearly always be positive but it might be only weakly positive. In cases of doubt, a blood pregnancy test may be performed, which is always positive in ectopic pregnancy.
In the case of ectopic pregnancy, the uterus will often be smaller than expected for the number of weeks since the woman's last period and this can be checked by an internal pelvic examination. The doctor might feel a tender swelling corresponding to an ectopic pregnancy.
An ultrasound scan will help the doctor differentiate between a possible miscarriage, a continuing pregnancy inside the womb and an ectopic pregnancy.
Further investigation depends on the woman's symptoms, the scan findings and the level of pregnancy hormone (HCG) in the woman's blood. If there is uncertainty about the diagnosis then waiting 48 hours and measuring the level of HCG again is often appropriate.
How is an ectopic pregnancy treated?
If an ectopic pregnancy is strongly suspected then the gynaecologist will perform a laparoscopy to confirm the diagnosis.
Laparoscopy is performed through small incisions on the abdomen and the ectopic pregnancy can usually be removed in this manner.
The Fallopian tube in which the ectopic pregnancy occurred is often, but not always, removed at the same time. However, in some instances, open surgery becomes necessary in which the pregnancy is removed through a larger incision above the pubic hair line. This option is usually chosen if technical problems occur during the laparoscopy or if the internal bleeding in the abdominal cavity is difficult to control.
An alternative treatment to surgery is a medicine called methotrexate (Maxtrex), which decreases the growth of cells in the ectopic pregnancy (unlicensed use). As a result the pregnancy shrinks and eventually disappears. The advantage of methotrexate is that it avoids the need for surgery but success rates with methotrexate tend to be slightly lower than with surgery. Occasionally, both surgery and methotrexate will be necessary.
What about future pregnancies?
The outlook for future pregnancies depends on several factors, especially whether the other Fallopian tube appeared normal or not.
As a general guide, after one ectopic pregnancy, 20 per cent of women will experience another ectopic pregnancy, 30 per cent will not become pregnant again and 50 per cent will have a successful pregnancy inside the womb.
What is a miscarriage?
A miscarriage is the loss of a pregnancy before 24 weeks, with most miscarriages actually occurring during the first 12 weeks of pregnancy. Unfortunately, miscarriage is very common, affecting one in eight pregnancies.
What causes a miscarriage?
There is seldom an adequate explanation for why a woman experiences a miscarriage. Studies inform us that approximately 50 per cent of lost pregnancies have failed to develop normally, either due to chromosome or genetic problems or because of structural (bodily) problems. There is no apparent explanation for the remaining 50 per cent of cases.
Certain maternal illnesses are associated with an increased risk of miscarriage, although these are very uncommon.
Smoking increases the risk of miscarriage.
There is a gradual increase in the risk of miscarriage as the woman gets older.
It is important to remember that an ordinary lifestyle that includes exercise, going to work, minor falls or taking the Pill before pregnancy does not increase the risk of miscarriage.
What are the symptoms of a miscarriage?
The most common symptom is bleeding from the vagina. Lower abdominal pain is also very common. Some women have no symptoms at all and the miscarriage is only diagnosed when they are given an ultrasound scan at their antenatal clinic. This is referred to as a 'silent miscarriage', and can be very distressing for the woman and her partner.
What to do if a miscarriage is suspected
If a woman is bleeding from the vagina and feels pain then she must consult her doctor.
When is it necessary to consult a doctor immediately?
If the woman is bleeding at such a rate that she needs more than one sanitary towel per hour. In this case, too much blood is being lost and the flow must be stopped.
If the woman feels weak or faint. These are both signs that she is losing too much blood.
If the woman experiences severe stomach pain, this may be a symptom of an ectopic pregnancy.
If the woman experiences fever, shivering or a smelly vaginal discharge, this can be a sign of an infection or inflammation.
All these conditions are potentially serious and must be treated immediately. What does the doctor do?
An abdominal examination is usually combined with an internal (pelvic) examination. In this way, it is possible to determine if the bleeding is a sign of a pregnancy that is destined to miscarry or one that may continue. An ultrasound scan is the most useful investigation. This is performed through the abdomen or through the vagina and gives precise information about whether the pregnancy is continuing or not.
What if my pregnancy is continuing?
Provided the bleeding is not too heavy and the pain is controlled by simple painkillers, then you can go home. As long as the bleeding continues, it is advisable to keep off work. Bed rest is not essential and does not influence whether the bleeding will continue and result in a miscarriage or not. If a pregnancy is destined to miscarry, there is, unfortunately, nothing effective that you or your doctor can do.
What if my pregnancy is not continuing?
Again, depending on the amount of bleeding and discomfort you may be admitted to the hospital or allowed home. If the scan shows that there is no blood clot or tissue in the womb then nothing further needs to be done. If there is more than just a little tissue or a blood clot then a small operation called a uterine evacuation may be recommended.
What happens after a miscarriage?
Following a miscarriage, it is advisable to take it easy and rest for a couple of days. It will help if the woman has someone she trusts with her, so that she can talk openly about her feelings. After a couple of days it is often helpful to return to a normal daily routine. After a miscarriage a woman might experience headaches or have trouble sleeping. She may also experience lack of appetite and fatigue.
Many women feel anger and sadness after a miscarriage, while many others experience a strong sense of guilt, even though it is not their fault. These are all natural reactions. A miscarriage can be frightening, confusing and depressing. It is natural to feel grief over the loss of a child. Women should not let people ignore or belittle what they have been through. The people they choose to talk to must be prepared to listen to what they have experienced and deal with the strong emotions involved.
Any woman who finds it too difficult to deal with her grief, or who continues to feel depressed, should consult her doctor for further help.
What if more than one miscarriage is experienced?
If a woman has three miscarriages in a row, this is known as a recurrent spontaneous miscarriage (RSM) and a referral to a gynaecologist for special investigation is recommended. Provided the investigations are negative, a woman's next pregnancy still has a 70 per cent chance of being successful.
When can I try for another baby?
There are no hard-and-fast rules. The right time to try for children again will vary from one couple to another: some will want to start a couple of weeks or months after the bleeding has stopped, others will want to wait longer. It is, of course, advisable to recover from the worst of the emotional upset before starting another pregnancy.
Will my next pregnancy be successful?
Following one miscarriage, the risk of the next pregnancy being a miscarriage is not increased beyond the overall risk of one in eight.
Remember to keep taking folic acid to reduce the risk of the baby being affected with spina bifida.
If you smoke, give up.
Often a woman gains considerable re-assurance by having an early scan. Ask your doctor or gynaecologist about this.
PREGNANCY-INDUCED HIGH BLOOD PRESSURE (PRE-ECLAMPSIA)
What is pre-eclampsia?
Up to 1 in 10 pregnant women develop raised blood pressure accompanied by the appearance of protein in the urine (proteinuria) and retention of excessive amounts of fluid in the body (oedema). It is not usually seen before the sixth month of pregnancy and most women develop the condition at the end of their pregnancy. However, only 1 out of 100 women will have the severe form of the condition.
Pre-eclampsia can also occur up to a week following delivery of the baby.
Why does this occur?
It is still not known why certain women develop high blood pressure during pregnancy.
Certain pre-existing conditions increase the risk of developing high blood pressure. They include:
essential hypertension (high blood pressure before pregnancy)
chronic kidney diseases
previous pregnancies affected by pre-eclampsia
carrying twins or triplets.
What are the symptoms?
Hypertension (high blood pressure)
Unless her blood pressure is very high, a woman will not be aware that it has increased. As a general rule a blood pressure greater than 140/90mmHg in pregnancy is considered to be raised.
Very high blood pressure (greater than 170/110mmHg)
Often accompanied by headaches and the appearance of flashing lights before the eyes. Measuring a woman's blood pressure is an essential part of any antenatal clinic visit.
Protein in the urine
This is detected by your doctor or midwife by using a special stick to dip into a clean sample of urine. There are other causes of proteinuria but pre-eclampsia is the cause with most significance for the mother and foetus.
Sudden or insidious weight gain with swollen hands, feet , face or other parts of the body
Some swelling is normal in pregnancy but it should prompt a woman to have her blood pressure and urine checked.
Pain in the right upper abdomen
May indicate involvement of the liver, which in severe cases can be complicated by an imbalance of the coagulation system that causes an increased or decreased ability of the blood to clot.
Headaches, fatigue, and pains in the upper abdomen
These are all symptoms of the more severe stage of the condition.
Pre-eclampsia is often subdivided into mild, moderate and severe depending on the level of blood pressure and the involvement of other organs in the disease process. In the worst cases, pre-eclampsia can develop into eclampsia, a situation where the mother has a convulsion. Fortunately, eclampsia is rare, but this is largely because women with pre-eclampsia are usually detected and treated before eclampsia can develop.
All the symptoms will disappear after the delivery and normally the blood pressure and protein level in the urine will be back to normal after a maximum of two weeks.
The primary aim is to monitor the mother and the foetus closely. This may require hospital admission. Pre-eclampsia can, in severe cases, influence the placental function and diminish the flow of nourishment and oxygen to the foetus, which will slow its growth. Antihypertensive medicines of different groups are often used to reduce blood pressure.
If the woman's condition deteriorates and the foetus is at risk, the only solution is to deliver the baby either by induction of labour or by performing a Caesarean section.
Monitoring of the woman's blood pressure and urine is essential. If hypertension is developing, it is vital to measure the blood pressure and test urine for protein regularly.
Giving women a small dose of aspirin (eg Nu-seals 75mg) throughout their pregnancy has been proposed as a preventive measure, but current research does not support this practice. There may still be very a small group of women at high risk of developing the disease who may benefit from aspirin.
Calcium supplementation is of uncertain benefit but may be of use for women with a high risk of pre-eclampsia.
The most recent development is in using antioxidants such as vitamin C and vitamin E to prevent pre-eclampsia. Research is at an early stage, although early results are promising.