Bleeding from the vagina is abnormal at any stage of pregnancy and may be due to many causes. Some are of little or no significance while others are potentially more dangerous. There is no way a pregnant woman can know if any bleeding from which she is suffering during pregnancy is significant or not, and she must, therefore, report it immediately to her doctor. Similarly she must report an excessive vaginal discharge or any acute abdominal pain.
An abortion by definition is the discarding by the uterus of the products of conception before the 28th week of pregnancy. There is no difference between an abortion and a miscarriage despite the . frequently held view that an abortion is something that is induced and a miscarriage is something which occurs spontaneously. The two terms are synonymous and are so used here.
A threatened abortion is bleeding from the vagina during the first 28 weeks of pregnancy and is not accompanied by any pain.
Inevitable abortion. A threatened abortion becomes an inevitable abortion when the woman experiences pain due to uterine contractions or when, on examination, the cervix, or neck of the uterus, is found to be opening so that abortion must inevitably occur sooner or later.
A complete abortion has occurred when all the products of conception have been passed from the uterus.
An incomplete abortion is a condition in which part of the products of conception have been passed but some remain within the uterus.
A missed abortion is said to occur when the pregnancy has died within the uterus but the uterus has failed to expel it. The dead pregnancy will be aborted sooner or later.
Recurrent abortion is miscarriage on three or more occasions. The cause may vary on each occasion so the abortion may occur at different stages during different pregnancies.
Habitual abortion is the term usually reserved for miscarriage on three or more occasions at approximately the same stage of pregnancy and therefore assumed to be for the same reason each time.
Any bleeding which occurs at any stage during the first 28 weeks of pregnancy must be considered a threatened abortion until proved otherwise. If a woman notices any such bleeding she should go to bed immediately and stay there until she has been seen or advised by her doctor. The bleeding may be very slight in amount and may or may not be mixed with mucus. On the other hand it may be comparatively severe and even as heavy as a normal period. Occasionally there may be a dull aching discomfort in the lower abdomen. A small amount of backache, especially in the lower part of the back, may occur both before and with the bleeding. The abdominal discomfort and the backache usually pass with rest in bed. It frequently happens that a woman is first conscious of the bleeding when she passes urine. This does not mean that micturition has made the uterus bleed, but that the uterus has been bleeding slowly into the vagina for some time before micturition and on straining slightly blood appears from the vagina as urine is passed.
There are many causes of threatened abortion, some of which are known and many of which are not. Possibly the commonest cause is hormone imbalance so that the bleeding occurs at the time when the woman would be having a period and is called a ‘partially suppressed period’. If the amount of circulating hormone is insufficient to maintain a pregnancy this will first become apparent when it fails to suppress completely the next menstrual period. Such bleeding may be slight in amount or, if the hormone levels are really low, it may become much more severe and may end in actual abortion.
A threatened abortion most commonly occurs at the time of the first, second or third suppressed period, that is at 4, 8 or 12 weeks of pregnancy. It also occurs at about the 14th week of pregnancy because it is at this stage that the placenta, which may be inefficient, takes over the production of hormone from the corpus luteum of the ovary.
The correct treatment for threatened abortion is immediate bed-rest. This means complete rest: going to bed, staying there and resting as quietly as possible. The woman may be allowed up for toilet purposes but for no other reason.
When a threatened abortion first begins the loss is usually bright red or pink which means that the blood is coming almost directly from the uterus. When it stops bleeding the colour of the loss from the vagina changes from bright to dark red and then brown. Normally bed-rest is continued until three days after the brown discharge has ceased.
Internal sanitary protection must not be used at any time during pregnancy unless specifically requested by your doctor. Sanitary towels must be used and changed frequently. They should be saved for your doctor to examine.
Complete bed-rest may, of course, be impracticable for someone who has no help in the house or for someone who has to look after small children, but it is nevertheless the ideal and the maximum rest possible must be taken. A mild amount of sedation or tranquillizer is frequently administered to women when they threaten to miscarry because not only are they upset but it also helps them to rest quietly. If threatened abortion recurs in a subsequent pregnancy a simple smear may be taken from the vagina to assess the hormone balance and if there is any evidence of progesterone deficiency the doctor may decide to prescribe a course of the hormone either by mouth or by injection. A doctor may consider that a woman should have some hormone treatment anyway, but it is not usually given unless there has been a previous threatened abortion.
It is impossible to know how many threatened abortions settle down and how many proceed to actual miscarriage. A threatened abortion does indicate a certain instability of the pregnancy and care should be taken to rest quietly at the time when the next period would normally be. The pregnant woman’s activities should also be appropriately restricted for at least the first 14 weeks of her pregnancy. Sexual intercourse should not occur until the baby has been felt moving and in any event not until her doctor advises.
Inevitable abortion is associated with pain in the lower abdomen which feels rather like the cramp of a period pain. The initial bleeding usually increases in amount and becomes brighter in colour. The woman should go to bed immediately and notify her doctor who will decide if admission to hospital is advisable. The amount of discomfort or pain depends on the stage of the pregnancy. The pain is actually caused by the uterus contracting so that it will eventually expel the pregnancy.
There is little that can constructively be done to treat an inevitable abortion and this is usually bed-rest and the administration of a sedative drug together with something to relieve the pain or dis-comfort if necessary.
An abortion begins as a threatened abortion and proceeds to become inevitable after which the contents of the uterus will be completely expelled or only partially expelled (incomplete abortion). Complete abortion is said to occur when all the products of conception have been passed so that the uterus no longer contains any of the products of conception. A complete abortion may take only one hour from the onset of bleeding and may be accompanied by comparatively little pain. Alternatively the process may take many hours and be associated with severe lower abdominal pain and profuse bleeding. If abortion is rapid it may be completed before the doctor arrives, or if slow, admission to hospital may have been arranged while the abortion was either threatened or inevitable.
When the abortion is complete all discomfort and pain ceases and the amount of bleeding rapidly diminishes. The abortion itself is passed as a clot of liver-like material which should if possible be saved for the doctor to examine and confirm that all the products of conception have been passed. The main treatment is rest in bed for one or two days and then a gradual return to normal activity over the next four or five days.
An incomplete abortion is a condition in which part of the products of conception have been expelled but some remain because they are adherent within the uterus. This is the only type of abortion that really causes problems, since the part of the pregnancy remaining predisposes the woman to the two major complications of abortion, which are haemorrhage and sepsis. Incomplete abortion can be the result of either an induced abortion or a spontaneous miscarriage. The diagnosis is usually made when bleeding continues from the uterus after some of the pregnancy has been passed. If a woman thinks she is suffering from an incomplete abortion she should get in touch with her doctor or with the nearest hospital as soon as possible.
The first measure in treating an incomplete abortion is to stop the bleeding from the uterus. This is done temporarily by giving an injection of a drug such as ergometrine or syntometrine which may cause uterine cramp to return together with lower abdominal pain, but the contracted uterus will cease to bleed. The woman is then transferred to hospital where the retained products of conception are removed from within the uterus by curettage, or scraping, while she is under a general anaesthetic. Once the products of conception have been completely removed the uterus will stop bleeding and there will be no danger of infection.
It cannot be emphasized too strongly that any woman who has had an abortion and finds herself bleeding heavily, should seek help from her doctor or from the nearest hospital as soon as possible.
When a pregnancy has died within the uterus but the uterus has failed to expel it a missed abortion has occurred. It will inevitably be aborted spontaneously sooner or later. A missed abortion can be a most disturbing and difficult problem. The story usually goes something like this. A woman is pregnant and she has all the signs and symptoms of early pregnancy but at about the 8 th week she has a small amount of either bright or dark vaginal bleeding. She goes to bed, rests, the bleeding stops and she assumes that her pregnancy is continuing normally. Eventually however, because it is dead, hormones are no longer manufactured and she may Slowly become aware of what is happening because the nausea, sickness and breast activity will cease and she will no longer ‘feel pregnant’. A few days later a further small amount of brown or red bleeding may occur and this type of loss may continue intermittently for several weeks. There is no pain and the uterus does not contract or do anything to expel the dead pregnancy.
It is impossible to distinguish an early missed abortion from a threatened abortion but later the doctor will notice the absence of the signs of pregnancy and also that the uterus is small for the expected duration of pregnancy. A missed abortion is a very distressing condition and naturally the woman may wish to go into hospital as soon as possible to have it removed by operation. This, however, is not always in her best interests, especially if the missed abortion has occurred at about the 12th or 14th week of pregnancy. She may be asked to wait a little longer to see if the uterus will contract and empty itself spontaneously but if it fails to do so after a couple of weeks she will probably be admitted to hospital for curettage. Following the operation the uterus will return to normal within one or two weeks.
Recurrent abortion is miscarriage on three or more occasions. The cause may vary on each occasion so the abortion may occur at different stages during different pregnancies. The causes of recurrent abortion are usually multiple so that one abortion cannot be related to another. Some may be the result of hormone deficiency, others the result of abnormal development of the pregnancy, and these may be related to abnormalities of the uterus or illness of the mother.
The prevention of recurrent abortion does, of course, depend upon discovering the cause. Fairly extensive investigations may be necessary to do this, but once the cause, or causes, has been determined, preventive measures or particular treatments can be undertaken to prevent a recurrence during a subsequent pregnancy. The husband will probably be examined and a seminal analysis performed. A higher than usual percentage of abnormal or dead sperms is sometimes considered a frequent cause of abortion.
Miscarriage on three or more occasions at approximately the same stage of pregnancy is assumed to be caused by the same factor each time, and is termed habitual abortion. It is impossible to define here the cause of habitual abortion, which may vary from congenital abnormality of the uterus to incompetence of the cervix. Extensive investigations may be necessary to discover why habitual abortion is happening and even then it may be very difficult to arrive at a definite diagnosis. The prevention and treatment of this type of abortion naturally depend upon its cause. Investigations may have defined the reason for the previous habitual abortions and factors such as fibroids can be treated before the next pregnancy. If the cause is known and pregnancy has already been established the woman will be treated to prevent further miscarriage.
Dangers of Abortion
There are two main dangers involved in any abortion. The first is haemorrhage and the second sepsis. Both induced and spontaneous abortion may result in the retention within the’ uterus of a small amount of the chorionic villi (incomplete abortion) whose very presence allows the uterus to continue bleeding and also predisposes it to infection.
Haemorrhage occurring in an abortion can be temporarily controlled by giving ergometrine or syntometrine to make the uterus contract. The remaining products of conception are then removed by curettage. If a woman has had an induced abortion and finds herself bleeding excessively she should seek medical help immediately because if some of the pregnancy still remains in the uterus the bleeding will continue until it has been removed.
Infection only occurs when a portion of the pregnancy is still retained within the uterus or as a result of induced abortion. The main symptoms of infection are pain and temperature, and any woman who has lower abdominal pain together with a temperature shortly after an abortion or miscarriage should seek medical aid immediately. Infection during or following an abortion can be serious if not treated promptly.
Gap before next Pregnancy
Once a woman has miscarried, how long should she wait before she again becomes pregnant? The answer must be an individual one and will vary according to her age, health, circumstances and the reason for the miscarriage. Sexual intercourse itself may be resumed as soon as vaginal bleeding has ceased. The better success rate for pregnancies of women waiting three months after a miscarriage before getting pregnant is now well established; thus, while a short wait may be desirable for various reasons, there is more than an element of truth in the saying that a uterus will not accept another pregnancy until it is fit and well enough to do so.
Some special treatment may have to be performed to prevent abortion recurring in which instance the space before another pregnancy will be advised by the doctor. There is no sense in waiting for longer than three months, time is always precious.