Most pregnancies are healthy and free from complications, but sometimes problems do arise. In most cases, risks to the mother and the baby are decreased if warning signals are recognised and dealt with early. So, it is important to know about them to recognize them early and take the help of specialized care.
Bleeding in early pregnancy can happen without any serious impact. Sometimes it may imply a miscarriage in the offing and it may progress to a spontaneous abortion. The abortion process may be asymptomatic and become evident only by a scan. This is called a missed abortion.
How often does bleeding occur?
20 to 25% of women have spotting to bleeding. through the vagina. However, the possibility of spontaneous abortion is relatively small (2.5% to 3%) and the most likely outcome of the pregnancy will be normal.
What can cause bleeding?
- Minimal spotting particularly at the expected time of menses or just prior to that is rather normal, which usually occurs at the time of implantation of the zygote .
- Under influence of estrogen the inner lining of the cervix overgrows causing spotting. This is medically known as ‘Erosion’ of cervix and can give rise to spotting particularly following deep intercourse in early pregnancy.
- Infection of vagina, cervix – like candidal (fungal) or trichomonal infection.
Ideally, a pregnancy should be implanted in the uterine cavity, but on occasions it gets implanted outside the uterine cavity, called as ectopic pregnancy. Of these in 95% of the time, the ectopic pregnancy gets implanted in the fallopian tube, known as tubal pregnancy. It can get implanted at various other sites like: outside the uterus like cervix, ovary, and abdominal cavity. This is quite rare, however.
How often does this occur?
Incidence is increasing, although the risk of maternal death is decreasing due to early diagnosis and better medical facilities.
Pelvic inflammatory disease (PID):
Global increase in incidence of sexually transmitted diseases and pelvic inflammatory diseases leads to defective transport of fertilised egg (zygote) to the uterine cavity. Thus the fertilized egg gets implanted into the tube.
It gets stretched up to certain point and gives way, causing rupture and bleeding in the abdominal cavity.
At this point, the woman gets acute pain.
Causing narrowing of tubal lumen at the site of surgery, causing obstruction to the passage of the fertilised egg.
IUD: (Intra Uterine Device)
The chances of an ectopic pregnancy are relatively more in an IUD user. The IUD protects more against an intrauterine than an extra uterine pregnancy.
What you feel?
Absence of menses (amenorrhoea): can last from days to weeks. Up to 15% may not have history of amenorrhoea?
- Mainly in lower abdomen on left or right side A sudden onset of cramping may occur with giddiness and fainting.
Many patients may have irregular scanty altered bleeding through the vagina. This is another reason why you may not realise that the period has been missed.
Other symptoms may include:
- Increased urinary frequency.
- Burning sensation during urination.
- Low grade fever.
- Feeling of motion (rectal tenesmus).
- What does the doctor see?
- Pale look on the face.
- Increased pulse rate (normal pulse rate =60-100 beats / minute )
- Decrease in blood pressure (hypotension).
- Tenderness in lower abdomen.
- Internal examination will be very painful.
- Blood investigations:
- Haemoglobin estimation, which shows fall in haemoglobin levels due to internal bleeding.
- Serum HCG estimation: Normally, hCG hormone doubles its previous value in 48 hours, in 1st 10weeks of pregnancy. In ectopic pregnancy, the rate increase much slower, in fact it may not increase at all.
Particularly, the trans-vaginal method can diagnose ectopic pregnancy early and more accurately.
Can be used as a confirmatory procedure when there is a high suspicion of an ectopic pregnancy. ‘Seeing believes’ and by this technique the doctor actually looks at the pelvic structures, under anaesthesia. If possible corrective surgery may be done at the same sitting.
Serial follow–ups by monitoring vital parameters serum hCG levels, serum progesterone is a must for ectopic pregnancy, when medical or surgical interventions are withheld.
- Either by laparoscopy or by laparotomy i.e. opening the abdomen surgically. However, laparoscopy is the preferred option. if possible
- Radical surgery: complete removal of the fallopian tube on the affected site. The advantages of surgical treatment are that it is a one step procedure that will take care of the ectopic, without any later risks.
In this, the agent which dissolves the ectopic pregnancy is used like:
- Injection methotrexate – locally or intramuscular.
- Injection KCL – locally.
These are used kill the pregnancy under sonographic guidance or laproscopically.
(Gestational trophoblastic tumours)
Technically called hydatidiform mole. The molar pregnancy occurs due to abnormal development of cells of placenta. They form grape like watery clusters, which cannot support a growing embryo. They are hence called “drakshagarbha” in local language in India.
How often does this occur?
0.5 to 8.3 per 1000 live births. The incidence is 7 to 10 times greater in Asian countries as compared to North America or Europe.
Molar pregnancy is caused by chromosomal problem in either the sperm that fertilises the egg or the egg itself or both.
- Age more than 40 years, the risk increases by 200 times.
- Socioeconomic status: Risk is higher in poor group probably due to malnutrition and protein deficiency.
- Previous occurrence of hydatidiform mole: repeat mole in 0.5 – 2%.
Women who have had a molar pregnancy are at a risk of developing neoplasm or invasive disease inside the uterus. Some of these, are highly metastatic likely to spread to other parts of body. Although, it is rare and its cure rate is high, any woman who has had a molar pregnancy is at risk for invasive disease. Hence proper follow up is necessary.
What do you feel?
- Amenorrhoea (Irregularity of menses): usually for 3 to 4 months.
- Bleeding: It is the first symptom in almost 95% of cases.
- Excessive vomiting: probably due to high levels of hormone hCG.
What the doctor sees?
- Increase in the size of uterus, which doesn’t correspond to the duration of pregnancy.
- Increase in the heart rate and the pulse rate.
- Increase in the blood pressure.
How to arrive at a diagnosis?
- CBC (complete blood count).
- Blood grouping and Rh typing.
- Serum electrolyte (sodium, chloride and potassium) levels.
This is an extermely important test as it Clinches diagnosis: It will show absence of foetus with ‘snow storm’ appearance.
Dilatation and evacuation: In this, under suitable anaesthesia, the cervix (mouth of uterus) is dilated (opened with mechanical force) and the contents are gently removed by suction. A medication called oxytocin / prostaglandin may be given at the same time for contraction of uterus. Before evacuation your gynaecologist may ask for reserving 1 bag of blood in the blood bank.
Hyper emesis gravid arum/ Severe Vomiting:
This is a condition where the normal nausea and vomiting of pregnancy is greatly exaggerated. The patient is unable to eat anything and can become dehydrated. This is commonly seen in twins. Treatment is with intravenous fluid and medicines to reduce vomiting. Vitamin B6 injections are also useful.
How often severe vomiting does occurs?
The severe form of vomiting occurs in one in every 300 pregnant women.
What can cause severe vomiting?
- It is not known for certain but probably related to the high level of hCG hormone and estrogens.
- It is more common in multiple pregnancies and during first pregnancy.
- Molar pregnancy is associated with high levels of hCG hormone, causing excessive vomiting.
How to arrive at the diagnosis?
- CBC – complete blood count.
- Blood group and Rh typing.
- Serum Beta hCG levels.
- Serum electrolytes may be abnormal.
- Serum thyroid tests.
- Urine test: urine test for ketone bodies, a sign of starvation.
- Liver function tests (may be abnormal)
- Blood sugar level (may be low).
For confirmation of pregnancy and to rule out molar pregnancy.
- After ruling out molar pregnancy and gastro-intestinal disturbances and hepatitis depending on the severity of the problem, your obstetrician will treat you.
- For mild cases, rest and antacid treatment will do.
- For moderate cases, rest, antacid and occasionally anti-emetic like dicyclomine or Vit. B6 (pyridoxine) is given. Adequate amount of fluids must be ingested. It is advisable to have juices, lemon water in good quantity.
- Severe cases need hospitalisation where the pregnant woman needs to be given fluids and nutrition through intravenous line.
If the mother has suffered an infection or has been exposed to radiation, the baby may develop congenital defects. Either an amniotic fluid sampling or ultrasound may diagnose this. Taking folic acid supplements can avoid defects known as neural tube defects.
Early diagnosis and prompt meticulous treatment prevents complications.