Early Pregnancy Complications

Bleeding

Vaginal bleeding or spotting during pregnancy can have many causes. Some are serious and some are not.

Many women have vaginal spotting or bleeding in the first 12 weeks of pregnancy. Bleeding of the cervix may occur during sex. An infection of the cervix also can cause bleeding. Slight bleeding often stops on its own.

A blood test may be done to measure Human Chorionic Gonadotropin (hCG). Your blood type also will be checked to see if you need treatment for Rh sensitization. Ultrasound may be used to find the cause of the bleeding. Sometimes the cause is not found.

Miscarriage

Miscarriage can occur any time in the first half of pregnancy. More than 80% of miscarriages occur within the first three months of pregnancy. Miscarriages are less likely to occur after 20 weeks gestation; these are termed late miscarriages.

Symptoms of a Miscarriage include:

–     Bleeding which progresses from light to heavy and passing of tissues.

–     Cramps felt low in the abdomen (often stronger than menstrual cramps).

–     Abdominal pain.

–     Fever.

–     Weakness.

–     Back pain.

Causes Miscarriage

–     Most miscarriages happen when the unborn baby has fatal genetic problems. Usually, these problems are unrelated to the mother.

–     Infection.

–     Medical conditions in the mother, such as diabetes or thyroid disease.

–     Hormone problems.

–     Immune system responses.

–     Physical problems in the mother.

–     Uterine abnormalities.

–     A woman has a higher risk of miscarriage if she is over age 35.

–     Has certain diseases, such as diabetes or thyroid problems.

–     Has had three or more miscarriages.

Cervical Insufficiency

A miscarriage sometimes happens because there is a weakness of the cervix, called an incompetent cervix, which cannot hold the pregnancy. A miscarriage from an incompetent cervix usually occurs in the second trimester.

There are usually few symptoms before a miscarriage caused by cervical insufficiency. A woman may feel sudden pressure, her “water” may break, and tissue from the fetus and placenta may be expelled without much pain. An incompetent cervix can usually be treated with a “circling” stitch in the cervix in the next pregnancy, usually around 12 weeks. The stitch holds the cervix closed until it is pulled out around the time of delivery. The stitch may also be placed even if there has not been a previous miscarriage if cervical insufficiency is discovered early enough, before a miscarriage does occur.

How is a Miscarriage Diagnosed and Treated?

Your healthcare provider will perform a pelvic exam, an ultrasound test and blood work to confirm a miscarriage. If the miscarriage is complete and the uterus is empty, then no further treatment is usually required. Occasionally, the uterus is not completely emptied, so a dilation and curettage (D&C) procedure is performed. During this procedure, the cervix is dilated and any remaining fetal or placental tissue is gently removed from the uterus. As an alternative to a D&C, certain medications can be given to cause your body to expel the contents in the uterus. This option may be more ideal in someone who wants to avoid surgery and whose condition is otherwise stable.

Blood work to determine the amount of a pregnancy hormone (hCG) is checked to monitor the progress of the miscarriage.

When the bleeding stops, usually you will be able to continue with your normal activities. If the cervix is dilated, you may be diagnosed with an incompetent cervix and a procedure to close the cervix (called cerclage) may be performed if the pregnancy is still viable. If your blood type is Rh negative, your doctor may give you a blood product called Rh immune globulin (Rhogam). This prevents you from developing antibodies that could harm your baby as well as any of your future pregnancies.

Blood tests, genetic tests, or medication may be necessary if a woman has more than two miscarriages in a row (called recurrent miscarriage). Some diagnostic procedures used to evaluate the cause of repeated miscarriage include pelvic ultrasound, hysterosalpingogram (an X-ray of the uterus and fallopian tubes), and hysteroscopy (a test in which the doctor views the inside of the uterus with a thin, telescope-like device inserted through the vagina and cervix).

How do I know if I had a Miscarriage?

Bleeding and mild discomfort are common symptoms after a miscarriage. If you have heavy bleeding with fever, chills, or pain, contact your healthcare provider right away. These may be signs of an infection.

How long will I have to wait before I can try again?

Some healthcare providers recommend waiting a certain amount of time (from one menstrual cycle to 3 months) before trying to conceive again. To prevent another miscarriage, your healthcare provider may recommend treatment with progesterone, a hormone needed for implantation and early support of a pregnancy in the uterus.

Taking time to heal both physically and emotionally after a miscarriage is important. Above all, don’t blame yourself for the miscarriage.

Counseling is available to help you cope with your loss. Pregnancy loss support groups may also be a valuable resource to you and your partner. Ask your healthcare provider for more information about these resources.

Can a Miscarriage be prevented?

Usually a miscarriage cannot be prevented and often occurs because the pregnancy is not normal. If a specific problem is identified with testing, then treatment options may be available.

Sometimes, treatment of a mother’s illness can improve the chances for a successful pregnancy.

Molar Pregnancy

A molar pregnancy — also known as hydatidiform mole — is a non-cancerous (benign) tumor that develops in the uterus. A molar pregnancy starts when an egg is fertilized, but instead of a normal, viable pregnancy resulting, the placenta develops into an abnormal mass of cysts.

In a complete molar pregnancy, there’s no embryo or normal placental tissue. In a partial molar pregnancy, there’s an abnormal embryo and possibly some normal placental tissue. The embryo begins to develop but is malformed and can’t survive.

A molar pregnancy can have serious complications — including a rare form of cancer — and requires early treatment.

Complete molar pregnancy

Complete molar pregnancies have only placental parts (there is no baby), and form when the sperm fertilizes an empty egg. Because the egg is empty, no baby is formed. The placenta grows and produces the pregnancy hormone, hCG. Unfortunately, an ultrasound will show that there is no fetus, only a placenta.

Partial molar pregnancy

Partial Mole occurs when the mass contains both the abnormal cells and an embryo that has severe birth defects. In this case the fetus will be overcome by the growing abnormal mass rather quickly.

An extremely rare version of a partial mole is when twins are conceived but one embryo begins to develop normally while the other is a mole. In these cases, the healthy embryo will very quickly be consumed by the abnormal growth.

Risk

–     In the US, approximately 1 out of 1,000 pregnancies is a molar pregnancy.

–     Mexico, Southeast Asia, and the Philippines have higher rates than the US for molar pregnancies in women.

–     White women in the US are at higher risk than black women.

–     Women over the age of 40.

–     Women who have had a prior molar pregnancy.

–     Women with a history of miscarriage.

Causes

A molar pregnancy is caused by an abnormally fertilized egg. Human cells normally contain 23 pairs of chromosomes. One chromosome in each pair comes from the father, the other from the mother. In a complete molar pregnancy, all of the fertilized egg’s chromosomes come from the father. Shortly after fertilization, the chromosomes from the mother’s egg are lost or inactivated and the father’s chromosomes are duplicated. The egg may have had an inactive nucleus or no nucleus.

In a partial or incomplete molar pregnancy, the mother’s chromosomes remain but the father provides two sets of chromosomes. As a result, the embryo has 69 chromosomes instead of 46. This can happen when the father’s chromosomes are duplicated or if two sperm fertilize a single egg.

Symptoms

A molar pregnancy may seem like a normal pregnancy at first, but most molar pregnancies cause specific signs and symptoms, including:

–     Dark brown to bright red vaginal bleeding during the first trimester.

–     Severe nausea and vomiting.

–     Sometimes vaginal passage of grape-like cysts.

–     Rarely pelvic pressure or pain.

If you experience any signs or symptoms of a molar pregnancy, consult your doctor or pregnancy care provider. He or she may detect other signs of a molar pregnancy, such as:

–     Rapid uterine growth – the uterus is too large for the stage of pregnancy.

–     High blood pressure.

–     Preeclampsia – a condition that causes high blood pressure and protein in the urine after 20 weeks of pregnancy.

–     Ovarian cysts.

–     Anemia.

–     Overactive thyroid (hyperthyroidism).

Diagnosis

A pelvic exam may reveal a larger or smaller uterus, enlarged ovaries, and abnormally high amounts of the pregnancy hormone hCG.

A sonogram will often show a “cluster of grapes” appearance, signifying an abnormal placenta.

Treatment

–     Most molar pregnancies will spontaneously end and the expelled tissue will appear grape-like.

–     Molar pregnancies are removed by suction curettage, dilation and evacuation (D&C), or sometimes through medication. General anesthetic is normally used during these procedures.

–     Approximately 90% of women who have a mole removed require no further treatment.

–     Follow-up procedures that monitor the hCG levels can occur monthly for six months or as your physician prescribes.

–     Follow-up is done to ensure that the mole has been removed completely. Traces of the mole can begin to grow again and may possess a cancerous-type threat to other parts of the body.

–     Pregnancy should be avoided for one year after a molar pregnancy.

–     Any birth control method is acceptable with the exception of an intrauterine device.

Complications

After a molar pregnancy has been removed, molar tissue may remain and continue to grow. This is called persistent Gestational Trophoblastic Disease (GTD). It occurs in about 1 of every 5 women after a molar pregnancy – usually after a complete mole rather than a partial mole.

One sign of persistent GTD is when the level of Human Chorionic Gonadotropin (HCG) – a pregnancy hormone – remains high after the molar pregnancy has been removed. In some cases, an invasive mole penetrates deep into the middle layer of the uterine wall, which causes vaginal bleeding. Persistent GTD can nearly always be successfully treated, most often with chemotherapy. Another treatment option is removal of the uterus (hysterectomy).

Rarely, a cancerous form of GTD known as choriocarcinoma develops and spreads to other organs. Choriocarcinoma is usually successfully treated with multiple cancer drugs.

Ectopic Pregnancy

Occurs when a fertilized egg implants somewhere other than the main cavity of the uterus. Pregnancy begins with a fertilized egg. Normally, the fertilized egg attaches itself to the lining of the uterus.

An ectopic pregnancy most often occurs in one of the tubes that carry eggs from the ovaries to the uterus (fallopian tubes). This type of ectopic pregnancy is known as a tubal pregnancy. In some cases, however, an ectopic pregnancy occurs in the abdominal cavity, ovary or neck of the uterus (cervix).

An ectopic pregnancy can’t proceed normally. The fertilized egg can’t survive, and the growing tissue might destroy various maternal structures. Left untreated, life-threatening blood loss is possible.

Symptoms of an Ectopic Pregnancy

–     Light vaginal bleeding.

–     Nausea and vomiting with pain.

–     Lower abdominal pain.

–     Sharp abdominal cramps.

–     Pain on one side of your body.

–     Dizziness or weakness.

–     Pain in your shoulder, neck, or rectum.

–     If the fallopian tube ruptures, the pain and bleeding could be severe enough to cause fainting.

Causes of an Ectopic Pregnancy

One cause of an ectopic pregnancy is a damaged fallopian tube that doesn’t let a fertilized egg into your uterus, so it implants in the fallopian tube or somewhere else.

You might not ever know what caused an ectopic pregnancy. But you are higher risk if you have:

–     Current use of an Intrauterine Device (IUD), a form of birth control.

–     History of Pelvic Inflammatory Disease (PID).

–     Sexually-transmitted diseases such as chlamydia and gonorrhea.

–     Congenital abnormality (problem present at birth) of the fallopian tube.

–     History of pelvic surgery (because scarring may block the fertilized egg from leaving the fallopian tube).

–     History of ectopic pregnancy.

–     Unsuccessful tubal ligation (surgical sterilization) or tubal ligation reversal.

–     Use of fertility drugs.

–     Infertility treatments such as In Vitro Fertilization (IVF).

Diagnosing an Ectopic Pregnancy

–     Pregnancy test.

–     Pelvic exam.

–     Ultrasound test may be performed to view the uterus’ condition and fallopian tubes.

Treating an Ectopic Pregnancy

If fallopian tube has ruptured, emergency surgery is necessary to stop the bleeding. In some cases, the fallopian tube and ovary may be damaged and will have to be removed.

If the fallopian tube has not ruptured and the pregnancy has not progressed very far, laparoscopic surgery may be all that is needed to remove the embryo and repair the damage. A laparoscope is a thin, flexible instrument inserted through small incisions in the abdomen. During this surgery, a tiny incision is made in the fallopian tube and the embryo is removed, preserving the fallopian tube’s integrity.

In some cases, medication may be used to stop the growth of pregnancy tissue. This treatment option may be appropriate if the tube is not ruptured and the pregnancy has not progressed very far.

After medical treatment for an ectopic pregnancy, you will usually have to have additional blood tests to make sure that the entire tubal pregnancy was removed. The blood tests detect the hCG level, the hormone that is produced during pregnancy.

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