This is always abnormal and patients may need to be admitted or referred. The commonest cause of bleeding in the first six months (<26 weeks gestation) is abortion

Abortion (miscarriage)

Loss of products of conception before 28 weeks of pregnancy

Cause

• Not known in the majority of patients
• May be intentional (induced abortion)
• May be spontaneous (often as a result of fever)

Clinical features

• Depend on the cause and stage of the abortion

Threatened abortion

Little vaginal bleeding and may be no lower abdominal pain. Pregnancy may still continue. Uterus is of size expected by dates and cervix is closed

Inevitable abortion

Process irreversible, contractions (pain similar to labour pains) and bleeding, cervix may proceed to open

Complete abortion

All uterine contents have been passed out, little bleeding, cervix closed. Uterus empty and reduced in size

Incomplete abortion

Uterine contents not completely passed out, bleeding sometimes with clots from the vagina (may be severe), severe lower abdominal cramps, cervix open and products of conception may be felt in the cervical canal

Septic abortion

Incomplete abortion with infection (often criminal): fever, offensive vaginal discharge, lower abdominal pain and tenderness on palpating the abdomen

Missed abortion

Foetus died, contents of the uterus not expelled, may be dark blood drops (spotting) from the vagina, uterus smaller than expected by dates

Molar abortion

Abnormal placenta, no foetus, vaginal bleeding and passing of red material like ripe coffee berries, uterus much bigger than expected, mother feels no foetal movements even after five months

Habitual abortion

More than two consecutive, spontaneous abortions - usually associated with incompetent cervix

Differential diagnosis

• Pregnancy outside the uterus (ectopic pregnancy)
• Other causes of bleeding from the vagina, eg. cancer
• Other causes of lower abdominal pain

Investigations

Urine: pregnancy test
Ultrasound
Blood: complete count

Management

Complete abortion

HC2

Bed rest

If patient in shock:

Resuscitate with IV fluids (see p354)

If anaemic:

Refer to HC4 for replacement of blood loss
Treat anaemia (see p154)

Threatened abortion

HC4

Bed rest
Abstain from sex for at least 14 days
Observation

For pain:

paracetamol 1g every 6-8 hours prn for 5 days

Incomplete abortion

HC2

methylergometrine 200-400 micrograms IM or IV stat

If signs of infection:

amoxicillin 500mg every 6 hours for 7 days
plus metronidazole 400mg every 8 hours for 7 days
Refer for manual vacuum aspiration evacuation of uterus

Septic abortion

HC4

Give 7-day course of antibiotics as in incomplete abortion (above)
Evacuate the uterus

Missed abortion

HC4

Refer to hospital

Molar abortion

HC4

Resuscitate and give methylergometrine as in incomplete abortion (above)
Refer to hospital for further management