Pregnancy is a wonderful condition that ensures the continuation of the human race. Most pregnancies are planned and the conception takes place is a controlled environment with the willing consent of both parties. The outcome is, most often, a healthy child or two that makes the parents proud and happy. But that is not always the case.
It is a rare day in the emergency department that we do not have to deal with a complication of at least one pregnancy. Sometimes the complications are social – the pregnancy is not wanted for whatever reason; or it is in a single, young teenager who is bewildered and afraid; or the mother has been brutally bashed and often kicked in the abdomen by a drug or alcohol crazed partner; or the mother has been involved in a motor vehicle smash; or a miscarriage threatens.
Sorting out these problems often requires the services of a social worker rather than a doctor and we try to analyse the problem and make the appropriate arrangements. Sometimes the police become involved and sort out the violence issues one way or another. Sometimes we have to decide if the foetus is at risk and take appropriate action. One of the most common problems of pregnancy we are faced with is the threatened miscarriage in the first trimester - the first three months of the pregnancy.
The young woman usually knows she is pregnant and presents to us with vaginal bleeding with or without pain. We take a medical and obstetric history and do a very gentle external examination. We do not do an internal examination for fear of exacerbating an already precarious situation. If we find heavy bleeding, blood clots, solid tissue or a foetal sac then all is lost and admission to hospital is usually mandatory.
If these sinister signs are not present then there are two simple laboratory investigations that determine the course of action. The first is a blood test called a quantitative beta-HCG. This measures the level, in the circulating blood, of a hormone called human chorionic gonadotrophin. It is produced by the developing placenta and can usually be detected in the blood stream at about ten days after conception. It is this hormone that is tested for in the common pregnancy test. A pregnancy test simply determines if the hormone is present or not. The quantitative test measures the level of hormone present in the bloodstream and this can be correlated to the duration of the pregnancy although interpretation does require caution. If the levels do correlate with the date of the last period then it is a fairly good indicator that the pregnancy is viable. Serial tests over a week or more give a clearer picture.
The other investigation is ultrasound. A probe placed on the abdomen bounces sound waves off the uterus and contents projecting a picture onto a screen. (Sometimes, especially in very early pregnancy, the probe may be placed into the vagina to give a clearer picture.) This can detect a pregnancy as early as 40 days after conception but is more reliable after six weeks when the baby’s heart beat can be detected. If this is found then the pregnancy is definitely still viable. Again, serial tests over a week or two give a clearer picture.
On a good day during working hours we can usually have all of this done within 4 to 6 hours and then discuss where to from there with the parents. Most often, with a simple bleed, she can go home, rest completely and the bleeding settles down. Occasionally we advise admission to hospital for close observation in the hope it will settle down. If the history, examination and tests indicate the foetus has died then the patient will usually be admitted.
This is all straight forward stuff. Where the pregnancy has failed we offer follow up by an obstetrician and counselling. It becomes difficult when the pregnancy is the patient’s first and very difficult when the patient is the victim of recurrent miscarriages. In these cases we need to be extra specially gentle and caring taking the time to explain things and listening to the patients express their feelings and fears and answering their questions. Single miscarriages are extremely common and, with first pregnancies and in the absence of any known pathology, we can confidently predict a normal later pregnancy. Some women have multiple miscarriages and no normal pregnancies. Others have both.
One such patient who presented with vaginal bleeding in early pregnancy previously had two normal pregnancies and seven miscarriages. In the medical notes this is recorded in shorthand as P2G9. I had to inform her, later, that the blood tests and ultrasound indicated that the pregnancy was not viable. She was philosophical about it all. Grateful she had two healthy children, wanting more, but resigned to the fact it was probably not going to happen given the recurrent miscarriages. I arranged for her obstetrician to see her that day.
Ultrasound examinations are now routine in pregnancy. They are extremely helpful in accurately determining the age of the foetus and its growth rate, detecting twins, conjoined twins (called Siamese twins in days gone by), developmental abnormalities and placenta praevia. This latter condition occurs when the placenta completely or partially lies across the cervical outlet – the only way the baby can get out of the uterus naturally. When this condition is detected the baby will most often be delivered by Caesarian section. If it is not detected then both mother and baby are at extreme risk from haemorrhage if the placenta tears in labour – or earlier.
These days it is rarely that haemorrhage from placenta praevia will present in ED but it is always a possibility. Vaginal bleeding in pregnancy from six months onward is considered due to placenta praevia until proven otherwise. Unfortunately, it is most likely to present in circumstances least likely to have a favourable outcome. That is in patients who have not had proper ante-natal care and therefore no ultrasounds. That is most likely in remote, isolated places where sophisticated emergency services do not exist.
Pregnant women present to us with conditions that may or may not be a consequence of the pregnancy. I saw a young lady, twenty eight weeks into her second pregnancy, who had a dreadful, extremely itchy rash all over her body and limbs. She was on holidays from a distant, country town. She emphatically informed me she had the same condition at the same time in her first pregnancy. The poor girl scratched incessantly as I examined her. The skin was red, inflamed and there were scratch marks everywhere. It resembled no rash I had ever seen previously. It did not resemble scabies either and she was not jaundiced (yellow). She did not feel ill with it and, on careful questioning, I could identify no allergen of any type.
The uterus was the right size for her dates and the foetal heart was beating away exactly as it should. The babe even moved a few times during the examination which was an entirely normal thing for it to do. I was perplexed and she was agitated and for that I could not blame her. She repeatedly stated it had gone on for months last time and driven her almost mad and she did not want to go through that again. Then I recalled a colleague who was in the same year as me in medical school. He had gone on to specialize in the medical illnesses related to pregnancy. I rang him and described my patient’s condition. After careful questioning he advised me the condition was most likely one known as the polymorphic eruption of pregnancy and would respond to certain treatment which he described for me.
I wrote the prescription, explained the condition as well as I could and told her about my colleague and his qualifications. I gave her a letter for her country GP which included reference to my colleague. I advised her to start treatment immediately and to return if it did not have an effect within 24 hours. I never saw her again and hope it was because the treatment was effective.
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