Powys Teaching Local Health Board
Directorate: Women and Children’s Service
Author: Lewis, Owen, Revell / Title: Guidelines for Bleeding in Early Pregnancy
Code: to be completed by Q&S Unit if new policy

Guideline for Bleeding in Early Pregnancy

Document
Code
/
Date
/ Version Number / Planned Review Date
Jan 2012 / First Issue / Jan 2015
Document Owner / Approved by / Date
Women’s and Children’s Directorate / Women’s and Children’s Directorate
Clinical Effectiveness Committee / 26/01/12
16/04/12
Document Type / Guidelines

Bwrdd Iechyd Addysgu Powys yw enw gweithredol Bwrdd Iechyd Lleol Addysgu Powys

Powys Teaching Health Board id the operational name of Powys Teaching Local Health Board

Guideline for Bleeding in Early Pregnancy

Contents / Page
Validation Form / 3
Equality Assessment / 4
Relevant to / 5
Purpose / 5
Definitions / 5
Responsibilities / 5
Process / 5
References / 5
Appendices

For Reviewed / Updated Policies Only:

Relevant Changes – / Date
e.g. NICE Guidelines 2011

VALIDATION FORM

To be completed by the Author – no policy, procedure or guidance will be accepted without completion of this section which must remain part of the policy

Title: Guidelines for Bleeding in Early Pregnancy
Author:Marie Lewis Practice Development Midwife, Donna Owen – Lead Midwife North Powys, Denise Revell Integrated Midwife
Directorate:Women and Children’s Service
Reviewed/Updated by: new
Evidence Base
Are there national guidelines, policies, legislation or standards relating to this subject area?
Association of Early Pregnancy Units (AEPU). (2011)
Chalmers B.Terminology used in early pregnancy loss. Br J Obstet Gynaecol 1992;99:357–8.
Love ER, Bhattacharya S, SmithNC, Bhattacharya S. Effect of interpregnancy interval on outcomes of pregnancy after miscarriage: retrospective analysis of hospital episode statistics in Scotland.BMJ 2010;341:c3967
RoyalCollege of Obstetricians and Gynaecologists (2006). The Management of Early Pregnancy Loss. Guideline No. 25, RCOG, London
CONSULTATION
Please list the groups, specialists or individuals involved in the development & consultation process:
Name / Date
Powys Midwives / 26.1.2012
Supervisor of Midwives / 26.1.2012
Practice Development Midwife / 26.1.2012
Agreed by Women’s and Children’s Directorate / 26.1.2012
Agreed by Head of Midwifery / 26.1.2012
Please insert the name of the Directorate/ Departmental/Discipline Committee or Group that has approved this policy/procedure/guidelines/protocol
Name / Date
Women’s and Children’s Directorate / 26/01/12
Clinical Effectiveness / 16/04/12
Implications
Please state any training implications as a result of implementing the policy / procedure.
. None
Please state any resource implications associated with the implementation.
No Additional Resources required
Please state any other implications which may arise from the implementation of this policy/procedure.
  • none

For Completion by Quality & Safety Unit
Checked by: / Date:
Submitted to CEC: / Date:

Equality Assessment StatementPlease complete the following table to state whether the following groups will be adversely, positively, differentially affected by the policy or that the policy will have no affect at all

Equality statement
No impact / Adverse / Differential / Positive / Comments
Age / X
Disability / X
Gender / X / Women focussed midwifery policy
Race / X
Religion/ Belief / X
Sexual Orientation / X
Welsh Language / X
Human Rights / X
Risk Assessment
Are there any new or additional risks arising from the implementation of this policy?
  • n/a

Do you believe that they are adequately controlled?
  • n/a

Relevant to:

Local guideline for all midwives working in Powys.

Purpose:

The overall aim must be to provide safe and effective care to a women in early pregnancy, whilst allowing her to make an informed choice from the care options available to her.

Responsibilities

All midwives working within Powys hold a recognised midwifery qualification. No additional qualifications are required to carry out this policy. Midwives will be required to attend yearly obstetric emergency drills as part of their midwifery updates.

Monitoring

This policy will be monitored through clinical midwifery supervision, issues raised through training days and the Datix reporting system.

Process:

Introduction

Around 1 in 5-10 women experience some bleeding during pregnancy (Miscarriage Association 2011). In the first trimester bleeding can be a sign of miscarriage, ectopic pregnancy, intrauterine fetal demise and cervical problems, although often the cause is never identified. Miscarriage occurs in 10–20% of clinical pregnanciesand accounts for 50,000 inpatient admissions to hospitals in the UK annually (RCOG 2006).

The main causes of miscarriage are thought to be:

  • Genetic: In about half of all early miscarriages, the embryo does not develop normally right from the start and cannot survive.
  • Hormonal: Women with very irregular periods may find it harder to conceive and when they do, are more likely to miscarry.
  • Immunological/ blood-clotting: Problems in the blood vessels which supply the placenta can lead to miscarriage, especially if the blood clots more than it should.
  • Infection: Minor infections like coughs and colds are not harmful, but a very high temperature and some illnesses or infections, such as German measles, may cause miscarriage.
  • Anatomical: There are three main anatomical causes of miscarriage:

If the cervix (the bottom of the uterus) is weak, it may start to open as the uterus becomes heavier in later pregnancy and this may lead to miscarriage.

If your uterus has an irregular shape, there may not be enough room for the baby to grow.

Large fibroids (harmless growths in the uterus) may cause miscarriage in later pregnancy. (Miscarriage Association 2011)

Terminology

When talking to women, the inadvertent use of inappropriate terms such as ‘pregnancy failure’, or ‘incompetentcervix’ can contribute to negative self-perceptions and worsen any sense of failure, guilt, shame and insecurity. The recommended medical term for pregnancy loss less than 24 weeks is ‘miscarriage’, and this should be used in clinical practice. (RCOG 2006).

The Following Terms Are Recommended:

Previous Term / Recommended Term
Spontaneous abortion / Miscarriage
Threatened abortion / Threatened miscarriage
Inevitable abortion / Inevitable miscarriage
Incomplete abortion / Incomplete miscarriage
Complete abortion / Complete miscarriage
Missed abortion / Missed miscarriage
Anembryonic pregnancy/blighted ovum (these reflect different stages in the same process) / Delayed miscarriage
Silent miscarriage
Septic abortion / Miscarriage with infection (sepsis)
Recurrent abortion / Recurrent miscarriage

Signs and Symptoms:

  • Pain which may be a dull ache or strong abdominal cramps, or sharp and severe (especially if an ectopic pregnancy)
  • Bleeding which may be heavy, or a brown vaginal discharge (‘spotting’)
  • No symptoms at all

Any episodes of bleeding following a positive pregnancy test should be treated as suspicious until investigations have proved otherwise. Midwives should ensure that all women with early pregnancy problems have access to a local Early Pregnancy Unit where the following may be carried out.

  • USS – (Usually transvaginal). Even with expert use it may not be possible to confirm if a pregnancy is intrauterine or extra uterine in 8-31% of cases at the first visit and viability will be uncertain in approximately 10% of intrauterine pregnancies on the first visit.
  • hCG Assessment – essential for diagnosis of asymptomatic ectopic pregnancy. Results should be available within 24 hours.
  • Serum Progesterone Levels – may be useful when ultrasound suggests a pregnancy of an unknown location. However active intervention should not be undertaken based on low initial progesterone.
  • Screening for Rhesus status if not known – non-sensitised rhesus (RH) negative women should receive anti-D in the following situations:

Ectopic pregnancy

All miscarriages over 12 weeks (including threatened)

Miscarriages where the uterus is evacuated either medically or surgically.

Threatened miscarriage under 12 weeks when bleeding is heavy or associated with pain.

Screening for infection, including Chlamydia and bacterial vaginosis, should be considered for women undergoing surgical uterine evacuation.

Women who are seen in the early pregnancy assessment unit may be treated in the following ways:

  • Expectant Management – an effective and acceptable method to offer in selected cases of confirmed first trimester miscarriage. Women should be aware that complete resolution may take several weeks, and overall efficacy rates are lower. Expectant management for incomplete miscarriage is highly effective.
  • Medical Management – an effective alternative for confirmed first trimester miscarriages. Women should be advised that bleeding may continue for up to 3 weeks afterwards. Efficacy rates vary from 13-96%. Misoprostol can be given orally or vaginally, and medical evacuation has been undertaken successfully on an outpatient basis. An increase in pain and bleeding may be a negative factor influencing choice, although many women are keen to avoid a general anaesthetic.
  • Surgical Uterine Evacuation (ERPC) – should be offered to women who prefer that option. Clinical indications include persistent excessive bleeding, haemodynamic instability, evidence of infected retained tissue and suspected gestational trophoblastic disease.
  • Antibiotic Prophylaxis – should be given based on individual clinical indications.

Follow Up

Many women go on to have healthy pregnancies following an early pregnancy loss. Women who conceive within six months of an initial miscarriage have the best reproductive outcomes and lowest complication rates in a subsequent pregnancy [Lover et al 2010]. Usual advice regarding smoking, diet, healthy lifestyle and folic acid should be given. Women should be offered contact telephone numbers in case of ongoing problems, as well as contact details for local midwives for future pregnancy.

Also refer to the following guidelines:

Antenatal care

All Wales Birth Centre Guidelines

Routine administration of Routine Anti-D

Useful contacts:

Miscarriage Association 01924 200799

Tommy’s Campaign 0800 0147 800

References:

Association of Early Pregnancy Units (AEPU). (2011)

Chalmers B.Terminology used in early pregnancy loss. Br J Obstet Gynaecol 1992;99:357–8.

Love ER, Bhattacharya S, SmithNC, Bhattacharya S. Effect of interpregnancy interval on outcomes of pregnancy after miscarriage: retrospective analysis of hospital episode statisticsin Scotland.BMJ 2010;341:c3967

RoyalCollege of Obstetricians and Gynaecologists (2006). The Management of Early Pregnancy Loss. Guideline No. 25, RCOG,London

The Miscarriage Association. 2011

Issue Date: 2011
Status: Final / Page 1 of 9 / Review Date: 2015
Approved by Clinical Effectiveness Committee 16/04/2012