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Antenatal Care Module: 20. Abortion and other Causes of Early Pregnancy Bleeding
Study Session 20 Abortion and other Causes of Early Pregnancy Bleeding
Introduction
In this study session you will learn about the main causes of early pregnancy bleeding, that is when a woman bleeds while pregnant and before 28 weeks, which should not happen normally. Abortion is one of the most common causes of early pregnancy bleeding and is an important cause of maternal mortality and morbidity globally. In addition, about 15 out of 100 pregnancies end in spontaneous abortion (miscarriage). You will learn how to classify abortions so you can give appropriate care, and about the legal aspects of abortion in Ethiopia and safe methods of abortion used in health facilities. Ectopic and molar pregnancies are the other main causes of early pregnancy bleeding. A woman can have serious health problems when a pregnancy ends early, so you need to know about the warning signs. The session ends with guidance on pre-referral emergency care that could save a woman’s life, and post-abortion counselling and family planning, which are important aspects of your role.
Learning Outcomes for Study Session 20
When you have studied this session, you should be able to:
20.1 Define and use correctly all of the key words printed in bold. (SAQ 20.1)
20.2 Describe common causes of bleeding in early pregnancy. (SAQ 20.2)
20.3 Describe the clinical classifications of abortion, the legal aspects of abortion in Ethiopia, and the safe methods used in health facilities. (SAQ 20.1)
20.4 Identify the warning signs and the emergency treatment required before referral for early pregnancy bleeding. (SAQ 20.2)
20.5 Describe the features of woman-friendly comprehensive post-abortion care, including the post-abortion family planning service. (SAQs 20.1 and 20.3)
20.1 What is early pregnancy bleeding?
Bleeding before 28 weeks of pregnancy is considered as early pregnancy bleeding. If it occurs after 28 weeks it is referred to as late pregnancy bleeding. This cut-off-point of 28 weeks is based on the chance of survival if the baby is born before the expected date at 28 weeks. Survival before 28 weeks is very minimal in countries like Ethiopia where there is a shortage of intensive care facilities for premature babies. Nowadays some countries have brought the cut off point to 20 weeks because of the increased chance of survival due to the improved care and technology their health system provides.
The main cause of early pregnancy bleeding is abortion, the ending of a pregnancy early with the loss of the fetus. Two other common causes are ectopic pregnancy (when the fetus implants and grows outside the uterus), and molar pregnancy (when a tumour grows in the uterus instead of a fetus). We will refer to both of these problems near the end of this study session, but our main focus will be on abortion.
20.2 Abortion
20.2.1 Spontaneous abortion
Spontaneous abortion (also known as a miscarriage) occurs naturally in 15% of pregnancies, often so early that the woman may not even realise that she was pregnant. However, spontaneous abortion may sometimes lead to heavy bleeding and threaten the woman’s life. Sexually transmitted infections, injury, violence, malaria and stress all can cause a pregnancy to end early. Sometimes miscarriages happen because a woman has been near poisons or toxic chemicals. It is not easy to know why a miscarriage happens all the time, but some causes of miscarriage are preventable. Some miscarriages can be prevented by treating women for illness and infection and by helping them to avoid chemical poisons and violence. But some women have one miscarriage after another, and you may not know why.
Women with a history of repeated miscarriages should be treated in a health facility with specialised services to find the cause and to help them carry this pregnancy all the way through.
20.2.2 Induced abortion
Unplanned and unwanted pregnancies, especially in adolescent girls, may result in the woman resorting to an induced abortion (deliberate termination of the pregnancy). Under certain conditions in some countries, a legal abortion may be induced safely in a health facility by trained health professionals. This procedure will not usually endanger a woman’s future pregnancies. The legal position in Ethiopia and the allowable methods of safe abortion are covered in Section 20.2.4 of this study session.
An unsafe abortion is a termination induced by the woman herself or by an unskilled person in an unhygienic environment (Figure 20.1).
A woman who was sick, injured or bled heavily after an abortion may have scars in her uterus that could cause problems for later pregnancies. Death from unsafe abortion is one of leading causes of mortality and morbidity globally and especially in developing countries. In Ethiopia it is an important cause of maternal death and needs to be addressed to reduce the high maternal mortality in the country.
Do you recall the Ethiopian maternal mortality ratio (MMR) from Study Session 1?
The 2005 Ethiopian Demographic Health Survey reported that 673 women died in every 100,000 live births. That is at least 22,000 women dying from causes related to pregnancy or childbirth every year.
20.2.3 Clinical classification of abortion
The outcomes of either a spontaneous or induced abortion are classified based on clinical presentation, as judged by the health care provider. It is important for you to know the different categories, because how you treat the woman depends on the clinical classification.
Complete abortion
A complete abortion means that all parts of the fetus and placenta have been expelled through the vagina; nothing is left behind in the uterus and the cervix has closed. No treatment procedure to evacuate (empty) the uterus is usually necessary. After a complete abortion which has been safely induced, the woman may feel light cramping pains in her abdomen, and bleeding from her vagina should be no more than during a normal menstrual period.
If bleeding is light to moderate, and there is fetal tissue protruding through the mouth of the uterus, you can gently remove it with a sterile gloved finger. Do not attempt to do this until you have completed your practical training in this competency. Give the woman 400µg (micrograms) of misoprostol orally before you refer her to the nearest health facility.
Incomplete abortion
An incomplete abortion is when part of the fetal tissue or placenta is still in the uterus and the cervix is open. If you leave an incomplete abortion without treatment for some time there is an increased risk that it will be complicated with infection and this could be life-threatening for the woman.
When you attend the practical skills training associated with this study session you will see how the tissue left behind in the uterus can be removed with instruments, using a technique called evacuation and curettage. You will also learn how to give drugs to the woman by mouth (orally) and by injection into the muscles of her thigh or buttocks (intramuscular injection, or IM) to assist this process.
Threatened abortion
When a pregnancy is complicated by bleeding from the vagina, but the cervix is closed, this may signal a threatened abortion. There is a chance that the pregnancy may continue normally, provided the fetus is showing signs of life.
If you suspect an abortion is threatened, refer the woman to the nearest health facility, where they may be able to preserve the pregnancy.
Inevitable abortion
An inevitable abortion is when the fetus is entirely in the uterus, but the pregnancy will definitely end in the expulsion of the fetus. Often the woman has lower abdominal pain and a cervical change called effacement, when the cervix has pulled back and become thinner; then the cervix starts to dilate and open as though during a normal full-term labour. (You will learn about effacement and dilatation of the cervix in Labour and Delivery Care, the next Module in this curriculum.) The contents of the uterus will often spontaneously come out, but if this does not happen soon, you will be taught to give the woman 400 µg (micrograms) of misoprostol orally, repeated once after 4 hours if necessary. Do not attempt to do this until you have completed your practical training in this competency.
Missed abortion
When the fetus is entirely in the uterus, but it has no signs of life and the cervix is completely closed, this situation is called a missed abortion. The dead fetus is likely to be retained in the uterus for some time unless there is an intervention in a specialised health facility.
Removing a dead fetus after a missed abortion usually requires the specialised services of a district hospital, so you should make every effort to transfer the woman to the highest available health facility.
20.2.4 Legal aspects of abortion in Ethiopia
Prior to 2004, abortion was permitted in Ethiopia only to save a woman’s life, protect her health and in cases of rape. According to the new penal code, adopted in 2004, abortion is not punishable when it is performed to save a woman’s life or health; in cases of rape, incest or serious fetal impairment; or when a pregnant woman lacks the capacity to care for a child because of her young age or her deficient physical or mental health. As a step toward implementing the new law, the Ethiopian Federal Ministry of Health released guidelines for safe abortion services in June 2006, which set out basic principles and standards for the delivery of abortion care.
Semira comes to see you and says she is pregnant. She is in good health. She has no stable partner and she does not want the baby. Does Ethiopian law provide for her to have a legal abortion? Explain why or why not.
Semira is not eligible for the abortion service in Ethiopia unless she was raped, the father is a close relative (incest), or she is not able to care for the baby because of serious mental or physical illness.
20.2.5 Methods of provision of abortion
Safe induced abortion is provided in Ethiopia for women who meet the legal criteria described above and who want to end their pregnancy. The procedures are carried out at a health centre or hospital, so you should refer women seeking help from the abortion service to go to the higher health facility. The methods for provision of a legal abortion depend on the gestational age of the pregnancy and the facilities available locally. They include:
- Medical abortion: where women are given medical drugs to initiate the process of abortion
- Manual vacuum aspiration or MVA: using an instrument like a syringe operated by hand that creates a negative pressure to suck out the contents of the uterus
- Evacuation and curettage: emptying the contents of the uterus using metallic instruments to remove the fetal tissue and clean the inner walls of the uterus.
Remember that women need emotional support before, during and after an induced abortion, just as they do after a spontaneous miscarriage. In the next section, we describe the post-abortion services that you should provide to the women in your community.
20.3 Woman-centred comprehensive post-abortion care
The Ethiopian guidelines define woman-centred comprehensive post-abortion care as:
‘a comprehensive approach to providing abortion services that takes into account the various factors that influence a woman’s individual mental and physical health needs, her personal circumstances, and her ability to access services ... that support women in exercising their sexual and reproductive rights.’
(Federal Democratic Republic of Ethiopia, Technical and Procedural Guidelines for the Provision of Safe Abortion Services in Ethiopia, 2006)
20.3.1 Goals of the post-abortion service
The goals of a woman-centred comprehensive post-abortion service are to:
- Provide safe, high-quality services
- Decentralise services to the most local level possible
- Be affordable and acceptable to women
- Understand each woman’s particular social circumstances and individual needs, and tailor her care accordingly
- Reduce the number of unplanned pregnancies and abortions
- Identify and serve women with other sexual or reproductive health needs
- Be affordable and sustainable to the health system.
To achieve these goals, you have many roles to play, including recognising the individual needs and social circumstances of individual women and guiding them where to get appropriate care at the appropriate time. You also have to act effectively in response to any referral note a woman may bring back to her village from a higher level health facility.
20.3.2 Important messages for women after a spontaneous or induced abortion
Giving emotional support
When a pregnancy ends early, a woman may feel afraid, sad or upset, or she may feel guilty or ashamed. Many women, especially unmarried women, feel they must hide a miscarriage or induced abortion because of attitudes against sex, family planning or abortion in their communities. As the closest and most trusted health worker locally, you have an important role to play in sympathising for the loss of the pregnancy and providing the woman with emotional support (Figure 20.2).
If she had a spontaneous abortion, tell her that this mostly occurs because of maternal illness or problems with the developing fetus. Reassure her that the chances for a subsequent successful pregnancy are good, unless there has been infection of the uterus, or the cause of her miscarriage has not been identified and it has an effect on future pregnancies (but this is rare). If the woman wants another baby, encourage her to delay the next pregnancy until she has completely recovered from the miscarriage or abortion.
Breaking the cycle of unwanted pregnancies
Another important role is providing a family planning service to those who need it, including breaking the cycle of unwanted pregnancies and induced abortions. If pregnancy is not desired after an abortion and there are no severe complications requiring further treatment, the woman should receive adequate counselling and help in selecting the most appropriate contraceptive method that can be started immediately. Section 20.5 of this study session gives a brief introduction to post-abortion family planning.
Care after an uncomplicated abortion
After an uncomplicated spontaneous or induced abortion, tell the woman that she should expect to feel mild pains or cramps in her lower abdomen for a few days, and some light bleeding from her vagina — no more than in a normal menstrual period. Tell her how she and her family can look after her for a few days (Box 20.1).
Box 20.1 Taking care after an uncomplicated abortion
Good care after a spontaneous or induced abortion can prevent infection and help a woman’s body to heal faster. She should:
- Drink plenty of liquids and eat nutritious foods
- Rest often and avoid heavy work for a week
- Wash regularly, but she should not douche or sit in a bath or tub of water until a few days after the bleeding stops
- Use clean cloths or pads to catch any blood, and change the pads often
- Not put anything inside her vagina, and avoid sexual intercourse for at least a few days after the bleeding stops.
Tell her to call you immediately or seek help from a higher health facility if she has any of the warning signs listed in the next section.
20.3.3 Follow-up care after an abortion
Prevention of abortion-related illness and mortality is dependent on the availability of comprehensive post-abortion care throughout the healthcare system. Whether it is health information and education, stabilisation of symptoms and timely referral, safe methods of abortion, or specialised care for the most severe complications, at least some components of post-abortion care should be available at every service delivery site in the healthcare system, including at Health Posts. If the woman had a miscarriage or a safely induced abortion at a health facility, she is less likely to develop a serious infection or injury than a woman whose abortion was done illegally by someone who used unsafe tools.
Emergency post-abortion care refers to the actions you should take if any of the complications in Box 20.2 arise after an abortion.
Box 20.2 Complications after an unsafe abortion
The most serious complication is death. It is estimated that around one-third of maternal deaths in Ethiopia are due to unsafe abortions. For every woman who dies, it is estimated that another 16 to 33 women suffer a complication after an unsafe abortion, including:
- Haemorrhage (heavy bleeding)
- Infection in the pelvic cavity, or in the bloodstream (e.g. tetanus)
- Perforation of the uterus (puncturing the wall of the uterus by a sharp instrument)
- Injury to adjacent organs in the pelvic cavity (e.g. vagina, urinary bladder, rectum, intestines)
- Poisoning from an overdose of medicines or herbs used to induce abortion.
In the longer term, a woman can suffer from chronic (persistent) pelvic pain, especially during menstruation, repeated spontaneous abortion or infertility.
If a woman has any of these warning signs after an abortion, refer her to the nearest health centre or hospital
You should check the woman’s health, pulse, temperature and blood pressure regularly after an abortion and question her carefully and sensitively to reveal any of the following warning signs and symptoms:
- Strong cramping pains in the lower abdomen
- Swollen or hard lower abdomen with no sounds or gurgles inside
- Heavy bleeding, large clots of blood or bleeding for more than 2 weeks
- Bad smell coming from the vagina
- Fever: temperature 38°C or above
- Fast pulse: more than 100 beats per minute
- Feeling very nauseated, faint or dizzy
- Low or falling blood pressure, below the bottom of the normal range of 120/70 mmHg.
If heavy bleeding occurs, you may not be able to see the blood if it is leaking into the woman’s abdomen from an injury to her uterus or other internal organs, which may occur after an unsafe abortion. Heavy loss of blood leads to a condition known as shock (Box 20.3).
Box 20.3 Signs of shock
A woman in shock will be pale and sweating, with a fast pulse (above 100 beats per minute), fast respiration, low or falling blood pressure (the diastolic pressure — the bottom number — is below 60 mmHg), and dizziness or confusion; she may even lose consciousness. You must act quickly to save her life.
20.3.4 Pre-referral treatment in an emergency
Emergency treatment of patients in shock includes starting an intravenous (IV) infusion, that is delivering a sterile fluid called Normal Saline or Ringer’s Lactate solution, directly into a vein to replace the blood fluids and salts that are being lost through heavy bleeding. You will learn the theory of how to do this in Study Session 22 of this Module, and in your practical skills training. As soon as the IV infusion is set up, you must make an immediate referral of the woman to the nearest health facility.
During transport make sure you position the woman appropriately with her head flat (do not use a pillow) and her legs raised and supported (see Figure 20.3). This position helps to keep her blood pressure from falling even lower. If possible, you should accompany her to the next level health facility to maintain the IV infusion and keep the bag of IV fluid held above her. If you cannot go with her, explain the importance to whoever accompanies her of keeping the woman and the fluid bag in the suggested positions; also tell them how to close the IV tubing when the bag of fluid has completely drained. Ideally, send a healthy person with her who could act as a blood donor if she needs a transfusion of blood when she gets to the health facility.
Make sure you write a referral note that covers all the essential details.
Recall what these details are (you learned this in Study Session 13).
A referral note should include the patient’s name, age and address; any medical or personal history that is relevant to her current condition; a clear description of her signs and symptoms; the details of any treatment you have performed; and your reasons for referring her to the health facility. Remember to sign and date the note and say how you can be contacted so you can follow-up the patient afterwards.
20.4 Other causes of early pregnancy bleeding
The warning signs and the emergency treatment described above are also relevant to two other common causes of early pregnancy bleeding.
20.4.1 Ectopic pregnancy
If you suspect an ectopic pregnancy you must send the woman for evaluation and treatment to the nearest health facility.
Ectopic pregnancy is when pregnancy occurs outside the endometrial cavity of the uterus. The most common site for an ectopic pregnancy is in a fallopian tube (the pair of tubes connecting the uterus with the interior of the abdomen, each one ending close to the ovary on that side. Look back at Figures 3.3 and 5.3 in Antenatal Care, Part 1, to remind yourself of the anatomy of the uterus and the adjacent structures. Other possible sites are the ovarian ligaments, the ovaries and the abdominal cavity surrounding the uterus.
If the embryo implants in the fallopian tube, it cannot support the growing fetus for longer than the first few weeks. There is a high risk that the tube will rupture and the woman will start bleeding into the abdominal cavity. This is a life-threatening situation leading to shock, which must be quickly treated to stop the bleeding. The typical symptoms of ectopic pregnancy are lower abdominal pain, late menstrual periods and vaginal or internal bleeding.
20.4.2 Molar pregnancy
Whenever you suspect a molar pregnancy, you must send the woman to a health facility as soon as possible.
The other cause of early pregnancy bleeding is molar pregnancy, which you already learned about in Study Session 10. You may encounter this problem occasionally. It is characterised by an abnormal growth of a tumour formed from the future placenta during early pregnancy. The uterus fills with grape-like tissues and grows bigger than the size it will attain at full term of a normal pregnancy (Figure 20.4).
Can you recall the signs of a molar pregnancy?
No fetal heartbeat can be heard. No baby can be felt when you palpate the mother’s abdomen. The woman has had nausea all through the pregnancy. She has spotting of blood and tissue like bunches of grapes coming from her vagina.
One of the feared complications in molar pregnancy is it may lead to severe bleeding which may result in the death of the mother. If the women presents with bleeding from the vagina, start an intravenous (IV) line and fluid infusion (as described in Study Session 22 and practised in your practical skills training) before making a referral. The fluid should run as fast as 60 drops per minute. The woman should be escorted to the health facility by healthy adults who can potentially be blood donors.
20.5 Post-abortion family planning
In the final section of this study session, we turn to the need for post-abortion family planning. In many instances, provision of emergency post-abortion care may be one of the few occasions that a woman and her partner come into contact with the healthcare system. Therefore, it represents an important opportunity for providing contraceptive information and services.
Post-abortion family planning should include the following components:
- Counselling about contraceptive needs in terms of the client’s reproductive goals
- Information and counselling about all available methods, their characteristics, effectiveness and side-effects (see Figure 20.5)
- Choices among methods (e.g. short- and long-term, hormonal and non-hormonal)
- Assurance of contraceptive resupply, so the woman does not run out of protection:
- Access to follow-up care
- Information about the need for protection against sexually transmitted infections (STIs).
Post-abortion family planning also should be based on an individual assessment of each woman’s situation: her personal characteristics, clinical condition and the service delivery capabilities in the community where she lives. You will learn about all of this in detail in the Module on Family Planning in this curriculum. Many women will receive post-abortion family planning while they are in the higher level health facility, but a few may have left too soon. You will also have to provide them with the continued supply of contraception when they are back in your community. Thus this is one area you have a big role in the provision of care to women who have had an abortion.
20.5.1 When to start family planning
Post-abortion family planning services need to be initiated almost immediately, because fertility returns quickly: within two weeks after a first-trimester abortion or miscarriage, and within four weeks after a second trimester abortion or miscarriage. All women receiving post-abortion care need counselling and information to insure they understand that they can become pregnant again before their next menstrual period, and that there are safe contraceptive methods to prevent or delay pregnancy.
If a woman wants to become pregnant again soon, encourage her to wait. Waiting at least six months after a spontaneous or induced abortion may reduce the chances of having a low birth weight or premature baby and the mother developing anaemia.
In the next study session, you will build on what you have learned in this study session when we describe the causes of bleeding in late pregnancy and how to manage this emergency situation.
Summary of Study Session 20
In Study Session 20 you have learned that:
- Early pregnancy bleeding occurs before 28 weeks of gestation.
- Spontaneous abortion (miscarriage) occurs spontaneously in about 15% of pregnancies.
- Common causes of early pregnancy bleeding are spontaneous or induced abortion, ectopic pregnancy and molar pregnancy. These conditions can lead to major complications, including maternal mortality, particularly when unsafe abortions are performed by unskilled people in unhygienic environments.
- When the law permits, women can get safe abortion services in health facilities. Medical and surgical options are available to provide safe abortion services under the provision of Ethiopian law.
- Warning signs after an abortion include strong cramping pains in the lower abdomen, swollen or hard abdomen, heavy bleeding, a bad smell coming from the vagina, fever, fast pulse, nausea, dizziness and shock. These are signs that emergency treatment and referral should begin immediately.
- Emergency treatment for haemorrhage or shock include starting an intravenous (IV) infusion before transferring the woman to a health facility, accompanied by a potential blood donor.
- Family planning should be part of woman-friendly comprehensive post-abortion care services, to break the cycle in case of induced abortions and to give time for recovery in cases where the abortion was spontaneous.
Self-Assessment Questions (SAQs) for Study Session 20
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the questions that follow. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
SAQ 20.1 (tests Learning Outcomes 20.1, 20.3 and 20.5)
Which of the following statements is false? In each case, explain what is incorrect.
A There is no need to refer all incomplete abortion cases to the next higher health facility.
B In a complete abortion the tissue inside the uterus has been entirely expelled and the cervix has closed.
C Women whose abortion is complete will not be able to get pregnant again for some months.
D After an abortion, a woman should be advised to delay another pregnancy until she has completely recovered.
Answer
A is false. All women with an incomplete abortion should be referred to the next higher health facility. If you leave an incomplete abortion without treatment for some time there is an increased risk that it will be complicated with infection and this could be life-threatening for the woman.
B is true. In a complete abortion the tissue inside the uterus has been entirely expelled and the cervix has closed.
C is false. Women whose abortion is complete can get pregnant again quickly, because fertility returns within two to four weeks.
D is true. After an abortion, a woman should be advised to delay another pregnancy until she has completely recovered.
First read Case Study 20.1 and then answer the questions that follow it.
Case Study 20.1 Mrs X
Mrs X is 26 years old and has been married for 4 years. She has one child who was born 3 years ago and is hoping that she is pregnant again. Mrs X says she has lower abdominal pain and has started bleeding two days ago. When you examine her she has a rapid pulse of 100 beats per minute and blood pressure of 110/60 mmHg. She also has pale conjunctiva and mild lower abdominal tenderness.
SAQ 20.2 (tests Learning Outcomes 20.2 and 20.4)
- a.What are the possible causes of bleeding at this early stage of her pregnancy?
- b.What do her other symptoms suggest may be happening?
- c.Give your reasons to indicate whether it would be safer to refer her to a higher health facility.
- d.If you refer her, what will you do before referral?
Answer
- a.The possible causes of bleeding in a woman like Mrs X in the early stage of a pregnancy are:
- spontaneous abortion (miscarriage)
- ectopic pregnancy
- molar pregnancy.
- b.The fact that she has lower abdominal pain, a rapid pulse of 100 beats/minute, low blood pressure (110/60mmHg), and pale conjunctiva (a sign of anaemia) suggests that she is going into shock due to blood loss.
- c.She should be referred quickly to a higher health facility because she may lose consciousness and die; she has already been bleeding for two days.
- d.Before transferring her to the health facility, you should:
- start an intravenous (IV) fluid infusion to replace the fluids lost through haemorrhage
- position her in the vehicle with her head flat and her legs raised
- send someone with her who could act as a blood donor if she needs a transfusion
- write a clear referral note that covers all essential details.
SAQ 20.3 (tests Learning Outcome 20.5)
Mention three things a good post-abortion family planning service will include.
Answer
You only had to identify three of the following, but a good post-abortion family planning service will include:
- Counselling about contraceptive needs in terms of the client’s reproductive goals
- Information and counselling about all available methods, their characteristics, effectiveness and side effects
- Choices among methods (e.g. short- and long-term, hormonal and non-hormonal)
- Assurance of contraceptive resupply, so the woman does not run out of protection
- Access to follow-up care
- Information about the need for protection against sexually transmitted infections (STIs).