Most pregnancies are healthy and free from complications, but
sometimes problems do arise. In most cases, risks
to the mother and the baby are decreased if warning
signals are recognised and dealt with early. So,
it is important to know about them to recognize
them early and take the help of specialized care.
Complications in 1st Trimester
- Bleeding in the 1st trimester.
- Excessive vomiting (Hyperemesis gravidarum).
- Ectopic pregnancy (pregnancy outside the uterus).
- Molar pregnancy
Spotting or bleeding through vagina is a frequent phenomenon
during 1st trimester of pregnancy. It
is rather difficult to say which of the cases may
land up in a problem and which may not. However,
bleeding, unless proved otherwise, should be considered
a symptom of impending abortion .
The patient must call on the doctor
How often does
20 to 25% of women have spotting to bleeding. through
the vagina. However, the possibility of spontaneous
abortion is relatively small (2.5% to 3%) and the
most likely outcome of the pregnancy will be normal.
What can cause bleeding?
Minimal spotting particularly at the expected time of menses
or just prior to that is rather normal, which
usually occurs at the time of implantation of
the zygote .
Under influence of estrogen the inner lining of the cervix
overgrows causing spotting. This is medically
known as 'Erosion' of cervix and can give rise
to spotting particularly following deep intercourse
in early pregnancy.
Infection of vagina, cervix – like candidal (fungal) or trichomonal
Threatened abortion to complete abortion – all cause bleeding
which is definite sign.
Unless proved otherwise, all bleeding cases should be considered
as cases of abortions and carefully investigated.
How to arrive at the diagnosis?
A thorough clinical (physical) and internal examination to
rule out the above causes.
- Blood investigation:
- CBC – complete blood count.
- Blood grouping and Rh typing.
Specific investigations :
For the health of foetus:
- Beta hCG levels.
- Serum progesterone levels.
For causes of problems
- TORCH titres.
- Fasting and post lunch sugar.
- VDRL for sexually transmitted
- Thyroid function tests.
- Urine for infection.
- Others as suggest by your doctor.
This gives very important information as to whether this bleeding
is an indicator of a serious problem. .
. It can tell you whether the
pregnancy is growing well or not, whether it is
an abnormally located pregnancy (ectopic). If the
heart beat is seen at 8 weeks, the risk of having
a miscarriage is not more than 2%.
- Bed rest.
- Healthy nutritious diet.
- Folic acid supplementation.
- Hormonal support: A Woman having low levels of hormone–serum
Beta hCG and serum progesterone, can be supplemented
from outside, however its role is still questionable.
- Specific treatment of any cause identified.
Hyperemesis Gravidarum / Severe Vomiting
Hyper – means ‘over’ emesis
means- vomiting, gravidarum means – ‘pregnant state’
so Hyperemesis gravidarum means excessive vomiting
during pregnancy. This is because B-hCG hormone
(hormone of pregnancy), which has stimulating effect
on the center of vomiting in brain. (CTZ center
More or less all pregnant women experience the complaint
of vomiting. When the vomiting becomes persistent,
frequent and severe, it leads to health problems.
It may keep the mother from getting the nutrition
and fluids she needs. If it is not treated in time, it may cause danger to
your life and that of the foetus, too.
How often does severe vomiting occurs?
The severe form of vomiting
occurs in one in every 300 pregnant women.
What can cause severe vomiting?
How to arrive at the diagnosis?
Blood Investigation: .
- CBC – complete blood count.
- Blood group and Rh typing.
- Serum Beta hCG levels.
- Serum electrolytes may be abnormal.
- Serum thyroid tests.
- Urine test: urine test for ketone bodies, a sign of starvation.
- Liver function tests (may be abnormal)
- Blood sugar level (may be low).
For confirmation of pregnancy
and to rule out molar pregnancy.
- After ruling out molar pregnancy and gastro-intestinal disturbances
and hepatitis depending on the severity of the
problem, your obstetrician will treat you.
- For mild cases, rest and
antacid treatment will do.
- For moderate cases, rest,
antacid and occasionally anti-emetic like dicyclomine
or Vit. B6 (pyridoxine) is given. Adequate amount
of fluids must be ingested. It is advisable to
have juices, lemon water in good quantity.
- Severe cases need hospitalisation where the pregnant woman
needs to be given fluids and nutrition through
early pregnancy loss / spontaneous
Human reproduction is a relatively inefficient process. Recently,
investigators have demonstrated overall pregnancy
loss of 31% with 22% occurring before the pregnancy,
which is implanted in the uterine cavity. Pregnancy
termination, when it is not induced voluntarily
before the period of viability i.e. 28 weeks, is
known as spontaneous abortion.
How often does the abortions occur?
The risk of spontaneous abortion for a woman with no history
of reproductive wastage is about 15%.The risk increases
gradually with prior history of spontaneous abortion.
Types of Spontaneous Abortion:
Inevitable / incomplete Abortion
Vaginal bleeding of varied severity, lower abdominal cramps
with backache are classical symptoms with threatened
abortion. The ultra sonography shows a live baby
corresponding to the period of amenorrhoea.
Bed rest and sedation to
decrease anxiety is the most logical treatment.
Hormonal support given without conformation has
and Incomplete Abortion
These are considered together because, although clinically
they are two distinct entities, they are present
similar problems and are treated similarly. An abortion
is considered incomplete, when some fragments of
products of conceptions have been expelled earlier.
A quick curettage of the uterine cavity prevents
excessive blood loss, and prevents lethal complications.
Retention of the products of conception in the uterus for four
weeks or longer after the death of the foetus is
classified as missed abortion. Clinical evaluation
with ultrasonagraphy clinches diagnosis. However
with easy availability of USG, once it is identified
that the foetus has no heartbeat, depending on the
clinical picture your doctor may suggest that removal
of the products even if you have no symptoms. Monitoring
of clotting factors with evacuation of uterine cavity
is the treatment.
Any abortion associated with
fever, lower abdominal pain and foul smelling vaginal
discharge should be considered as septic abortion.
Treatment with higher antibiotics, removal of origin
of sepsis is the treatment of choice.
This means three or more consecutive spontaneous abortions.
Incidence of this condition is believed to be less
than 1%. Investigations and treatment of habitual
abortion should begin between pregnancies.A thorough
systemic examination with cytogenetic studies should
be helpful to arrive at a diagnosis.
Pathology / Causes
Genetic Causes (in 50% to 60% of cases)
Chromosomal abnormalities are found in approximately
80% of blighted ovum and 5% to 10% of the abortions
in which a foetus is present.
Endocrine Causes (10%
to 15% of cases)
required for the maintaining of pregnancy, is
diabetes can have a significantly increased
risk of spontaneous abortion.
Thyroid Deficiency : Rarely
decreased or increased secretion causes spontaneous
Polycystic ovarian syndrome: In this, the elevated levels
of leutinising hormone (LH) may have deleterious
effect on pregnancy.
Infection: Viral infection by rubella, toxoplasmosis, parvovirus, herpes
simplex, chlamydia and mycoplasma can lead to
miscarriage.Acute infectious fever may lead
Abnormalities of the genital tract: Congenital structural
abnormalities of the uterus and adhesion or
fibrous bands within the uterus may give rise
to recurrent abortions.
¨ Sub-chorionic haematomas
and chorio-amniotic separation :
Collection of blood clot between the foetal
sac and the uterine wall. This is a frequent
cause of 1st trimester vague bleeding,
but an uncommon cause of pregnancy loss. This
clot usually gets absorbed over a period of
time, approximately by 4 - 6 weeks. During this
time one may observe continuous altered dark
brown discharge from the vagina, which is the
collected blood being expelled.
How to arrive at
If you have had 3 or more
abortion you are said to have recurrent / habitual
abortion. If so, it is advisable to go to a gynaecologist
who will order a battery of test to be done before
conception so that adequate treatment can be given.
The investigations are:
- CBC with ESR.
- VDRL to rule out syphilis
(one type of sexually transmitted disease).
- Blood group with Rh factor to rule out Rh – incompatibility.
- Blood sugar levels: to rule out diabetes, which causes early
- Beta-hCG levels in blood : very sensitive tests of blood
for confirmation of pregnancy levels correspond
to week of gestation with doubling time less than
Specific test done in selected cases:
- TORCH titres: done to rule out infections like toxoplasmosis,
cytomegalovirus, rubella, herpes group and other.
- Serum thyroid levels – to rule out thyroid hormone imbalance.
- Serum prolactin levels – to rule out hyperprolactinemia.
- Karyotyping of parents: this is done to diagnose any genetic
abnormality in either parents or its occurrence
in the foetus.
Urine routine test with culture – to rule out infection of
It is most specific and informative test regarding abortion.
It gives information regarding:
- Foetal viability.
- Stage of abortion.
- Congenital abnormalities of uterus like septum, fibroids,
- Bleeding inside the uterine cavity, or in the abdominal cavity
(as in ectopic).
- Status of other pelvic organs condition of the ovaries. Presence
of any cyst.
In cases of habitual abortions,
chromosomal studies of either of the partners and
of the products of conception may be done. Your
obstetrician is the ideal person to decide about
Treatment for Habitual
Ideally, with prior record of abortion, you should be investigated
before she becomes pregnant.
When pregnant, you should have:
- Bed rest.
- Avoid intercourse particularly in 1st trimester.
- Good nutritious diet .
- Mental and physical rest.
- Folic acid supplementation: Around conception time, folic
acid is believed to prevent congenital abnormalities
of the brain in the foetus. It also may reduce placental
- Depending on any specific conditions identified, your doctor
will suggest special further treatment.
Ideally, a pregnancy should be implanted in the uterine cavity,
but on occasions it gets implanted outside the uterine
cavity, called as ectopic (ecto-outside) pregnancy.
Of these in 95% of the time, the ectopic pregnancy
gets implanted in the fallopian tube, known as tubal
pregnancy. Ectopic pregnancy per se is an emergency, which must be dealt
under specialized supervision in a hospital set
up. It can get implanted at various other sites
like: outside the uterus like cervix, ovary,
abdominal cavity. This is quite rare, however.
How often does this occur?
- 1 in 150 to 1 in 500 pregnancies.
- Incidence is increasing, although the risk of maternal death
is decreasing due to early diagnosis and better
Pelvic inflammatory disease (PID):
Global increase in incidence
of sexually transmitted diseases and pelvic
inflammatory diseases leads to defective transport
of fertilised egg (zygote) to the uterine cavity.
. Thus the fertilized egg gets implanted
into the tube.
The tube is naturally meant
for transport and not to support the growing
egg. Physiology of reproduction
in Sexual Activity.
It gets stretched upto
a certain point and gives way, causing rupture
and bleeding in the abdominal cavity.
At this point, the woman
gets acute pain.
Depending on the severity of bleeding and the physical status
the woman might experience fainting episodes,
giddiness over a period of time.
Causing narrowing of tubal lumen at
the site of surgery, causing obstruction to
the passage of the fertilised egg.
IUD: (Intra Uterine Device)
The chances of an ectopic pregnancy
are relatively more in an IUD user. The IUD
protects more against an intrauterine than an
extra uterine pregnancy. However, the overall
incidence of ectopic pregnancy is much less
in IUD user as compared to non-IUD users.
What you feel?
Absence of menses
(amenorrhoea) : can last from days to weeks.Up
to 15% may not have history of amenorrhoea.
- Mainly in lower abdomen on left or right side A sudden onset
of cramping may occur with giddiness and fainting.
- May have repeated attacks
of pain before acute pain followed by fainting
due to rupture of ectopic pregnancy.
Many patients may have irregular scanty altered
bleeding through the vagina. This is another reason
why you may not realise that the period has been
Other symptoms may include:
- Increased urinary frequency.
- Burning sensation during urination.
- Low grade fever.
- Feeling of motion (rectal tenesmus).
does the doctor see?
- Pale look on the face.
- Increased pulse rate (normal pulse rate =60-100 beats / minute
- Decrease in blood pressure (hypotension).
- Tenderness in lower abdomen.
- Internal examination will be very painful.
Particularly, the trans-vaginal method can diagnose ectopic
pregnancy early and more accurately.
Procedure by which needle aspiration of the most dependent
part of abdominal (pouch of Douglas) cavity
is done for diagnostic purpose. This is done
by vaginal route, to check for any free blood
in abdomen (peritoneal cavity) for confirmation
of ruptured ectopic pregnancy. This clinical
test is done in emergency cases when facility
or time for special tests is not available.
It is positive only if the ectopic is ruptured
Can be used as a confirmatory
procedure when there is a high suspicion of
an ectopic pregnancy. 'Seeing is believing'
and by this technique the doctor actually looks
at the pelvic structures, under anaesthesia.
If possible corrective surgery may be done at
the same sitting.
With modern techniques, ectopic
pregnancy may be diagnosed at a very early stage:
Some cases of ectopic pregnancy
may not need any intervention at all – resolve spontaneously.
But theoretically, it gives false sense of security
Serial follow–ups by monitoring vital parameters serum hCG
levels, serum progesterone is a must for ectopic
pregnancy, when medical or surgical interventions
Either by laparoscopy or by laparotomy i.e. opening the abdomen
surgically. However, laparoscopy is the preferred
option. if possible
The surgery could be conservative
like – salphingostomy (making an incision on
the unruptured ectopic pregnancy site and milking
out the disease).
Partial salphingectomy: removing only the diseased part of
Radical surgery: complete removal of the fallopian tube on
the affected site. The advantages of surgical
treatment is that it is a one step procedure
that will take care of the ectopic, without
any later risks.
In this, the agents which
dissolves the ectopic pregnancy are used like:
These are used kill the pregnancy under sonographic guidance
or laproscopically. A drug called RU 486 given orally
can also act on the pregnancy to destroy it. These
methods however require serial follow up.
(gestational trophoblastic tumours)
Technically called hydatidiform mole (hydatid – means ‘A drop
of water’ mole means ‘spot’). The molar pregnancy
occurs due to abnormal development of cells of placenta.
They form grape like watery clusters, which cannot
support a growing embryo.They are hence called 'drakshagarbha'
in local language in India.
often does this occur?
0.5 to 8.3 per 1000 live
births. The incidence is 7 to 10 times greater in
Asian countries as compared to North America or
Molar pregnancy is caused
by chromosomal problem in either the sperm that
fertilises the egg or the egg itself or both.
- Age more than 40 years,
the risk increases by 200 times.
- Ethnic group: Asians / blacks / Caucasians. Asians have greater
risks than blacks. Blacks have more risk than
- Socioeconomic status : Risk is higher in poor group probably
due to malnutrition and protein deficiency.
- Previous occurrence of hydatidiform mole: repeat mole in
0.5 – 2%.
Women who have had a molar pregnancy are at a risk of developing
neoplasm (rapid growth of new cells) or invasive
disease inside the uterus. Some of these, are highly
metastatic (likely to spread to other parts of body).
Although, it is rare and its cure rate is high,
any woman who has had a molar pregnancy is at risk
for invasive disease. Hence proper follow up is
do you feel?
- Amenorrhoea (Irregularity of menses): usually for 3 to 4
- Bleeding: It is the first symptom
in almost 95% of cases. Occasionally, altered
brownish ‘prune – juice’ like discharge.
- Excessive vomiting: probably due to high levels of hormone
- Passage of grape like vesicles: spontaneous expulsion of
a part or complete molar pregnancy can occur.
Others: Some other complaints which are not very specific
- Intolerance to heat.
- Increased appetite.
- Swelling of legs.
the doctor sees?
- Increase in the size of uterus, which doesn’t correspond
to the duration of pregnancy.
- Increase in the heart rate and the pulse rate.
- Increase in the blood pressure.
Early diagnosis and prompt meticulous treatment prevents complications.
How to arrive at a diagnosis?
- CBC (complete blood count).
- Blood grouping and Rh typing.
- Serum electrolyte (sodium, chloride and potassium) levels.
- Serum Beta-hCG levels: they are very high as compared to
normal pregnancy levels, usually in lakhs. Serial
Beta-hCG levels are done regularly for the management
as they reflect disease activity.
- Serum thyroxin and thyroid stimulating hormone levels.
This is an extermely important test as
it Clinches diagnosis: It will show absence of foetus with ‘snow
Dilatation and evacuation: In this, under suitable anaesthesia,
the cervix (mouth of uterus) is dilated (opened
with mechanical force) and the contents are gently
removed by suction. A medication called oxytocin
/ prostaglandin may be given at the same time for
contraction of uterus. Before evacuation your gynaecologist
may ask for reserving 1 bag of blood in the blood
Usually, the above treatment is adequate in most
of the cases. But it is advisable to monitor your
blood levels of Beta-hCG hormone to rule out chances
of invasive diseases. As these can manifest even
months after evacuation. Most women are advised
not to become pregnant for at least 6 months. The
relatively rare form of malignant disease that may
follow a molar pregnancy are managed by chemotherapy
(specialized treatment for cancer). The success
rate of treating these tumors is very high – almost
100%.if picked up early.