Introduction

Complications arise more frequently during the first trimester than at any other stage of pregnancy. Most present with bleeding, pain, or both. Vaginal bleeding occurs in about 20% of clinically diagnosed pregnancies.It causes considerable anxiety for the woman and her partner. In the vast majority of cases, no intervention alters the outcome. The main aim of clinical management is a prompt and accurate diagnosis, with reassurance if the pregnancy is appropriately developed and viable, or appropriate intervention if not. This chapter focuses on the principles of diagnosis and management and three principal diagnoses: miscarriage, ectopic pregnancy, and gestational trophoblastic disease. The other differential diagnoses are shown in Table 5.1.

Approximately 15–20% of clinically recognized pregnancies miscarry. When bleeding occurs in the first trimester, about 30% of pregnancies will miscarry, 10–15% will be an ectopic pregnancy, approximately 0.2% will be a hydatidiform mole (HM), and about 5% of women will have a termination of pregnancy. The remaining 50% will continue beyond 20 weeks.

Ectopic pregnancy is themajor contributor tomaternal mortality in the first trimester of pregnancy in the United Kingdom6 and other western countries. The 2006–08 UK Confidential Enquiry into Maternal Mortality reported six deaths due to ectopic pregnancies (in contrast to five women who died following spontaneous miscarriage). Four of the six women with ectopic pregnancies presented with gastrointestinal symptoms to emergency departments, and thus the report recommended that the diagnostic label “pregnancy of unknown location” should be abandoned.

Understanding the psychological effects of early pregnancy loss has lagged behind that of perinatal bereavement. However, there is now greater recognition of the psychological and psychiatric sequelae and the consequent need for support that should be part of the management of couples who suffer early pregnancy loss, though there is not as yet any evidence to show that support (as counseling) is effective.