Obstetrics and Gynaecology — Early Pregnancy, NMC MBBS licence examination syllabus (Nepal Medical Council).
Early pregnancy: bleeding, loss and the care that follows
Common, frightening, and handled badly more often than almost anything else in obstetrics.
Bleeding in early pregnancy is one of the commonest reasons a woman attends an emergency department, and the clinical task divides cleanly. First, exclude the diagnosis that kills — ectopic pregnancy. Then work out what is actually happening to this pregnancy, and manage the bleeding and any infection.
But there is a second task that is just as consequential and much easier to get wrong. Early pregnancy loss is a bereavement, and how it is handled — whether anyone explains that it was not her fault, whether she is told what will happen next, whether she is treated with dignity when the loss was not a wanted pregnancy — determines a great deal about her experience of the health service and whether she returns to it.
🩺 Where this lives: Unsafe abortion remains a significant and entirely preventable cause of maternal death and injury. Where safe services are unavailable, inaccessible or feared, women turn to alternatives that cause haemorrhage, sepsis, uterine and bowel injury, and infertility. The clinical rule that follows is unambiguous: a woman presenting with complications is treated first, urgently and without interrogation about how it happened. A judgemental reception does not only harm the woman in front of you — it deters the next one from coming at all, and she may not survive the delay.
💡 A note on law and numbers. This chapter gives no doses, no gestational cut-offs and no hCG values. It also deliberately makes no statement of Nepal's abortion law — gestational limits, permitted grounds, provider requirements and consent rules are matters of national law and policy which have changed and may change again, and stating them from memory would carry legal as well as clinical risk. Take them from current national policy and the NMC code. Ectopic pregnancy is covered in the Gynaecology chapter and the thiamine-before-glucose rule in the Delirium chapter.
Bleeding in early pregnancy
The order of thinking is fixed. Is she shocked? — resuscitate first. Is this ectopic? — pain with bleeding and a positive pregnancy test is ectopic until excluded, and a ruptured ectopic bleeds internally so shock precedes visible loss. Only then does the differential open out to miscarriage, cervical causes, infection and molar pregnancy. And in every case, check the rhesus status, because anti-D may be indicated per national guidance.
Classifying miscarriage
THE CLASSIFICATION IS A CLINICAL DECISION TOOL
It is not academic terminology — each type implies a
different action.
THREATENED Bleeding, os CLOSED, pregnancy still viable.
Most continue. The right response is
explanation, reassurance and follow-up — not
intervention, and not bed rest, which does not
change the outcome.
INEVITABLE Bleeding, os OPEN. The pregnancy cannot
continue. Manage the bleeding and pain and
plan for completion.
INCOMPLETE Some tissue passed, some retained, os open.
Ongoing bleeding and INFECTION RISK. Managed
expectantly, medically or surgically per
guidance and the woman's preference.
COMPLETE All tissue passed, os closed, bleeding
settling. Confirm, and give follow-up advice.
MISSED The fetus has died but nothing has been
expelled. Often found at a routine scan with
no symptoms at all — which makes the telling
of it particularly difficult.
SEPTIC Fever, offensive discharge, tender uterus,
systemic illness. A LIFE-THREATENING
EMERGENCY. Resuscitate, take cultures, give
antibiotics urgently, and EVACUATE THE UTERUS
— the retained infected tissue is the source,
and antibiotics alone will not control it.
Source control again.
A NOTE ON WHAT TO SAY: most miscarriages result from
chromosomal abnormality and are not caused by anything the
woman did — not by working, lifting, arguing, travelling or
having sex. Saying this explicitly matters, because many
women assume otherwise and are not asked.
Unsafe abortion and its complications
💡 Exam angle: the examinable principle here is professional rather than technical — treat first, and do not delay care to establish how the pregnancy ended. A woman with fever, offensive discharge, heavy bleeding or peritonism after a recent pregnancy loss needs resuscitation, antibiotics and evacuation, in that order, regardless of the circumstances. Confidentiality applies here as everywhere else, and is covered in the Ethics chapter.
Molar pregnancy
The phrase worth carrying is that the pregnancy seems "too much" — a uterus larger than expected for dates, disproportionately severe vomiting, very high hCG, and no fetal heart. Treatment is evacuation, but the part students forget is the follow-up: serial hCG monitoring matters because a small proportion progress to persistent trophoblastic disease or choriocarcinoma, which is highly treatable when caught. Pregnancy is avoided until follow-up is complete, because a new pregnancy makes the hCG uninterpretable.
Hyperemesis gravidarum
THE THIAMINE RULE APPLIES HERE TOO
Hyperemesis is distinguished from ordinary nausea and
vomiting of pregnancy by its consequences: WEIGHT LOSS,
DEHYDRATION, ketosis and electrolyte disturbance.
THE CRITICAL PRESCRIBING POINT
Prolonged vomiting depletes thiamine. Giving a
glucose-containing fluid to a thiamine-deplete patient
consumes the remaining thiamine and can precipitate
WERNICKE'S ENCEPHALOPATHY — confusion, ataxia and ocular
signs, which may become irreversible.
So GIVE THIAMINE BEFORE OR ALONGSIDE glucose-containing
fluids. This is exactly the same rule as in alcohol
dependence, and it is examined in both settings.
ALSO CONSIDER, PARTICULARLY IF SEVERE
MOLAR pregnancy or multiple pregnancy — both produce
higher hCG
Urinary tract infection
Thyroid disturbance
AND TREAT THE SUFFERING SERIOUSLY. Hyperemesis is
frequently minimised as an exaggeration of normal
pregnancy sickness. It causes genuine debility, affects
work and family life, and is associated with low mood.
Antiemetic choice follows national guidance and
pregnancy-safety considerations.
Clinical reasoning: four presentations
🔍 Case 1 — bleeding with a closed os
PresentationA woman in early pregnancy has light bleeding and mild cramping. She is haemodynamically stable, the os is closed, and a scan shows a viable intrauterine pregnancy. She is admitted for bed rest and told to avoid all activity.
IssueIntervention without benefit.
ReasoningThis is a threatened miscarriage. Most continue to viable pregnancies, and bed rest does not change the outcome — but it does convey that activity caused the bleeding, which adds guilt.
AnswerExplain the situation and the likely outcome, state explicitly that she did not cause this, check rhesus status, arrange follow-up, and give clear advice on when to return.
🔍 Case 2 — fever after a pregnancy loss
PresentationA woman presents with fever, offensive vaginal discharge, lower abdominal tenderness and heavy bleeding some days after a pregnancy ended. Staff question her at length about what happened before starting treatment.
Two problemsSeptic miscarriage, and a delay that is causing harm.
ReasoningThis is septic miscarriage — life-threatening, and progressing while she is being interrogated. Retained infected tissue is the source, so antibiotics alone will not control it.
AnswerResuscitate, take cultures, give antibiotics urgently and evacuate the uterus. Treat first; the circumstances do not change the clinical management and questioning can wait.
🔍 Case 3 — a uterus larger than dates
PresentationA woman has severe vomiting and light bleeding. The uterus is considerably larger than expected for her dates, hCG is very high, and no fetal heart is found. She is treated for hyperemesis and discharged.
Diagnosis missedMolar pregnancy.
ReasoningA uterus large for dates with disproportionate vomiting, very high hCG and no fetal heart suggests a molar pregnancy — and severe hyperemesis should itself prompt the thought.
AnswerUltrasound, evacuation with histology, and — the part most often omitted — serial hCG follow-up, avoiding pregnancy until it is complete, because a proportion progress to persistent trophoblastic disease.
🔍 Case 4 — glucose before thiamine
PresentationA woman admitted with two weeks of severe vomiting, weight loss and ketosis is started on intravenous glucose-containing fluid. Two days later she is confused and ataxic with abnormal eye movements.
What happenedWernicke's encephalopathy.
ReasoningProlonged vomiting depletes thiamine. Glucose metabolism consumes what remains, precipitating Wernicke's — the same mechanism as in alcohol dependence, and it may become irreversible.
AnswerGive thiamine urgently per protocol, and in future give thiamine before or alongside glucose-containing fluids in any patient with prolonged vomiting or poor intake.
Commonly confused
Confusion
The distinction
Why it matters
Miscarriage vs ectopic
Exclude ectopic first — it kills
Ectopic bleeding is concealed.
Threatened vs inevitable
The cervical os: closed or open
One may continue; one cannot.
Incomplete vs complete
Retained tissue means ongoing risk
Bleeding and infection continue.
Septic miscarriage vs antibiotics alone
Retained tissue is the source
The uterus must be evacuated.
Treating vs investigating circumstances
Treat first, always
Delay kills and deters the next woman.
Hyperemesis vs normal sickness
Weight loss, dehydration, ketosis
It is minimised far too often.
Glucose vs thiamine first
Thiamine before or alongside
Glucose can precipitate Wernicke's.
Evacuating vs following up a mole
Serial hCG is essential
Some progress to choriocarcinoma.
Rapid revision
MUST-KNOW FACTS
1. In early pregnancy bleeding, EXCLUDE ECTOPIC FIRST.
2. Resuscitate a shocked woman before completing the diagnosis.
3. Check RHESUS status — anti-D may be indicated per guidance.
4. THREATENED: bleeding, os CLOSED, pregnancy viable — most continue.
5. Bed rest does NOT change the outcome of a threatened miscarriage.
6. INEVITABLE: bleeding, os OPEN — the pregnancy cannot continue.
7. INCOMPLETE: some tissue retained, os open, ongoing bleeding and infection risk.
8. COMPLETE: all tissue passed, os closed.
9. MISSED: fetus died, often found on a routine scan without symptoms.
10. SEPTIC MISCARRIAGE: fever, offensive discharge, tender uterus.
11. It is a LIFE-THREATENING EMERGENCY.
12. Resuscitate, antibiotics, and EVACUATE THE UTERUS — source control.
13. Most miscarriages are chromosomal and NOT the woman's fault — say so.
14. UNSAFE ABORTION causes haemorrhage, SEPSIS, injury and infertility.
15. TREAT FIRST — never delay care to establish how the pregnancy ended.
16. A judgemental response deters the next woman from attending.
17. Take Nepal's legal framework from CURRENT NATIONAL POLICY.
18. MOLAR PREGNANCY: uterus LARGER than dates, severe vomiting, very high hCG.
19. No fetal heart · bleeding.
20. Manage by evacuation with histology.
21. SERIAL hCG FOLLOW-UP IS ESSENTIAL.
22. A proportion progress to persistent disease or CHORIOCARCINOMA.
23. Avoid pregnancy until follow-up is complete — it confuses the hCG.
24. HYPEREMESIS: vomiting with WEIGHT LOSS, DEHYDRATION, ketosis.
25. GIVE THIAMINE BEFORE OR ALONGSIDE GLUCOSE-CONTAINING FLUIDS.
26. Glucose in thiamine deficiency precipitates WERNICKE'S ENCEPHALOPATHY.
27. The same rule applies in alcohol dependence.
28. Severe hyperemesis — consider MOLAR or multiple pregnancy.
29. Also consider urinary infection and thyroid disturbance.
30. Do not minimise hyperemesis — it causes real debility and low mood.
💡 Exam angle: three threads. Exclude ectopic before anything else. Septic miscarriage needs the uterus emptied, not just antibiotics. And thiamine goes before glucose in anyone who has been vomiting for weeks — the same rule you learnt for alcohol.
Syllabus points
Assessing bleeding in early pregnancy
Excluding ectopic pregnancy first
Rhesus status and anti-D
Threatened and inevitable miscarriage
Incomplete, complete and missed miscarriage
Septic miscarriage and evacuation
What to tell a woman about the cause
Complications of unsafe abortion
Why care is never delayed to investigate
Molar pregnancy and its presentation
Serial hCG follow-up
Hyperemesis and its complications
Thiamine before glucose
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