24. Managment Of Spontaneous Miscarriages Flashcards
What term was previously used to describe both spontaneous and induced pregnancy loss before 22 weeks?
The term ‘abortion’ was previously used.
What is the current terminology for spontaneous pregnancy loss in the first and second trimester?
The term ‘miscarriage’ is now used.
What does ‘termination of pregnancy’ (TOP) refer to?
Induced pregnancy loss in the first and second trimester.
What is an ‘unsafe abortion’?
A procedure characterized by lack of provider skills, hazardous techniques, and unsanitary facilities—whether spontaneous or induced.
What are the two main categories of miscarriage?
First-trimester miscarriage and second-trimester miscarriage.
What are the clinical features of a threatened miscarriage?
- Small amount of bleeding
- No or minimal abdominal pain
- Closed cervix
What percentage of threatened miscarriages resolve and result in a normal pregnancy?
60% - 80% resolve successfully.
What is the treatment for a threatened miscarriage?
- Confirm fetal viability on ultrasound
- Reassure if the fetus is viable
- Uterine evacuation (medical +/- surgical) if non-viable
- Serial beta-hCG if viability is uncertain or ectopic pregnancy needs to be excluded
What are the clinical features of an inevitable miscarriage?
- Severe vaginal bleeding
- Painful uterine contractions
- Dilated cervix
What are the two possible outcomes of an inevitable miscarriage?
It may progress to either a complete or incomplete miscarriage.
What are the clinical features of a complete miscarriage?
- All products of conception (POC) expelled
- Cervix closes within 24 hours
- Bleeding settles
What is the treatment for a complete miscarriage?
- Conservative management
- Monitor beta-hCG if unsure of diagnosis
What are the clinical features of an incomplete miscarriage?
- Some products of conception are retained
- Bleeding continues
- Cervix remains open
What is the treatment for an incomplete miscarriage?
- Resuscitation if necessary
- Suction evacuation of the uterus
What is a missed miscarriage?
A miscarriage where the fetus dies but remains in utero.
What are the clinical features of a missed miscarriage?
- Small amount of vaginal bleeding
- Disappearance of pregnancy symptoms
- No increase in uterine size over time
How is a missed miscarriage diagnosed?
By ultrasound.
What is the treatment for a missed miscarriage?
Suction evacuation of the uterus, usually by Manual Vacuum Aspiration (MVA).
What is a septic miscarriage?
A miscarriage complicated by infection, leading to sepsis.
What are the clinical features of a septic miscarriage?
- Pyrexia (fever) and tachycardia
- Abdominal tenderness
- Offensive products of conception (POC) or blood loss
- Risk of septic shock (high temperature, hypotension, reduced consciousness)
What are the common causes of septic miscarriage?
- Unsafe abortion
- Immunosuppression
Which type of miscarriage is associated with the highest morbidity?
Second-trimester septic incomplete miscarriages.
Why is unsafe septic abortion significant globally?
It is a major cause of maternal mortality internationally.
What is the treatment for septic miscarriage?
See following sections for detailed management.
What defines recurrent miscarriage?
Three or more consecutive miscarriages.
What are the key steps in managing an incomplete miscarriage in the first trimester?
- Assess blood loss
- IV fluids and resuscitate if necessary
- Check haemoglobin and crossmatch blood if needed
- Remove POC from cervical os (to prevent vasovagal shock) with sponge-holding forceps
- Check for complications: excessive bleeding or signs of sepsis
- Evacuate the uterus using MVA (preferred), performed as a side-ward procedure with conscious sedation (Dormicum + Fentanyl)
How does the management of incomplete miscarriage in the second trimester differ from the first trimester?
Includes all steps as in the first trimester, with additional measures:
- If the fetus is still in utero, initiate abortion using oxytocin infusion or oral misoprostol
- Check if the placenta and membranes are completely expelled; if incomplete, careful evacuation of the uterus is required
- If evacuation is required, perform suction and blunt curettage to minimize the risk of perforation
- Administer ergometrine IV to contract the uterus if necessary
What are the key monitoring steps for septic miscarriage?
- Monitor temperature, pulse, blood pressure, and respiratory rate every 30 minutes
- Perform blood culture
- Assess for signs of septic shock (warm peripheries, hypotension, decreased urine output)
Why is catheterization important in septic miscarriage?
To monitor urine output, which should be more than 30ml/hr.
What are the initial resuscitation steps in septic miscarriage?
- IV fluids (crystalloids)
- Crossmatch blood and transfuse if necessary
- Administer broad-spectrum IV antibiotics (penicillin, gentamycin, metronidazole)
What investigations should be performed in septic miscarriage?
- Full blood count (FBC)
- Urea and electrolytes (U&E)
- Disseminated intravascular coagulation (DIC) screen
- Liver function tests (LFTs) to assess organ dysfunction
- Arterial blood gases (ABG)
What additional supportive treatments should be provided?
- Oxygen via face mask
- ICU admission if in septic shock
When should uterine evacuation be performed in septic miscarriage?
Within 24 hours, preferably in theatre under general anesthesia (GA).
When is a hysterectomy indicated in septic miscarriage?
If sepsis persists and/or there is more than one dysfunctional organ system.
How does gynecological ultrasound aid in the management of early pregnancy bleeding?
It enables confirmation of pregnancy viability.
What is the recommended model of care for early pregnancy assessment?
A day-care early pregnancy evaluation unit where:
- Women are assessed and examined
- Beta-hCG estimation is done
- Transvaginal ultrasound is performed
This allows for prompt diagnosis and management.
In a woman with a positive pregnancy test, closed cervix, bleeding, and pain, what must always be excluded?
Ectopic pregnancy.
What are pregnancies of unknown location?
Pregnancies where ultrasound does not yet confirm an intrauterine or ectopic pregnancy.
What ultrasound findings confirm a viable intrauterine pregnancy?
- A visible intrauterine sac
- A fetal pole
- Fetal heartbeat
At what beta-hCG level should an intrauterine pregnancy be visible on transvaginal ultrasound?
When beta-hCG is >1500 IU.
At what beta-hCG level should an intrauterine pregnancy be visible on transvaginal ultrasound?
When beta-hCG is >1500 IU.
