Miscarriage

Question 1

What are the 5 types of miscarriage? Is the cervical os open in each case?

Answer 1

1. Threatened miscarriage - closed, FHR present
2. Missed miscarriage - closed
3. Inevitable miscarriage - open
4. Incomplete miscarriage - open
5. Complete miscarriage - closed

Tip:“Open your I’s” = cervix open in inevitable and incomplete miscarriage

Question 2

How does threatened miscarriage present? How common is it?

Answer 2

• painless vaginal bleeding occurring at <24 weeks, but typically ~6 - 9 weeks
• the bleeding is
• cervical os is closed

complicates up to 25% of all pregnancies

Question 3

What is a missed miscarriage?

Answer 3

A gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion

Question 4

When is a missed miscarriage called a ‘blighted ovum’/’anembryonic pregnancy’?

Answer 4

When the gestational sac is > 25 mm and no embryonic/fetal part can be seen

Question 5

How does missed miscarriage present?

Answer 5

• dead fetus before 20 weeks without the symptoms of expulsion
• mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
• cervical os is closed

Question 6

How does inevitable miscarriage present?

Answer 6

• heavy bleeding with clots and pain
• cervical os is open

Question 7

How does incomplete miscarriage present?

Answer 7

• not all products of conception have been expelled
• pain and vaginal bleeding

Question 8

How do you manage vaginal bleeding in the first trimester (<6 weeks and _>_6 weeks)?

Answer 8

>= 6 weeks gestation
If the pregnancy is > 6 weeks gestation (or of uncertain gestation) and the woman has bleeding she should be referred to an early pregnancy assessment service

< 6 weeks gestation
If the pregnancy is < 6 weeks gestation and women have bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly. These women should be advised:

• to return if bleeding continues or pain develops
• to repeat a urine pregnancy test after 7–10 days and to return if it is positive
• a negative pregnancy test means that the pregnancy has miscarried

Question 9

Define miscarriage.

Answer 9

Miscarriage is a pregnancy that ends spontaneously before 24 weeks’ gestation.

Question 10

What is the most common sign of miscarriage?

Answer 10

Vaginal bleeding

Question 11

How common is miscarriage?

Answer 11

10-20% pregnancies affected

Risk increases with maternal age

Question 12

List 4 causes of miscarriage.

Answer 12

• Chromosomal abnormalities
• Medical/endocrine disorders
• Uterine abnormalities
• Infections
• Drugs/cheimicals

Question 13

What are the USS findings in the different types of miscarriage?

Answer 13

• Threatened - IU pregnancy + FH
• Incomplete - retained products of conception
• Inevitable - IU pregnancy + no FH
• Missed - IU pregnancy + no FH
• Complete - empty uterus (check serum hCG to exclude ectopic)

Question 14

What investigations should be done in miscarriage?

Answer 14

TVUSS/transabdominal - diagnostic if pregnancy is within the uterine cavity

Hb and ‘Group and Save’ - cross-match if the patient is severely compromised; measure to assess the degree of vaginal loss and rhesus status

Question 15

What is expectant management? When is expectant management used in miscarriage?

Answer 15

= Waiting for a spontaneous miscarriage; involves waiting for 7-14 days for the miscarriage to complete spontaneously

First-line -

1. Bleeding and pain should resolve within 7-14 days + most will require no further treatment
   
   • If not resolved or bleeding is persisting/increasing then return for scan
2. Advise to take pregnancy at 3 weeks
   
   • Return if it is still positive
3. Review patient 2 weeks after initial appointment

If expectant management is unsuccessful then medical or surgical management may be offered

Question 16

When should you not consider expectant management as first line?

Answer 16

1. increased risk of haemorrhage
   
   • she is in the late first trimester
   • if she has coagulopathies or is unable to have a blood transfusion
2. previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
3. evidence of infection

OR if it is not acceptable to the patient.

Question 17

What are 2 causes of increased risk of haemorrhage in expectant management of miscarriage?

Answer 17

• she is in the late first trimester
• if she has coagulopathies or is unable to have a blood transfusion

Question 18

What is the medical management of miscarriage and when is it used?

Answer 18

=’Using tablets to expedite the miscarriage’

1. Vaginal misoprostol (800 mcg once only)
   
   • The addition of oral mifepristone is not currently recommended by NICE in contrast to US guidelines
   • Oral misoprostol if patient’s preference
   • If bleeding hasn’t started in 24 hours advise to contact doctor.
2. • antiemetics and pain relief
3. After 3 weeks carry out urine pregnancy test
   
   • ​​If postive return for scan

Question 19

What is the MOA of misoprostol?

Answer 19

Prostaglandin analogue,

Binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue

Question 20

What are the side effects of misoprostol?

Answer 20

• Pain
• Diarrhoea
• Nausea

Offer antiemetics and pain relief .

Question 21

What is the surgical management of miscarriage?

Answer 21

= ‘Undergoing a surgical procedure under local or general anaesthetic’

The two main options are:

1. Vacuum aspiration (suction curettage) - done under local anaesthetic as an outpatient
2. Surgical management in theatre

Question 22

What miscarriage management is used in a patient with haemodynamic instability?

Answer 22

In all cases of early pregnancy loss with haemodynamic instability –> urgent surgical evacuation of products of conception is required to minimise further blood loss. e.g. dilation and curettage is a common and controlled method of uterine evacuation.

Question 23

Can you definitively diagnose miscarriage with one USS? What should you look for on USS?

Answer 23

No - it is not 100% correct and there may be a small chance that this is wrong.

1. Look for fetal heartbeat
2. Measure crown-rump length - if <7mm + no FH then rescan in minminum 7 days; if >7mm then get second opinion on viability +/- rescan in 7-14 days.

You should give women a 24 hr number to contact someone with experience of complications of pregnancy while they wait for the 2nd scan.

Question 24

What should you say when counselling someone with miscarriage?

Answer 24

• I’m afraid I don’t have good news to deliver; would you like someone in the room with you?
• You’ve had a miscarriage
• I know its not what you wanted to hear so take as much time as you need.
• Miscarriage is very common and affects up to 1 in 5 women
• None of this is your fault
• I know this is going to be a lot of information to take in so I will give you a leaflet and please stop me to ask questions at any time.
• We are going to give you some medication which will cause your womb to contract to get the rest of the tissue out so you may experience heavy bleeding (don’t need to cover in too much detail as likely to be upset) DO NOT CALL IT A FETUS
• This bleeding can last for up to 2 weeks
• Doesn’t increase your chances of having a miscarriage in the future and does not affect your chances of having a baby
• However, we know this is difficult and advise that you only try for another baby once you and your partner are mentally and physically ready to do so.
• If you would like some help, I will give you a leaflet to explain this. You can also ask your GP to refer you to a counselling service.

Question 25

A 22-year-old woman has a booking ultrasound scan. Her last menstrual period was 8 weeks ago. This shows an intrauterine sac with no fetal pole. These findings are confirmed with a transvaginal ultrasound.

What is the diagnosis?

Answer 25

She is likely to be 6-8 weeks pregnant

On US you should see:

• gestational + yolk sac by approx 5 weeks
• pole by approx 6 weeks
• heart by approx 7 weeks

Therefore if no pole seen then this is likely a missed miscarriage.