Miscarriage

Question 1

What is a miscarriage?

Answer 1

Miscarriage is the spontaneous termination of a pregnancy.

Question 2

Briefly differentiate between an early and late miscarriage

Answer 2

Early miscarriage is before 12 weeks gestation.

Late miscarriage is between 12 and 24 weeks gestation.

Question 3

What is a missed miscarriage?

Answer 3

The fetus is no longer alive but no symptoms have occurred.

Question 4

What is a threatened miscarriage?

Answer 4

Vaginal bleeding with a closed cervix and a fetus that is alive.

Question 5

What is a inevitable miscarriage?

Answer 5

Vaginal bleeding with an open cervix.

Question 6

What is an incomplete miscarriage?

Answer 6

Retained products of conception remain in the uterus after the miscarriage.

Question 7

What is a complete miscarriage?

Answer 7

A full miscarriage has occurred, and there are no products of conception left in the uterus.

Question 8

What is an anembryonic pregnancy?

Answer 8

A gestational sac is present but contains no embryo.

Question 9

What imaging is used to diagnose a miscarriage?

Answer 9

A transvaginal ultrasound scan is the investigation of choice for diagnosing a miscarriage.

Question 10

What 3 features are assessed in early pregnancy to determine the viability?

Answer 10

There are NICE guidelines (2019) and local protocols for diagnosing a miscarriage on ultrasound. Always check local and national guidelines when managing patients.

There are three key features that the sonographer looks for in an early pregnancy. These appear sequentially as the pregnancy develops. As each appears, the previous feature becomes less relevant in assessing the viability of the pregnancy. These features are:

• Mean gestational sac diameter
• Fetal pole and crown-rump length
• Fetal heartbeat

Question 11

How is a viable pregnancy confirmed?

Answer 11

When a fetal heartbeat is visible, the pregnancy is considered viable. A fetal heartbeat is expected once the crown-rump length is 7mm or more.

Question 12

How is a non-viable pregnancy confirmed?

Answer 12

When the crown-rump length is less than 7mm, without a fetal heartbeat, the scan is repeated after at least one week to ensure a heartbeat develops.

When there is a crown-rump length of 7mm or more, without a fetal heartbeat, the scan is repeated after one week before confirming a non-viable pregnancy.

Question 13

How is an anembryonic pregnancy confirmed?

Answer 13

A fetal pole is expected once the mean gestational sac diameter is 25mm or more. When there is a mean gestational sac diameter of 25mm or more, without a fetal pole, the scan is repeated after one week before confirming an anembryonic pregnancy.

Question 14

Briefly describe the management of a miscarriage in less than 6 weeks gestation

Answer 14

Women with a pregnancy less than 6 weeks’ gestation presenting with bleeding can be managed expectantly provided they have no pain and no other complications or risk factors (e.g. previous ectopic). Expectant management before 6 weeks gestation involves awaiting the miscarriage without investigations or treatment. An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen.

A repeat urine pregnancy test is performed after 7-10 days, and if negative, a miscarriage can be confirmed. When bleeding continues, or pain occurs, referral and further investigation is indicated.

Question 15

Briefly describe the management of a miscarriage in greater than 6 weeks gestation

Answer 15

The NICE guidelines (2019) suggest referral to an early pregnancy assessment service (EPAU) for women with a positive pregnancy test (more than 6 weeks’ gestation) and bleeding.

The early pregnancy assessment unit will arrange an ultrasound scan. Ultrasound will confirm the location and viability of the pregnancy. It is essential always to consider and exclude an ectopic pregnancy.

There are three options for managing a miscarriage:

• Expectant management (do nothing and await a spontaneous miscarriage)
• Medical management (misoprostol)
• Surgical management

Question 16

Briefly describe the expectant management in a miscarriage

Answer 16

Expectant management is offered first-line for women without risk factors for heavy bleeding or infection. 1 – 2 weeks are given to allow the miscarriage to occur spontaneously. A repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm the miscarriage is complete.

Persistent or worsening bleeding requires further assessment and repeat ultrasound, as this may indicate an incomplete miscarriage and require additional management.

Question 17

Briefly describe the medical management in a miscarriage

Answer 17

Medical management of miscarriage involves using a dose of misoprostol to expedite the process of miscarriage. This can be as a vaginal suppository or an oral dose.

Question 18

What is the mechanism of action of misoprostol? How does this lead to a miscarriage?

Answer 18

Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions.

Question 19

What are the side effects of mistoprolol?

Answer 19

The key side effects of misoprostol are:

• Heavier bleeding
• Pain
• Vomiting
• Diarrhoea

Question 20

Briefly describe the surgical management of a miscarriage

Answer 20

Surgical management can be performed under local or general anaesthetic.

There are two options for surgical management of a miscarriage:

• Manual vacuum aspiration under local anaesthetic as an outpatient
• Electric vacuum aspiration under general anaesthetic

Question 21

What is given to woman before surgical management for a miscarriage?

Answer 21

Prostaglandins (misoprostol) are given before surgical management to soften the cervix.

Question 22

What is given to rhesus negative women before having surgical management for a miscarriage?

Answer 22

Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of miscarriage.

Question 23

Briefly describe manual vaccum aspiration

Answer 23

Manual vacuum aspiration involves a local anaesthetic applied to the cervix. A tube attached to a specially designed syringe is inserted through the cervix into the uterus. The person performing the procedure then manually uses the syringe to aspirate contents of the uterus. To consider manual vacuum aspiration, women must find the process acceptable and be below 10 weeks gestation. It is more appropriate for women that have previously given birth (parous women).

Question 24

Briefly describe electric vacuum aspiration

Answer 24

Electric vacuum aspiration is the traditional surgical management of miscarriage. It involves a general anaesthetic. The operation is performed through the vagina and cervix without any incisions. The cervix is gradually widened using dilators, and the products of conception are removed through the cervix using an electric-powered vacuum.

Question 25

What is an incomplete miscarriage? What is the risk of this?

Answer 25

An incomplete miscarriage occurs when retained products of conception (fetal or placental tissue) remain in the uterus after the miscarriage. Retained products create a risk of infection.

Question 26

How is an incomplete miscarriage treated?

Answer 26

There are two options for treating an incomplete miscarriage:

• Medical management (misoprostol)
• Surgical management (evacuation of retained products of conception)

Question 27

Briefly describe evacuation of retained products of conception (ERPC)

Answer 27

Evacuation of retained products of conception (ERPC) is a surgical procedure involving a general anaesthetic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping).

Question 28

What is an important complication of ERPC?

Answer 28

A key complication is endometritis (infection of the endometrium) following the procedure.