Miscarriage

Question 1

What does a missed miscarriage refer to?

Answer 1

where fetus is no longer alive but no symptoms have occured

Question 2

What does a threatened miscarriage refer to?

Answer 2

vaginal bleeding with a closed cervix and a fetus that is alive

Question 3

What does an incomplete miscarriage refer to?

Answer 3

retained products of conception remain in uterus after miscarrriage

Question 4

What does a complete miscarriage refer to?

Answer 4

full miscarriage has occured

Question 5

What does an anembryonic pregnancy refer to?

Answer 5

a gestational sac is present but contains no embryo

Question 6

What is the gold standard investigation for diagnosing a miscarriage?

Answer 6

transvaginal ultrasound scan

Question 7

What are the three features you should look for on an US in early pregnancy?

Answer 7

• mean gestational sac diameter
• fetal pole and crown-rump length
• fetal heartbeat

Question 8

When is a pregnancy considered viable on US scan?

Answer 8

• when a fetal heartbeat is visible

- fetal heartbeat is expected when crown-rump length is 7mm or more

Question 9

What should be done when US shows a crown-rump length < 7mm without a fetal heartbeat?

Answer 9

-scan is repeated after at least one week to ensure heartbeat develops

Question 10

What should be done when US shows a crown-rump length > 7mm without a fetal heartbeat?

Answer 10

-scan is repeated after one week before confirming non viable pregnancy

Question 11

When is a fetal pole expected?

Answer 11

-once the mean gestational sac diameter is 25mm or more

Question 12

What should be done when US shows a mean gestational diameter > 25mm with no fetal pole?

Answer 12

-scan is repeated after one week before confirming an anembryonic pregnency

Question 13

What is the general management of miscarriage before 6 weeks?

Answer 13

• expectant management which involves waiting without investigations or treatment
• US is likely to be unhelpful as too early so too small t be seen
• repeat urine pregnancy test after 7-10 days, if negative a miscarriage can be confirmed
• if bleeding continues referral and further investigation is needed

Question 14

What is the general management of miscarriage after 6 weeks?

Answer 14

• referral to EPAU for women with positive pregnancy test and bleeding
• EPAU will arrange an US which will confirm location and viablity of pregnancy

Question 15

What are the 3 options of managing a miscarriage?

Answer 15

• expectant management
• medical management (misoprostol)
• surgical management

Question 16

Which women are offered expectant management for a miscarriage?

Answer 16

• first-line for women without rfs for heavy bleeding or infection
• 1-2 weeks are given to allow miscarriage to occur spontaneously
• repeat urine pregnancy test repeated 3 weeks after to see if complete

Question 17

What is the medical management for miscarriage?

Answer 17

-dose of misoprostol to stimulate miscarriage - a prostaglandin analogue which softens cervix and stimulates uterine contractions
-can be vaginal suppository or oral

Question 18

What are key side effects of misoprostol?

Answer 18

• Heavier bleeding
• Pain
• Vomiting
• Diarrhoea

Question 19

What are the surgical management options for miscarriage?

Answer 19

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

Question 20

how is manual vacuum aspiration performed?

Answer 20

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 21

how is electric vacuum aspiration performed?

Answer 21

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 22

A 28-year-old woman attends the early pregnancy assessment unit at 7 weeks gestation due to heavy vaginal bleeding. Ultrasound confirms an intra-uterine miscarriage.

After 14 days of expectant management the patient attends for follow up. She describes ongoing light vaginal bleeding. There are no signs of ectopic pregnancy and she is haemodynamically stable. Ultrasound scan confirms incomplete miscarriage.

What is the most appropriate next step?

A. Admission and observation

B. Manual vacuum aspiration under local anaesthetic

C. Oral methotrexate

D. Surgical management under a general anaesthetic

E. Vaginal misoprostol

Answer 22

E. vaginal misoprostol

The NICE miscarriage Clinical Knowledge Summary states that medical management is offered if expectant management is not clinically appropriate or a woman has ongoing symptoms after 14 days of expectant management. This may be with either vaginal or oral misoprostol.

Manual vacuum aspiration and surgical management are options which may be used if products of conception are retained despite medical treatment or if symptoms are ongoing after 14 days of expectant management. These options may be considered at this stage but it would be unusual with only mild ongoing symptoms and haemodynamic stability.

Admission and observation would not normally be required in a patient who is not haemodynamically compromised. In most cases, women can go home after taking misoprostol for the miscarriage to complete.

Oral methotrexate is used in the medical management of ectopic pregnancy.

Question 23

definition of miscarriage

Answer 23

expulsion from its mother of an embryo or foetus <24 weeks gestation (& weighing <=500g)

Question 24

what’s a septic miscarriage?

Answer 24

where there is retained products of conception either in the uterus or in the cervical canal.
This can then become infected–> sepsis
-temperature/feeling unwell
-cervical os will likely be open

Question 25

Miscarriage types summary

Answer 25

Question 26

A 24 year old primigravida woman is identified via prenatal screening to be rhesus D negative.

In which of the following situations would it be inappropriate to give anti-D?

A. At 28 and 34 weeks of this woman’s uneventful pregnancy

B. Miscarriage, medically managed at 8 weeks

C. Delivery of a Rhesus positive stillborn.

D. Termination of pregnancy at 10 weeks

E. Amniocentesis

Answer 26

B. Miscarriage, medically managed at 8 weeks

Miscarriage at 12 weeks or beyond, or surgically managed miscarriage at any time is an indication for anti-D prophylaxis.

Examples of sensitisation events include:

-Antepartum haemorrhage
-Placental abruption
-Abdominal trauma
-External cephalic version
-Invasive uterine procedures such as amniocentesis and chorionic villus sampling
-Rhesus positive blood transfusion to a rhesus negative woman
-Intrauterine death, miscarriage or termination
-Ectopic pregnancy
-Delivery (normal, instrumental or caesarean section)

Question 27

types of miscarriage summary

Answer 27

Question 28

miscarriage management options

Answer 28

Question 29

options for managing an incomplete miscarriage (& risks associated):

Answer 29

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.

There are two options for treating an incomplete miscarriage:

1. Medical management (misoprostol)
2. Surgical management (evacuation of retained products of conception)

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): ERPC interchangable with D & C (dilation and curettage)

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