MISCARRIAGE

Question 1

MANAGEMENT: UNSTABLE

Answer 1

Bolus 30 mL / kg NS

2 U O- blood if blood type not know and blood needed immediately

Norepinephrine 0.01 - 0.3 ug/kg/min if indicated

Oxytocin IV if non viable pregnancy and ongoing heavy bleeding

If Rh(D)-:
Rh(D) immunoglobulin 50 μg IM (<13 weeks gestation) as soon as possible and within 72 hours.

If 50 ug not available, give 300 μg IM dose.

STAT REFERRAL TO OBGYN

INVESTIGATIONS
Rh status
Quantitative Serum Beta-hCG
CBC
Coags
Group and Screen

Transvaginal U/S

Question 2

MANAGEMENT: STABLE

Answer 2

Expectant
management.

OR

Misoprostol 800 mcg vaginally or buccaly

May repeat dose in 7 days if complete expulsion does not occur

+/-

Mifepristone 200 mg PO 24 hrs before Misoprostol

OR

Surgical (D+C)

• If os is open: attempt to remove products of conception to relieve pain, if
  unsuccessful consult OB

Rh(D) immunoglobulin:
50 μg IM (<13 weeks gestation)

300 μg IM (>13 weeks gestation) should be given as soon as possible and within 72 hours.

If 50 ug not available, give 300 μg

DISPOSITION
Viable Uterine Pregnancy / Threatened Abortion: Follow up with Family Physician or OB
Repeat bHCG and US

Inevitable / Incomplete
Complete / Missed:
strict return precautions, including heavy vaginal bleeding (eg, more than 2 saturated pads/hour), fever and worsening pain.

Question 3

DOCUMENTATION

Answer 3

HISTORY
Vaginal Bleed
Uterine Cramping

PHYSICAL
Pelvic and Speculum may be omitted with hemodynamically stable with mild-to-moderate bleeing

Pelvic and Speculum required in heavy bleeding and hemodynamic instability

Positive within 7-10 days of contraception
Beta HCG should double every 48 hrs
Lowest level Beta HCG an IUP can be visualized is 3000 transabdominally and 1500 transvaginally

EDE TRANSABDOMINAL: CRITERIA FOR IUP
Yolk sac (double ring) or Fetal Pole with Heart Rate
Gestational Sac
Decidual Reaction

Bladder-Uterine Juxtaposition
Vaginal Uterine Continuity

Adequate myometrial mantle (>/ 8 mm)

HR >/100 = viable

Question 4

DDX for vaginal bleeding in 1st TM pregnancy

Answer 4

Trauma

Septic Miscarriage

Miscarriage:
Threatened
Inevitable
Incomplete
Complete
Missed
Septic

Ectopic / Heterotopic Pregnancy

Pregnancy of Unknown Location

Molar pregnancy
subchorionic hematoma
implantation bleeding