Miscarriage and Ectopic Pregnancy

Question 1

How common is ectopic pregnancy?

Answer 1

Affects 1-2% of pregnancies

Question 2

Where is the most common place for an ectopic pregnancy to implant?

Answer 2

Fallopian tube

Question 3

Miscarriage is defined as _________

Answer 3

A loss of a pregnancy before 24 weeks

Question 4

How common is miscarriage?

Answer 4

~ 20% of pregnancies miscarry

Question 5

Consider an ectopic pregnancy in all women of reproductive age with _________

Answer 5

Abdominal pain or vaginal bleeding

Question 6

When is it appropriate to order investigations in the community?

Answer 6

If clinically stable and low suspicion of ectopic pregnancy

Question 7

What investigations should you order?

Answer 7

Urinary pregnancy test if not already done
Blood tests
Pregnancy ultrasound to determine location and viability of pregnancy if appropriate

Question 8

What situations should you order a community USS with possible miscarriage/ectopic

Answer 8

Unknown gestation
> 6 weeks by dates (intrauterine pregnancy is only visible on transvaginal ultrasound from approximately 5 to 6 weeks gestation, and when bHCG is greater than 1500 IU/L).
Low suspicion of ectopic, clinically stable, and same day ultrasound is available.

Question 9

What can cause people to become clinically unstable in suspected miscarriage/ectopic pregnancy?

Answer 9

Cervical shock when POC are in the cervix
Blood loss (may be internal)
Severe pain or sepsis
Ruptured ectopic pregnancy

Question 10

Management if clinically unstable

Answer 10

Resuscitate as necessary.
Remove any POC from the cervix with sponge forceps.
Arrange transport by ambulance to ED
Insert two large-bore IV lines.
Give analgesia and continue to resuscitate until assistance arrives.
Contact the gynaecology service to let them know the patient is coming:
Send any available products of conception for histology

Question 11

Management if clinically stable

Answer 11

Symptoms highly suggestive of possible ectopic, request acute gynaecology assessment.

Prescribe anti-D immunoglobulin if rhesus negative and anti-D immunoglobin is indicated

Manage according to scan results

Question 12

tip top

Question 13

Management if scan shows viable intrauterine pregnancy

Answer 13

Reassure.
If the patient is experiencing pain, consider alternative causes and manage accordingly.

If there is ongoing vaginal bleeding:
examine the cervix (if not previously done) to exclude cervical causes of bleeding, e.g. cervical cancer, polyps, infection.
check that cervical screening is up to date

Question 14

Management if scan shows non-viable intrauterine pregnancy

Answer 14

Expectant management in primary care
Active management in secondary care

Question 15

Management if scan shows intrauterine pregnancy of uncertain viability

Answer 15

Repeat scan in 1 to 2 weeks (depending on radiologist recommendation)
Acknowledge this will be an anxious wait for your patient, but explain that performing a scan earlier may lead to another inconclusive result
Advise the patient that they may develop pain or bleeding while waiting for the scan, and what to do in this circumstance.

Question 16

If there is no USS evidence of pregnancy despite positive hCG consider…

Answer 16

Complete or incomplete miscarriage
Early intrauterine pregnancy
Extrauterine pregnancy

Question 17

Management if scan shows pregnancy of unknown location and the patient is clinically well with minimal symptoms

Answer 17

Repeat hCG in 48 hours
Repeat scan in 1 week or if hCG >2000

Question 18

Expected hCG trends in ongoing intrauterine pregnancies

Answer 18

Ongoing intrauterine pregnancies are usually expected to have a doubling of hCG over 48h up to 6 weeks gestation

Question 19

Expected hCG trends in pregnancies that are miscarrying

Answer 19

Pregnancies that are miscarrying usually see hCG levels fall by ≥50%

Question 20

Monitoring of hCG in miscarriage

Answer 20

Continue to monitor weekly until the hCG returns to zero

Question 21

hCG in ectopic pregnancies

Answer 21

Interpret hCG levels in conjunction with patient symptoms, as hCG levels in some ectopic pregnancies can mimic the expected rise or fall of a continuing pregnancy or a miscarriage.

Question 22

Management if scan shows retained products of conception - when to refer to gynae

Answer 22

Severe pain
Signs of infection
Heavy bleeding, e.g. soaking a pad in <1 hour
AP diameter of POC >20 mm on scan
USS suggestive of molar pregnancy or other concern

Question 23

Management if scan shows retained products of conception - If stable with only small amounts of POC (10 to 15 mm)

Answer 23

Reassure and consider expectant management.
Offer prophylactic abx e.g. amoxicillin + clavulanic acid 500/125 mg TDS for one week.
Inform patient: bleeding normally settles and products are usually passed with next period.

Question 24

Management if suspected molar pregnancy on USS or prev molar pregnancy/gestational trophoblastic disease

Answer 24

Refer gynae

Question 25

Management if ectopic pregnancy seen on USS

Answer 25

Refer gynae

Question 26

Expectant management of miscarriage is suitable for women who… (need to meet all these criteria)

Answer 26

First trimester
Likely to be compliant with regular follow-ups
Live locally close to hospital
No signs of infection
No evidence of cardiovascular compromise
Are informed about the time scale of passing of the POC (may be >2 weeks)

Question 27

Success rate of expectant management if missed miscarriage, (i.e. no vaginal bleeding) and/or an empty sac on ultrasound scan

Answer 27

30%

Question 28

What does expectant management of miscarriage involve

Answer 28

See weekly or more frequently if patient has concerns. Monitor hCG weekly until <5
Warn about increasing pain, infection, or heavy bleeding, and the need to be seen urgently.
Use simple analgesia.
Advise against intercourse or use of tampons while ongoing vaginal bleeding

Question 29

Options for active management of miscarriage

Answer 29

Medical or surgical
Both in secondary care

Question 30

How effective is medical management of miscarriage?

Answer 30

Effective treatment for 1st trimester miscarriage. Success rate >80%

Question 31

Pros of medical management

Answer 31

Avoids potential surgical complications and anaesthetic risks
The process of miscarriage occurs at home
Side effects are rare and mild

Question 32

Cons of medical management

Answer 32

In a small percentage of women, it is not successful, and some tissue may be left in the womb. Surgical management may be required.
For some women these medications may not be suitable, eg. certain cardiovascular or neurological medical conditions.

Question 33

When to consider surgical management of miscarriage

Answer 33

Patient lives >60 minutes from hospital
No vaginal bleeding (missed miscarriage) and an empty sac on ultrasound
Suggestion of gestational trophoblastic disease or molar pregnancy on ultrasound
Previous history of gestational trophoblastic disease or molar pregnancy
For other reasons (e.g. poor compliance), the patient is considered unsuitable for both expectant management and medical management.

Question 34

How to explain surgical management of miscarriage to patients

Answer 34

Small operation using an instrument to open the cervix and remove the remaining pregnancy tissue using a suction device. Done under local or general anaesthetic.

Question 35

Advantages of surgical management

Answer 35

You know that your miscarriage will be completed on the day of the surgery

Question 36

Cons of surgical management

Answer 36

Risks of surgery
Have to come back at a seperate date/time

Question 37

Post miscarriage patients should see their GP in ________ (time frame) and this review should include…

Answer 37

2 weeks
Review symptoms e.g. bleeding and pain.
Check your patient’s feelings about her experience, mood, and grief, and refer for counselling if necessary
Discuss contraception. Provide prescription if appropriate.
Give pre-conception advice. Script for folic acid if planning another pregnancy.

Question 38

What to do if prolonged bleeding (more than 3 weeks after miscarriage) or heavy bleeding after miscarriage

Answer 38

Consider taking swabs
If bleeding is not heavy, give broad-spectrum antibiotics such as amoxicillin + clavulanic acid, 500/125 mg three times daily for one week and review.
Check CBC

If not improved at review, or if and there are concerning features suggestive of retained POC, arrange a scan

Question 39

What effect can starting hormonal contraceptives immediately post miscarriage have

Answer 39

May experience prolonged vaginal bleeding

Question 40

If prolonged or heavy bleeding posting miscarriage need to exclude…

Answer 40

Retained POC

Question 41

Are USS funded post miscarriage?

Answer 41

Part funded if <2 weeks since miscarriage