OGCO-E24 Management of 1st trimester miscarriage (<12 week)

Question 1

Define threatened miscarriage

Answer 1

Pregnant women present with vaginal bleeding, with or without abdominal pain.

Question 2

Define silent miscarriage

Answer 2

Pregnant women may be asymptomatic, or present with bleeding with or without abdominal pain.

Question 3

Define incomplete miscarriage

Answer 3

Women present with bleeding with or without abdominal pain and passage of tissue mass.

Question 4

How to make a dx of threatened miscarriage

Answer 4

• The cervix is closed and the fetus remains viable inside the uterine cavity. The fetus is considered viable if fetal heartbeat is seen on transvaginal scanning.
• If an intrauterine gestation sac is seen or no fetal heartbeat is not observed in a fetus with CRL <7mm, the pregnancy is considered pregnancy of uncertain viability and pelvic rescan is arranged.

Question 5

How to make a dx of silent miscarriage

Answer 5

Silent miscarriage is diagnosed if, on TVUS
* CRL <7mm with no visible heart beat, and no interval change on rescan at least 7 days later
* CRL>7mm with no visible heartbeat, confirmed by second opinion or rescan at least 7 days later
* Intrauterine gestational sac with mean sac diameter <25mm and no visible fetal pole, and no interval growth on rescan at least 7 days later
* Intrauterine gestational sac with mean sac diameter >25mm, confirmed by 2nd opinion or rescan at least 7 days later

Rescan performed at least 14 days later if transabdominal scan is used.
Private scans with reports done by radiologists or gynaecologists can be accepted as a second opinion.

Question 6

What are the steps for identifying viability of fetus in early 1st trimester?

Answer 6

TVUS is preferred
* 1st to identify a fetal heart beat
* If no visible heart beat but there is a visible fetal pole, measure the crown rump length (CRL)
* Only measure the mean gestational sac diameter (MSD) if the fetal pole is not visible

Question 7

Mx

Answer 7

Question 8

Mx?

Answer 8

Question 9

How to make a dx of incomplete miscarriage?

Answer 9

Diagnosed when there was a positive pregnancy test result, a history of passage
of tissue and blood, and ultrasound findings of heterogenous material (with or without a gestational sac) with a thickness greater than 15mm inside of uterine cavity.

Question 10

How to make a dx of pregnancy of unknown location?

Answer 10

• Diagnosed when there was a positive pregnancy test result but the transvaginal ultrasound scanning does not show an intrauterine or ectopic gestation, nor does it show the retention of conception products
• Women should be followed up by serial serum hCG level with or without
  transvaginal ultrasound till hCG level is not detectable or a diagnosis of intrauterine/ ectopic pregnancy can be made.

Question 11

What are the Ix for 1st trimester miscarriages?

Answer 11

• Rhesus group if not already known (if Rh-ve will require anti-D Ig)
• Complete blood picture and type & screen if clinically indicated

Question 12

Mx of threatened miscarriage?

Answer 12

Progestogen (dupahston 10mg tds) prescribe to women who have 1 or more previous 1st trimester spontaneous miscarriage and continued till 12 completed weeks of gestation or 1 week after the bleeding stops, whichever is later. Endometrin 10mg bd vaginally can be used if patients are allergic to duphaston.
They will be followed up once every 2 weeks to asess bleeding pattern and to confirm fetal viability by transvaginal scanning.

Question 13

Mx of threatened miscarriage?

Answer 13

Expectant, medical and surgical management.

NICE guideline recommends expectant management for 7-14 days as the 1st line management therapy.

Anti-RhD prophylaxis: for non sensitized RhD-ve women with miscarriage up to 12 weeks, at least 250 IU anti-D Ig should be given as soon as possible after surgical treatment. Also should be considered for women underoing medical treatment.

Question 14

Medical tx for 1st trimester miscarriage?

Answer 14

• Done at outpatient EPAC
• Silent miscarriage: mifepristone 200mg taken orally in the presence of EPAC nurse. Women can go home after 1 hour after taking mifepristone. 4-8 hours later, misoprostol 800mg taken vaginally or sublingually at home
• Incomplete miscarriage: misoprostol 800mg taken vaginally or sublingually at home
• Asked to attend the EPAC if no vaginal bleeding 2 days after misoprostol. A 2nd dose misoprostol 800mg inserted vaginally by the EPAC nurse/doctor.
• Patient given a specimen bottle to collect any tissue mass passed vaginally. The tissue mass sent to EPAC next working day for histopathological examination to confirm product of gestation and exclude GTD.
• TVUS done at EPAC 2 weeks after misoprostol. Another dose of misoprostol 800mg or surgical evacuation can be offerred if gestational sac is found in the uterine cavity. 3 weeks after medical treatment if pregnancy test positive look for molar or ectopic pregnancy.

Those with pretreatment ultrasound with an intrauterine sac but no histopathological confirmation of product of gestation, urine pregnancy test should be checked at 6 weeks at OCFU to exclude a molar pregnancy.

Question 15

What are the contraindications to expectant or medical treatment in silent or incomplete miscarriage?

Answer 15

• Allergy to misoprostol
• Haemodynamic instability
• Suspicion of ectopic pregnancy
• Clinical evidence of sepsis or pelvic infection