Miscarriage

• Most common cause of miscarriage in the first trimester - chromosomal abnormality
• Miscarriage = spontaneous loss of pregnancy before 24 weeks
• Late miscarriage is between 12 and 24 weeks gestation
• Risk factors:

  • Increasing maternal age
  • Number of previous miscarriages
• Miscarriage in the second trimester is commonly due to an incompetent cervix e.g. previous cervical surgery, or systemic maternal illness
• Recurrent miscarriage = 3 or more (has to be consecutive)
• Threatened miscarriage:

  • Vaginal bleeding
  • Cervical os is closed
  • Ultrasound shows a viable intrauterine pregnancy
• Inevitable miscarriage:

  • Vaginal bleeding
  • Open cervical os
  • Pregnancy loss will occur
• Incomplete miscarriage:

  • Vaginal bleeding
  • Open cervical os
  • Products of conception seen on examination
• Complete miscarriage:

  • products of conception have passed
  • Cervical os closed
  • USS shows an empty uterine cavity
• Missed:

  • absent/minimal symptoms
  • Os closed
  • non-viable embryo/empty gestation sac seen on USS
  • Usually picked up on first ultrasound scan at around 12 weeks
• Symptoms:

  • vaginal bleeding
  • Cramping abdominal pain
  • Passage of any foetal tissue or clots
• Important areas to cover in the history:

  • symptoms of, and risk factors, for ectopic pregnancy
  • Menstrual history - LMP, cycle length, days bleeding
  • Pregnancy history
  • Past obstetric history
  • Past gynaecological history
  • Social history
• Clinical exam:

  • Basic observations
  • Abdominal examination - assess for signs of acute abdomen (ectopic pregnancy)
  • Speculum exam - should be performed to asses to cervical os, rule out other sources of bleeding, and assess for visible products of conception
  • If ectopic pregnancy is suspected, a bimanual examination should be performed - adnexal tenderness or a mass, and cervical motion tenderness (excitation), may be present in an ectopic pregnancy
• Investigations:

  • Transvaginal USS
  • IU pregnancy should be seen with a hCG level over 1000
  • Earliest IU pregnancy can be seen at 4+3 weeks (31 days gestation) - gestation sac
  • Embryo visible at 5+6 weeks (41 days) - foetal heart beat should be seen
• Beta-HCG:

  • Hormone produced by the placenta during pregnancy
  • If the ultrasound scan is inconclusive for an IU (there is a pregnancy of unknown location), serial beta-HCG measurements are performed
  • Levels should increase by more than 63% in 48 hours in a progressing pregnancy - ectopic is not excluded, although is unlikely
  • Levels that fall by more than 50% in 48 hours indicate a failing pregnancy
  • Levels that fall by less than 50% or fail to rise by more than 63% over 48 hours require clinical review to exclude ectopic pregnancy
• Emergency management:

  • Patients with significant haemorrhage and/or evidence of haemodynamic instability - ABCDE approach and urgent senior input
  • Speculum examination should be performed and products of conception removed - products of conception in the cervical os can lead to cervical shock
  • Continued bleeding in a haemodynamically unstable patient warrants surgical management
• 3 options for management:

  • 1st line = expectant
  • Medical
  • Surgical
• Expectant management:

  • Waiting for spontaneous passage of the products of conception
  • Lasts for 7-10 days
  • Only offer if no increased risk of bleeding, adverse experience with pregnancy, coagulopathy or evidence of infection
  • If pain/bleeding stops within this time - suggests complete miscarriage - repeat pregnancy test in 3 weeks to confirm
  • Review at 2 weeks - if pain/bleeding not started - suggests incomplete miscarriage - repeat USS
• Medical management:

  • Offered if expectant management not acceptable, or persists beyond 14 days
  • Oral 200mg mifepristone - antiprogestogenic steroid - sensitises the myometrium to prostaglandin induced contractions
  • 48hrs later misoprostol - prostaglandin analogue - induce uterine contractions and effacement of the cervix (vaginal suppository or sublingual)
  • Seek advice if bleeding not started within 24hr
  • Pregnancy test after 3 weeks
• Surgical management:

  • Patients with significant bleeding or expectant/medical management has failed, or signs of infection
  • Manual vacuum aspiration - local anaesthetic - manual suction aspiration of the uterus
  • Surgical evacuation - general anaesthetic - electronic suction
  • Often cervical priming performed beforehand to aid cervical dilatation - misoprostol
  • Rhesus negative patients should be given anti-D rhesus prophylaxis