24. Managment Of Spontaneous Miscarriages

Question 1

What term was previously used to describe both spontaneous and induced pregnancy loss before 22 weeks?

Answer 1

The term ‘abortion’ was previously used.

Question 2

What is the current terminology for spontaneous pregnancy loss in the first and second trimester?

Answer 2

The term ‘miscarriage’ is now used.

Question 3

What does ‘termination of pregnancy’ (TOP) refer to?

Answer 3

Induced pregnancy loss in the first and second trimester.

Question 4

What is an ‘unsafe abortion’?

Answer 4

A procedure characterized by lack of provider skills, hazardous techniques, and unsanitary facilities—whether spontaneous or induced.

Question 5

What are the two main categories of miscarriage?

Answer 5

First-trimester miscarriage and second-trimester miscarriage.

Question 6

What are the clinical features of a threatened miscarriage?

Answer 6

• Small amount of bleeding
• No or minimal abdominal pain
• Closed cervix

Question 7

What percentage of threatened miscarriages resolve and result in a normal pregnancy?

Answer 7

60% - 80% resolve successfully.

Question 8

What is the treatment for a threatened miscarriage?

Answer 8

• Confirm fetal viability on ultrasound
• Reassure if the fetus is viable
• Uterine evacuation (medical +/- surgical) if non-viable
• Serial beta-hCG if viability is uncertain or ectopic pregnancy needs to be excluded

Question 9

What are the clinical features of an inevitable miscarriage?

Answer 9

• Severe vaginal bleeding
• Painful uterine contractions
• Dilated cervix

Question 10

What are the two possible outcomes of an inevitable miscarriage?

Answer 10

It may progress to either a complete or incomplete miscarriage.

Question 11

What are the clinical features of a complete miscarriage?

Answer 11

• All products of conception (POC) expelled
• Cervix closes within 24 hours
• Bleeding settles

Question 12

What is the treatment for a complete miscarriage?

Answer 12

• Conservative management
• Monitor beta-hCG if unsure of diagnosis

Question 13

What are the clinical features of an incomplete miscarriage?

Answer 13

• Some products of conception are retained
• Bleeding continues
• Cervix remains open

Question 14

What is the treatment for an incomplete miscarriage?

Answer 14

• Resuscitation if necessary
• Suction evacuation of the uterus

Question 15

What is a missed miscarriage?

Answer 15

A miscarriage where the fetus dies but remains in utero.

Question 16

What are the clinical features of a missed miscarriage?

Answer 16

• Small amount of vaginal bleeding
• Disappearance of pregnancy symptoms
• No increase in uterine size over time

Question 17

How is a missed miscarriage diagnosed?

Answer 17

By ultrasound.

Question 18

What is the treatment for a missed miscarriage?

Answer 18

Suction evacuation of the uterus, usually by Manual Vacuum Aspiration (MVA).

Question 19

What is a septic miscarriage?

Answer 19

A miscarriage complicated by infection, leading to sepsis.

Question 20

What are the clinical features of a septic miscarriage?

Answer 20

• Pyrexia (fever) and tachycardia
• Abdominal tenderness
• Offensive products of conception (POC) or blood loss
• Risk of septic shock (high temperature, hypotension, reduced consciousness)

Question 21

What are the common causes of septic miscarriage?

Answer 21

• Unsafe abortion
• Immunosuppression

Question 22

Which type of miscarriage is associated with the highest morbidity?

Answer 22

Second-trimester septic incomplete miscarriages.

Question 23

Why is unsafe septic abortion significant globally?

Answer 23

It is a major cause of maternal mortality internationally.

Question 24

What is the treatment for septic miscarriage?

Answer 24

See following sections for detailed management.

Question 25

What defines recurrent miscarriage?

Answer 25

Three or more consecutive miscarriages.

Question 26

What are the key steps in managing an incomplete miscarriage in the first trimester?

Answer 26

- Assess blood loss - IV fluids and resuscitate if necessary - Check haemoglobin and crossmatch blood if needed - Remove POC from cervical os (to prevent vasovagal shock) with sponge-holding forceps - Check for complications: excessive bleeding or signs of sepsis - Evacuate the uterus using MVA (preferred), performed as a side-ward procedure with conscious sedation (Dormicum + Fentanyl)

Question 27

How does the management of incomplete miscarriage in the second trimester differ from the first trimester?

Answer 27

Includes all steps as in the first trimester, with additional measures: - If the fetus is still in utero, initiate abortion using oxytocin infusion or oral misoprostol - Check if the placenta and membranes are completely expelled; if incomplete, careful evacuation of the uterus is required - If evacuation is required, perform suction and blunt curettage to minimize the risk of perforation - Administer ergometrine IV to contract the uterus if necessary

Question 28

What are the key monitoring steps for septic miscarriage?

Answer 28

- Monitor temperature, pulse, blood pressure, and respiratory rate every 30 minutes - Perform blood culture - Assess for signs of septic shock (warm peripheries, hypotension, decreased urine output)

Question 29

Why is catheterization important in septic miscarriage?

Answer 29

To monitor urine output, which should be more than 30ml/hr.

Question 30

What are the initial resuscitation steps in septic miscarriage?

Answer 30

- IV fluids (crystalloids) - Crossmatch blood and transfuse if necessary - Administer broad-spectrum IV antibiotics (penicillin, gentamycin, metronidazole)

Question 31

What investigations should be performed in septic miscarriage?

Answer 31

- Full blood count (FBC) - Urea and electrolytes (U&E) - Disseminated intravascular coagulation (DIC) screen - Liver function tests (LFTs) to assess organ dysfunction - Arterial blood gases (ABG)

Question 32

What additional supportive treatments should be provided?

Answer 32

- Oxygen via face mask - ICU admission if in septic shock

Question 33

When should uterine evacuation be performed in septic miscarriage?

Answer 33

Within 24 hours, preferably in theatre under general anesthesia (GA).

Question 34

When is a hysterectomy indicated in septic miscarriage?

Answer 34

If sepsis persists and/or there is more than one dysfunctional organ system.

Question 35

How does gynecological ultrasound aid in the management of early pregnancy bleeding?

Answer 35

It enables confirmation of pregnancy viability.

Question 36

What is the recommended model of care for early pregnancy assessment?

Answer 36

A day-care early pregnancy evaluation unit where: - Women are assessed and examined - Beta-hCG estimation is done - Transvaginal ultrasound is performed This allows for prompt diagnosis and management.

Question 37

In a woman with a positive pregnancy test, closed cervix, bleeding, and pain, what must always be excluded?

Answer 37

Ectopic pregnancy.

Question 38

What are pregnancies of unknown location?

Answer 38

Pregnancies where ultrasound does not yet confirm an intrauterine or ectopic pregnancy.

Question 39

What ultrasound findings confirm a viable intrauterine pregnancy?

Answer 39

- A visible intrauterine sac - A fetal pole - Fetal heartbeat

Question 40

At what beta-hCG level should an intrauterine pregnancy be visible on transvaginal ultrasound?

Answer 40

When beta-hCG is >1500 IU.

Question 41

At what beta-hCG level should an intrauterine pregnancy be visible on transvaginal ultrasound?

Answer 41

When beta-hCG is >1500 IU.