Bleeding in pregnancy and miscarriage

Question 1

Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later.

Answer 1

Ectopic pregnancy

Question 2

Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis.

Answer 2

Hydatidiform mole/molar pregnancy

Question 3

Constant lower abdominal pain, patient is more shocked than you’d expect from the amount of blood loss. Tender and tense uterus.

Answer 3

Placental abruption

Question 4

Vaginal bleeding, no pain. Non-tender uterus but lie and presentation may be abnormal

Answer 4

Placenta praevia

Question 5

Rupture of membranes followed immediately by vaginal bleeding. Classically seen with foetal bradycardia

Answer 5

Vasa praevia

Question 6

Painless vaginal bleeding around 6-9 weeks and the cervical os is closed. Viable pregnancy.

Answer 6

Threatened miscarriage

Question 7

Light vaginal bleeding and symptoms of pregnancy. Potentially small for dates uterus and No foetal heart beat, crown rump is >7mm.

Answer 7

Missed (delayed) miscarriage

Question 8

Heavy bleeding with products of conception and clots, crampy lower abdominal pain

Answer 8

Incomplete miscarriage

Question 9

Hx of bleeding, passing clots and POC and pain but symptoms have now settled. No products of conception are seen in the uterus

Answer 9

complete miscarriage

Question 10

What is the medical management for a missed miscarriage? (3 steps)

Answer 10

1. Oral mifepristone is used to cause endometrial wall softening and induction of uterine contractions
2. 48 hours after Mifepristone, give Misoprostol which causes STRONG myometrial contractions to cause expulsion of conception contents
3. If bleeding hasn’t started within 48h after Misoprostol, contact GP

Question 11

What is the medical management of an incomplete miscarriage?

Answer 11

a single dose of misoprostol (vaginal, oral or sublingual)

Question 12

What should women with miscarriage be offered?

Answer 12

antiemetics and pain relief

Question 13

When is pregnancy test performed after miscarriage?

Answer 13

3 weeks after

Question 14

What does the cervix appear like to indicate an incomplete miscarriage?

Answer 14

Cervical os is open

Question 15

Heavy bleeding, clots, pain and cervical os is open

Answer 15

Inevitable miscarriage

Question 16

When is surgical management indicated in ectopic pregnancy?

Answer 16

All ectopic pregnancies >35 mm in size or with a serum B-hCG >5,000IU/L should be managed surgically

Question 17

When is surgical management indicated in miscarriage?

Answer 17

1. Increased risk of haemorrhage
2. The patient is in the late first trimester
3. if she has coagulopathies or is unable to have a blood transfusion
4. previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
5. evidence of infection