Miscarriage

Question 1

A 23-year-old primigravida presents with two episodes of dark brown spotting and abdominal pain in the first trimester. How would you assess and manage?

A 36-year-old presents with a miscarriage. Discuss your investigations and management.

Answer 1

Impression
Salient features of dark brown spotting and abdominal pain in 1st trimester, concerned about threatened miscarriage in this primigravida woman, would need to consider whether incomplete or complete miscarriage if so.

Definitions

• miscarriage: lost pregnancy before 20wks
• stillbirth: lost pregnancy after 20 wks

Would consider other obstetric diagnoses, including implantation bleed (normal), placental abruption, placenta/vasa praevia, and rule out ectopic pregnancy +/- rupture, GTD. Gynae including bleed from other source (polyp, ectropion, trauma, etc)

Question 2

Miscarriage - Assessment

Answer 2

Assessment

• would initially take AtoE assessment approach given PV bleeding in pregnancy, as risk of massive bleed with several potential complications and thus a need to rule out/assess for HD compromise, and institute appropriate management/temporising measures.
• consider need for urgent transfer to the emergency department

Question 3

Miscarriage - History

Answer 3

History

• sx: bleeding; volume, duration, colour, timing. Pain; SOCRATES, getting better or worse?
• RISK: advanced age, hx miscarriage, multiparity, infection, trauma, maternal comorbidites (SLE/APLS), previous ectopic,

Question 4

Miscarriage - Examination

Answer 4

Examination

• general appearance + vitals
• abdominal examination: tenderness, guarding, rigidity, , fundal height, rest of antenatal check
• speculum examination: site of bleeding, if ongoing, removal of any tissue for histopathological analysis
• bimanual: cervical os dilation, size of uterus, tenderness,

Question 5

Miscarriage - Investigations

Answer 5

Investigations
- Key/diagnostic: miscarriage workup including; ß-HCG, ultrasound, CTG/FHR doppler
o ß-HCG: perform serials if indicated to watch for normal rise. normally rise >66% every 48 hours, therefore can provide indication of whether viable or non-viable
o ultrasound (TA/TV): confirm location and fetal cardiac activity

• Bloods: ß-HCG, blood group + hold (+Rh, Kleihauer), FBC, coags, UEC, LFT
• Other: histopathology of any ?POC removed from birth canal, exclude GTD

Question 6

Miscarriage - Management

Answer 6

Management
Supportive
- patient education
- counselling +/- referral
- Anti-D if Rh neg
- analgesia, antipyretic

Definitive
Surgical removal of POC if expectant management failed, patient choice, or other increased risk factors of complications (bleeding, etc). management decisions depend on type of miscarriage:

Threatened:
- expectant management; waiting for normal passage of POC, follow-up/weekly ultrasound, return if bleeding worsens/persists, repeat ß-HCG

Inevitable/Incomplete/Missed miscarriage

• expectant
• Medical: misoprostol (prostaglandin analogue) +/- mifepristone (progesterone antagonist), +/- antibiotics if septic miscarriage
• Surgical: D&C, vacuum curettage; risks (Asherman’s syndrome, where scarring to the uterus and reduce future fertility).