Miscarriage

Question 1

Conservative management

Answer 1

Wait for products of conception to be passed naturally

Advantages - at home, on call gynae services
Disadvantages - Unpredictable timings, need for surgical conversion, bleeding and pain

Follow up with 2w scan / 3 week test

Contraindicated if infection, haemodynamically unstable

Question 2

Medical management

Answer 2

Mifepristone followed by misoprostol

Advantages - at home, on call gynae services
Disadvantages - side effects (D+V, bleed, pain), may need emergency surgery

Follow up with 3w pregnancy test

Question 3

Surgical management

Answer 3

Vacuum aspiration or evacuation of retained products

Indicated if infection, haemodynamically unstable.

Advantages - planned, asleep during procedure
Disadvantages - anaesthetic risk, bleed, perforation / damage to bowel, products left, infection

Question 4

Threatened miscarriage

Answer 4

Mild bleeding +/- pain
Cervix closed
TV USS: Viable pregnancy

Admit / observe if heavy bleeding
If not, reassure

If >12w and Rh-, give anti-D

Question 5

Inevitable miscarriage

Answer 5

Heavy bleeding, clots, pain
Cervix open
TV USS: internal cervical os open, fetus viable / non-viable

Admit / observe if heavy bleeding
Offer conservative / medical /surgical options - likely to proceed into incomplete / complete miscarriage.

If >12w and Rh-, give anti-D

Question 6

Missed miscarriage

Answer 6

Asymptomatic or hx of threatened miscarriage, ongoing discharge, small for dates uterus
TVUSS: no metal heart pulsation

Rescan - confirm with 2nd person
Conservative management / medical / surgical

If >12w and Rh-, give anti-D

Question 7

Incomplete miscarriage

Answer 7

POC partially expelled - sx of missed miscarriage or bleeding / clots
TV USS: Retained POC with AP endometrial diameter > 15mm AND proof of previous IU pregnancy

Expectant / medical / surgical management

If >12w and Rh-, give anti-D

Question 8

Complete miscarriage

Answer 8

Hx of bleeding, passing clots, POC and pain. Settled now
TV USS: No POC seen, endometrial diameter < 15mm

D/C to GP

If >12w and Rh-, give anti-D

Question 9

Septic miscarriage

Answer 9

Infected POC - fevers, riggers, uterine tenderness, bleeding / discharge / pain
TV USS: Leucocytosis, raised CRP, features of complete or incomplete miscarriage

Medical / surgical
IV abx and fluids

If >12w and Rh-, give anti-D