History

Fact Explanation
Per-vaginal bleeding Miscarriage is defined as pregnancy loss under 24 weeks’ gestation. Spontaneous miscarriage is further classified according to clinical presentation and USS findings to threatened miscarriage, inevitable miscarriage, incomplete miscarriage, complete miscarriage & missed miscarriage. The incidence of miscarriage is 10-20% of all pregnancies.[1] Early pregnancy loss is most commonly seen in the 1st trimester but can occur in the 2nd trimester as well.
Lower abdominal pain The patient may experience cramping type lower abdominal pain due to uterine spasms. Pain & per-vaginal bleeding may be resolved in complete miscarriage while absent in missed miscarriage.[2]
Passage of tissue parts per-vaginally In incomplete and complete miscarriage products of conception will be passed per-vaginally.[2]
Fever Due to the development of infection of the products of conception.[2]
The patient can present in a collapsed state Hypovolaemic shock can develop due to heavy per-vaginal bleeding.[3]
Missed miscarriage is diagnosed by ultrasound scan (USS) where the woman is asymptomatic Missed miscarriage is the ultrasonic diagnosis of miscarriage in the absence of symptoms.[2] The patient may present with or without pain & bleeding. She may experience loss of pregnancy symptoms.
Some patients may present with recurrent miscarriages Recurrent miscarriage is defined as three or more consecutive miscarriages. Etiological agents include antiphospholipid syndrome, genetic causes, fetal chromosomal abnormalities, uterine anatomical abnormalities, thrombophilic diseases, cervical incompetence (late miscarriage) etc.[4]
References
  1. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.
  2. Ectopic pregnancy and miscarriage. National institute of health and clinical excellence, December 2012 [Viewed on 14 may 2014]. Available from : http://guidance.nice.org.uk/CG154
  3. PRINE L.W, MACNAUGHTON H. Office Management of Early Pregnancy Loss. American Family Physician. 2011 Jul,84(1), 75-82.
  4. Recurrent Miscarriage, Investigation and Treatment of Couples (Green-top 17). Royal College of Obstetricians and Gynaecologists, 2003 [Viewed on 13 May 2014]. Available from : http://www.rcog.org.uk/womens-health/clinical-guidance/investigation-and-treatment-couples-recurrent-miscarriage-green-top-

Examination

Fact Explanation
General examination: Features of shock – Increased pulse rate, low blood pressure, low urine output Due to heavy per-vaginal bleeding.[1]
General examination: Fever Infection can develop as a complication.[1]
Abdominal examination The patient may exhibit mild lower abdominal tenderness.[1]
Speculum examination This is used to assess whether the cervical os is open / closed. Cervical os is closed in threatened miscarriage while it is open in inevitable miscarriage, incomplete miscarriage. A closed cervix is observed in complete & missed miscarriage.[2] Visualization of products of conception and blood at the external os can also be made.
Vaginal examination Assess the uterine size and cervical dilatation. Adnexal mass, cervical excitation & unilateral tenderness may suggest an ectopic pregnancy which should be considered as a differential diagnosis.[3]
References
  1. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.
  2. Ectopic pregnancy and miscarriage. National institute of health and clinical excellence, December 2012 [Viewed on 14 may 2014]. Available from : http://guidance.nice.org.uk/CG154
  3. PRINE L.W, MACNAUGHTON H. Office Management of Early Pregnancy Loss. American Family Physician. 2011 Jul,84(1), 75-82.

Differential Diagnoses

Fact Explanation
Ectopic pregnancy The patient usually presents with lower abdominal pain with per vaginal bleeding. The bleeding is dark colored due to altered blood. Most of the patients will have a period of amenorrhoea. Presentation may be in a collapsed state due to hemorrhage from a ruptured ectopic pregnancy. Examination usually reveals no specific signs but cervical motion tenderness, adnexal mass, adnexal tenderness may be present occasionally. Diagnosis is made by an ultrasound scan and beta- hCG measurements.[1]
Hydatidiform mole Hydatidiform mole is a benign tumor composed of proliferating trophoblastic tissue.[2] Divided into two types : Partial mole & complete mole. Presentation is with PV bleeding, abdominal pain, passage of vesicles per vaginally, hyperemesis gravidarum and rarely symptoms of hyperthyroidism. Examination will reveal a uterine size larger than the gestational age. The beta-hCG level is usually elevated. Ultrasound scan will show a vesicular cystic image. (Snowstorm appearance)
References
  1. LOZEAU A.M, POTTER B. Diagnosis and Management of Ectopic Pregnancy. American Family Physician. 2005 Nov, 72(9), 1707-1714.
  2. Gestational Trophoblastic Disease (Green-top 38). Royal College of Obstetricians and Gynaecologists, 2010 [Viewed on 14 May 2014]. Available from : http://www.rcog.org.uk/womens-health/clinical-guidance/management-gestational-trophoblastic-neoplasia-green-top-38

Investigations - for Diagnosis

Fact Explanation
Pregnancy test - urine For the diagnosis of pregnancy.[1]
Ultrasound scan (USS) of the abdomen Aids in arriving at a diagnosis. The type of miscarriage can also be decided.[1] Retained products of conception can be visualized.
USS : Threatened miscarriage Intrauterine gestation sac is present with a fetal pole. Fetal heart activity is present.[2]
USS : Inevitable miscarriage Intrauterine gestation sac is present with or without fetal pole and fetal heart beat.[2]
USS : Incomplete miscarriage Retained products of conception can be seen. The gestation sac may be absent.[3]
USS : Complete miscarriage The uterus will be empty with an endometrial thickness < 15mm.[3]
USS : Missed miscarriage The fetal pole (>6mm) may be seen with no fetal heart activity or the gestational sac may be present with no fetal pole.[3]
References
  1. Ectopic pregnancy and miscarriage. National institute of health and clinical excellence, December 2012 [Viewed on 14 may 2014]. Available from : http://guidance.nice.org.uk/CG154
  2. PRINE L.W, MACNAUGHTON H. Office Management of Early Pregnancy Loss. American Family Physician. 2011 Jul,84(1), 75-82.
  3. JAUNIAUX E, JOHNS J, BURTON GJ. The role of ultrasound imaging in diagnosing and investigating early pregnancy failure. Ultrasound Obstet Gynecol [online] 2005 Jun, 25(6):613-24 [viewed 14 September 2014] Available from: doi:10.1002/uog.1892

Investigations - Fitness for Management

Fact Explanation
Full blood count For assessment of the hemoglobin level. An elevated white cell count can be seen in the presence of infection.[1]
Blood cross matching For emergency management of heavy per vaginal bleeding.[1]
References
  1. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.

Management - General Measures

Fact Explanation
Patient education The patient should be educated about the disease course and the management options.[1][2] The patients should be made aware about the sudden risk of spontaneous heavy PV bleeding and advised to seek medical care as quickly as possible.
Psychological support Patients who experience miscarriage need emotional support.[3] Patients should be told that it is not their fault and stress at work, heavy work, sex etc has minimal effect in precipitating a miscarriage. Advise on adequate bed rest.
Patient counseling on future pregnancies The patient should be counseled that miscarriage occurs in about 10-20% of pregnancies and this same risk carries into subsequent pregnancies.[4] There is no specific consensus on how long to wait before conceiving again. The couple can try to conceive again once both partners are physically and emotionally ready.
References
  1. GRIEBEL C.P, HALVORSEN J, et al. Management of Spontaneous Abortion. American Family Physician, 2005 Oct, 72(7), 1243-1250.
  2. BUI Q. Management Options for Early Incomplete Miscarriage. American Family Physician, 2011 Feb, 83(3), 258-260.
  3. MURPHY FA, LIPP A, POWLES DL. Follow-up for improving psychological well being for women after a miscarriage. Cochrane Database Syst Rev [online] 2012 Mar 14:CD008679 [viewed 14 September 2014] Available from: doi:10.1002/14651858.CD008679.pub2
  4. Ectopic pregnancy and miscarriage. National institute of health and clinical excellence, December 2012 [Viewed on 14 may 2014]. Available from : http://guidance.nice.org.uk/CG154

Management - Specific Treatments

Fact Explanation
Management options Miscarriages can be managed expectantly, medically and surgically.[1]
Expectant management Expectant management is considered in women who have minimal bleeding.[2][3] Patients diagnosed with incomplete miscarriage can be considered for expectant management. Patients should be warned of sudden heavy PV bleeding needing emergency surgical treatment.[4] Failure of resolution with expectant management will require surgical evacuation on a later date.
Medical management Prostaglandin analogues (misoprostol/ gemeprost) are administered either vaginally or orally. In combination, anti-progesterone agents such as mifepristone can be used.[5] As with conservative management precautions should be taken for the occurrence of sudden heavy PV bleeding.
Surgical management Evacuation of retained products of conception (ERPC) is used in patients who have heavy per vaginal bleeding.[5] The procedure performed under general anesthesia, involves cervical dilatation and manual curettage of the uterine cavity. ERPC has a high success rate of 95-100%.[6] However surgical evacuation can lead to complications such as pelvic infection, uterine perforation, haemorrhage, cervical trauma with subsequent cervical incompetence, intrauterine adhesion formation etc.
Management of heavy bleeding Manage the airway, breathing and circulation if presenting in a state of shock. After resuscitation and stabilization of the patient surgical evacuation is required.
Anti-D prophylaxis The bleeding associated with early pregnancy loss may lead to sensitization of a non sensitized rhesus-negative patient.[7] This can be prevented by administering anti-D antibodies. Anti-D 250 IU intramuscularly (IM) is administered for women undergoing uterine evacuation whose gestational age is less than 12 weeks. All women whose gestational age is more than 12 weeks need Anti-D prophylaxis with 250 IU IM before 20 weeks and 500 IU IM after 20 weeks.
References
  1. SOTIRIADIS A, MAKRYDIMAS G, PAPATHEODOROU S, IOANNIDIS JP. Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis. Obstet Gynecol [online] 2005 May, 105(5 Pt 1):1104-13 [viewed 15 May 2014] Available from: doi:10.1097/01.AOG.0000158857.44046.a4
  2. BLOHM F, FRIDéN B, PLATZ-CHRISTENSEN JJ, MILSOM I, NIELSEN S. Expectant management of first-trimester miscarriage in clinical practice. Acta Obstet Gynecol Scand [online] 2003 Jul, 82(7):654-8 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12790848
  3. SHELLEY JM, HEALY D, GROVER S. A randomised trial of surgical, medical and expectant management of first trimester spontaneous miscarriage. Aust N Z J Obstet Gynaecol [online] 2005 Apr, 45(2):122-7 [viewed 15 May 2014] Available from: doi:10.1111/j.1479-828X.2005.00357.x
  4. TRINDER J, BROCKLEHURST P, PORTER R, READ M, VYAS S, SMITH L. Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial). BMJ [online] 2006 May 27, 332(7552):1235-40 [viewed 15 May 2014] Available from: doi:10.1136/bmj.38828.593125.55
  5. CAHILL DJ. Managing spontaneous first trimester miscarriage : We don't yet know the optimal management BMJ [online] 2001 Jun 2, 322(7298):1315-1316 [viewed 15 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1120413
  6. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.
  7. KARANTH L, JAAFAR SH, KANAGASABAI S, NAIR NS, BARUA A. Anti-D administration after spontaneous miscarriage for preventing Rhesus alloimmunisation. Cochrane Database Syst Rev [online] 2013 Mar 28:CD009617 [viewed 14 September 2014] Available from: doi:10.1002/14651858.CD009617.pub2