Miscarriage

Diagnosis

Ultrasound scan for miscarriage

Management

Blood transfusion

This includes threatened, inevitable, incomplete, complete & missed miscarriages.

The term ‘abortion’ should be replaced by ‘miscarriage’ especially when used in front of patients.

Miscarriage may cause extreme distress to some patients while others seem genuinely untroubled & accepting. Patients’ feelings, especially self-blame & grief, must be considered. Reassurance is important. Patients need to know that spontaneous miscarriages are not their fault, & that miscarriage is mostly a natural process that removes faulty pregnancies. Subsequent pregnancies can usually be expected to be successful. 

Diagnosis

• The patient presents with bleeding and usually a history of missed periods
• Products of conception (fetus, placenta, ‘fleshy’ fragments) may have been passed suggesting a complete miscarriage (cervix closed) or incomplete miscarriage (cervix open)
• The presence of pain &/or bleeding without passage of products & a closed cervix suggests threatened miscarriage. Bleeding, however slight, with a closed cervix & a dead embryo or fetus on scan is technically not a ‘missed’ miscarriage. ‘Missed’ miscarriage does mean discovered without symptoms.
• Inevitable miscarriage presents with pain, an open cervix, & no passage of products (as yet). Remember the external os may be open in the parous patient (who has had a previous birth) when the internal os is closed. Always check for fetal heart beat on ultrasound.
• Incomplete miscarriage – if there are products emerging from an open os the sonar is merely to confirm that the fetus has passed
• Complete miscarriage should be diagnosed if the patient has passed products, the pregnancy test is positive, the uterus is empty, & an ectopic pregnancy has been excluded. The bleeding on history should have been more than expected for menstruation, usually with clots. Lower abdominal tenderness is mild, unless there is uterine sepsis
• Consider other causes of bleeding & pain, including ectopic pregnancy

Ultrasound scan for miscarriage

• Ultrasound is not necessary if products of conception are found in the cervical os & uterine size is clear, as this indicates incomplete miscarriage
• Ultrasound may show:
  • A viable intrauterine pregnancy
  • A nonviable intrauterine pregnancy
  • An empty uterus
  • Other pathology – hydatidiform mole, adnexal mass, free fluid etc.
• Ectopic pregnancy & complete miscarriage can be distinguished on history (amount of bleeding: Ectopic – little, Complete miscarriage – a lot) & not necessarily on sonar. If in doubt, follow-up if necessary

Management

Threatened miscarriage

1. No specific treatment
2. Reassure the patient: if the fetal heart is active there is a 90+% chance that the pregnancy will continue
3. Discharge the patient home, to attend the antenatal clinic, to return if the pain/bleeding increase

Complete miscarriage

1. Ensure that this is truly a complete miscarriage, as stated above
2. Explain what has happened
3. Discharge the patient home if she is clinically stable

Inevitable & incomplete miscarriage

1. If there are few products in the cavity, the fetus has passed & the os is open in the first trimester, the modern management is conservative. Advise the patient that bleeding will settle over 2-10 days. No manual vacuum aspiration (MVA) is required.
2. If there is (or has been) significant bleeding, insert an IV drip (14 or 16 gauge), with oxytocin 20 units in 1L Ringer-lactate. Resuscitate with IV fluids if there is hypovolaemic shock
3. If at all unstable, take blood for FBC, U&E & X-match, ABG
4. Do a ‘ward’ haemoglobin level to guide X match/resusc
5. If the patient is clinically stable, less than 14-16 weeks pregnant, the fetus has been expelled, with a normal ward Hb (>9-10 g/dL), & with no evidence of sepsis or suspicion of unsafe abortion, an MVA can be offered to all incomplete miscarriages (see below). At </= 10 weeks management may be conservative if there is NO possibility of sepsis
6. Other patients should be admitted for uterine evacuation
7. Antibiotics should be given if there is any suggestion of infection, or a history of interference: use the same regimens as for PID (Pelvic Inflammatory Disease)
8. Ensure that patients who are severely anaemic are on blood transfusion at the time they need to go for evacuation
9. The evacuation list should be compiled on the morning post-intake round
10. Septic or severely bleeding patients may need emergency evacuation
11. Many second trimester miscarriages may be pregnancy terminations from private or other practitioners, & that this history may not be given
12. Some patients may be more unwell than they at first appear
13. ALWAYS inform the anaesthetist, other staff of an unwell patient

Blood transfusion

A pre-operative Hb level of 8 g/dL may be adequate for evacuation in theatre if the patient is stable, not bleeding, has passed a fetus & is not septic. Other patients should have an Hb level of 10 g/dL before evacuation can be safely done, & should be transfused to that level. Discuss with the anaesthetist.

Septic incomplete miscarriage

1. Severe cases may rapidly go into septic shock & multiple organ failure
2. Signs are hypotension, offensive products, tachycardia, pyrexia, & tachypnoea (with nasal flaring)
3. Assess thoroughly for organ dysfunction – FBC, U&E, clotting, chest x-ray, ABG if necessary. Occasionally ventilation may be required. Check the chest for pathology too..
4. Hourly nursing observations to identify septic shock
5. Urinary catheter & monitor urine output hourly. If good - vigorous fluid resusc should be used
6. Speculum to inspect the cervix for trauma & necrosis (dusky blue or black areas –ask someone if you are not sure)
7. Triple intravenous antibiotics, as for severe acute PID (Pelvic Inflammatory Disease)
8. Emergency evacuation may be necessary
9. Uterine evacuation must be done by at least a senior MO or registrar
10. Hysterectomy if there is a dusky or gangrenous cervix, generalized peritonitis, septic shock, failure of two or more organ systems or uncontrollable bleeding. Look for disseminated intravascular coagulopathy, renal failure, & acidosis (tachypnoea, arterial blood gas).
11. If hysterectomy is required there is no need to remove ovaries, unless they are involved in adnexal abscesses. This surgery MUST be performed by a consultant