Miscarriage

Assessment

For patients with a positive pregnancy test, consider investigation for miscarriage and ectopic if

• Abdominal or pelvic pain

• Bleeding

History

• LMP

• Gynaecological history

• Obstetric history

• The Severity of abdominal or pelvic pain

• Amount of vaginal bleeding

• Presence of IUD

• Blood group and rhesus status

Examination

• Temperature, pulse, BP

• Abdomen for tenderness

• If bleeding is heavy or hypotensive consider bimanual pelvic or spec exam. POC may not removal

• Signs of ectopic pregnancy

  • Pelvic tenderness

  • Abdominal tenderness

• Other signs may include:

• pallor.

• tachycardia (> 100 beats per minute) or hypotension (< 100/60 mmHg).

• shock or collapse.

• orthostatic hypotension.

• abdominal distension.

• rebound tenderness.

• pelvic mass.

• cervical motion tenderness.

• enlarged uterus.

Investigations

• If suspicion of infection consider swabs

• Consider pathology for POC

• If stable

  • Serial BHCG

  • Blood group and antibody screen

  • Pelvic Ultrasound

Management

• Resus if needed

• Emergency department if clinically unstable

• Send POC for histology

• If a sensitising event and the patient is rhesus negative follow bleeding in Rh neg women pathway

• If anti-D is required, give it within 72 hours

Ultrasound

• Viable intrauterine

  • Reassure

• Non-viable intrauterine pregnancy

  • No foetal heartbeat was seen in the presence of a crown-rump length >=7mm or no yolk sac seen within a gestation sac which is >=25mm. Then no significant change over 2 scans at least a week apart.

  • Expectant, medical, and surgical management

• Intrauterine pregnancy of uncertain viability

  • No foetal heart beat seen in presence of crown-rump length <7mm or no foetal pole in gestation sac <=25mm

  • Repeat scan 1-2 weeks

• Ectopic

  • If unstable, ambulance > ED

  • If stable, seek urgent advice and / or ED

• Molar

  • Refer to EPAS and contact on-call gynae

• Pregnancy of unknown location

  • No ultrasound evidence but a positive pregnancy test consider

    • Complete or incomplete miscarriage

    • Early intrauterine

    • Ectopic

  • Can do serial urinary BHCG

    • Rise of 67% over 58 hours if intrauterine

    • Miscarriage usually drops off by 50%

    • If the above patterns are not followed, ectopic more likely

  • If the diagnosis is not obvious and clinically well, repeat BHCG 48 hours

  • Repeat scan when levels >1500 or in one week

Reference

• HNE Pathways