Malady Wise

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Miscarriage

Maladywise

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