see also:

• miscarriage
• 2nd trimester miscarriage
• gynaecology
• pregnancy and risks of fetal loss
• Rh isoimmunisation and Anti-D prophylaxis
• Western Health early pregnancy assessment service (EPAS) referral process
• DOH Victoria Guidelines on Mx of bleeding in early pregnancy 2011 (pdf)
• patient information sheets:
  • Western Health ED - early pregnancy loss - Vietnamese version

• implantation bleed
• miscarriage - threatened / inevitable / incomplete / complete / missed / septic
• ectopic pregnancy
• molar pregnancy
• in 2nd TM, chorioamnionitis
• uncommonly, local causes:
  • cervical polyps
  • cervical dysplasia / CIN / cervical cancer
  • cervicitis
  • cervical ectropion

• stable patients may be streamed to the appropriate ED stream eg. SSU or Fast Track
  • pain manageable with oral analgesia (paracetamol and codeine are safe in early pregnancy)¹⁾
  • mild-mod vaginal bleeding
  • no ongoing passage of products of conception (POC)
  • not significantly tachycardic or hypotensive
• unstable patients should be streamed to an emergent ED care cubicle for possible iv bung and early medical assessment:
  • patients with very heavy PV bleeding with clots and severe pain should have an urgent vaginal speculum examination to look for, and remove any products of conception (POC) at the cervical os which may otherwise cause cervical shock which is a vasovagal reflex bradycardia mediated hypotensive episode.
  • removal of POC is usually best performed using a sponge holder forcep under direct vision of the os once blood within the vaginal vault has been adequately cleared using gauze.
  • any POC removed should be sent for histology for confirmation as decidual lining or clot can be mistaken as being POC.
  • as long as this procedure is performed prior to 20 weeks when there is no risk of placenta praevia, and the procedure is restricted to gentle evacuation of the external os, there is no evidence to suggest there is risk to an ongoing pregnancy.
  • note that multiparous women often have a patulous os which can be mistaken for an open os and thus care should be taken in giving pessimistic advice on this finding alone in the multiparous.
  • on-going heavy bleeding should consider:
    • IV blood Tx as indicated
    • rapid access to theatre - or, at least escalation to gynae team
    • tranexamic acid IV
    • ergometrine
    • repeat vaginal spec exam to further remove products
• spontaneous miscarriage whilst waiting for assessment:
  • whilst the above tries to risk manage patients at risk of miscarriage²⁾, some relatively stable patients will inevitably go to the toilet whilst waiting to be assessed and some may have the miscarriage in the toilet.
  • this regrettable and distressing circumstance cannot always be predicted and thus cannot always be avoided

• ask about LNMP and determine estimated gestation of this pregnancy
• ask about dates and results of pregnancy tests or USS for this pregnancy
• if not had a documented positive HCG or USS evidence of pregnancy, then check urine HCG
• if more than ~12 weeks, abdominal palpation may confirm approximate gestation
  • fundus at umbilicus = 20wks
  • fundus half way to umbilicus from pubic symphysis = 15wks

• prior pregnancies & document as GxPy
• significant past history, allergies, medications (including folate supplements)
• last Pap smear (cervical dysplasia is an uncommon cause of pregnancy bleeding but easily missed)
• IVF program or ovulation induction to get pregnant
  • this raises possibility of multiple pregnancies and the problem that US may not be able to exclude an ectopic.
• location of lower abdominal pains - if lateral, strongly consider ectopic pregnancy.
• Rh status (may need to check path. system or ask patient for a blood group card) & whether patient has had Anti-D before unless patient has already received Anti-D within past 2wks, then if unknown or Rh negative, take blood for Rh Gp & Ab's, notify lab of possible need for AntiD if you wish to have the AntiD available in a timely manner.
• if taking blood and patient is less than 8-9wks pregnant then also take a serum HCG
• if patient is less than 7 weeks pregnant, take blood for serum HCG

• with the advent of timely USS examinations and serial HCG's where needed, the role of vaginal examinations for bleeding in early pregnancy has become much narrower³⁾, and usual indications now include:
  • to help exclude ectopic pregnancy and risk manage those patients who can be safely discharged home when USS is not available
  • removal of possible POC in patients with heavy bleeding and pain
  • to exclude local causes if patient is felt to be at risk of having a local pathology (eg. trauma, infection, polyps, etc)
  • to perform vaginal swabs in those with 2nd TM liquor loss or PV bleeding to exclude chorioamnionitis
• patients can be reassured that vaginal examination does not increase nor decrease the risk of miscarriage.
• the finding of a large for dates uterus suggests either:
  • incorrect dates
  • multiple pregnancies
  • uterine fibroid
  • or rarely, molar pregnancy
• the finding of pain on rocking the cervix (cervical excitation) or adnexal tenderness raises the possibility of ectopic pregnancy

• if patient has POC then place in specimen container, show ED doctor and label as for pathology specimen and sent for histology
• contact O&G registrar to consider management options, else proceed as follows.

• ie. ectopic unlikely
• discharge home with LMO to follow up serial HCG's.

• at Western Health consider referral to WH EPAS that day for screening USS if possible
• if IVF or ovulation induction with lateral pain then contact O&G registrar as US cannot exclude ectopic.
• if intrauterine pregnancy seen with FH present then:
  • if 2nd TM, then d/w gynae reg as may need admission or cervical swabs to exclude chorioamnionitis
  • otherwise, counseling & discharge home with F/U by LMO to arrange formal USS.
• if intrauterine pregnancy seen but no FH detected then:
  • formal USS that day or next day and send serum HCG if not done.
• if no intrauterine pregnancy seen on screening USS:
  • possibilities are very early pregnancy (<6wks), ectopic pregnancy or complete miscarriage
  • re-check gestation with patient paying attention to LNMP, date of 1st positive pregnancy test
  • if some lateral pain/tenderness, then urgent formal US to help exclude ectopic pregnancy
  • if definitely < 6wks and no clinical features of ectopic pregnancy then LMO F/U with serial HCG's and if rising normally, a formal US in 7-10days.
  • if > 6wks and no clinical features of ectopic pregnancy then LMO F/U with serial HCG's and a formal US in 1-2days.
• if screening USS is not able to be performed before discharge:
  • the patient may be discharged home for outpatient formal USS and/or review in a EPAS clinic, if:
    • bleeding is settling and no evidence of cervical shock
    • clinical suspicion of ectopic pregnancy is low
    • patient is able to cope with current level of bleeding and pain
  • other patients should be discussed with gynae registrar to consider admission for observation.

• contact O&G registrar for Mx of ectopic pregnancy.

• counseling & discharge home with F/U by LMO

• at Western Health consider referral to WH EPAS
• if confident of missed abort then contact O&G registrar to determine Mx option such as D&C (expectant Mx has a low probability of success in this group with less than a third achieving complete evacuation without curettage). 
  • missed abort is suggested by either:
    • fetal pole > 2mm but no FH
    • gestational sac > 15-25mm, especially if > 6wks pregnant by 1st positive pregnancy test
      • an empty gestational sac > 20mm is 99.5% sensitive for non-viable pregnancy (as 1 in 200 may still be viable, some repeat US in 7-10 days to confirm non-viability unless sac size is > 25mm)⁴⁾
    • repeat formal USS more than 7 days after a first USS which showed an intrauterine pregnancy
  • NB. HCG's may continue to rise for 1st 15wks or so in blighted ovum but will then fall after D&C
• if possible early pregnancy (eg. sac size < 15-25mm) or significant patient anxiety, consider repeat US in 7-10 days

• if < 7wks and haemodynamically stable:
  • expectant Mx at home is reasonable
• if haemodynamically unstable or passing very large clots with pain:
  • IV fluids, send blood for FBE, Gp & hold +/- HCG level.
  • speculum examination to exclude POC in cervix which may cause cervical shock - if present, remove if possible and call O&G reg.
  • call O&G reg for probable admission and suction curettage
• if > 7wks, haemodynamically stable without ongoing large clots:
  • call O&G reg to discuss options:
    • expectant Mx
    • expectant Mx after misoprostol PV
      • “In general, the evidence demonstrates advantages of misoprostol over available alternatives for use in medical management of miscarriage and termination of pregnancy in the first and second trimesters. The advantages are that it is at least as effective as alternatives, has fewer side effects, is more practical to use and is cheaper. Recent research reports suggest that alternatives to misoprostol are used with diminishing frequency. The occurrence of maternal side effects is reduced when using lower doses of misoprostol, when compared with higher cumulative doses.”
      • RANZCOG guideline - misoprostol Nov 2007 (pdf)
    • suction curettage

• at Western Health consider referral to WH EPAS
• possibilities are very early pregnancy (<6wks), ectopic pregnancy or complete abort
• re-check gestation with patient paying attention to LNMP, date of 1st positive pregnancy test
• if definitely < 6wks and no clinical features of ectopic pregnancy then LMO F/U with serial HCG's and if rising normally, a repeat formal US in 7-10days, but warn to return ASAP if pain develops.
• check serum HCG level and discuss with O&G registrar as intrauterine pregnancy should be seen on formal TV USS if HCG is > 1500 units, otherwise consider ectopic pregnancy.
• if falling HCG's, then probable complete abort, LMO F/U with repeat HCG in 1wk to confirm still falling as occasionally tubal aborts may present like this and then have delayed rupture.
• although not usually available, a serum progesterone level < 20nM predicts spontaneous pregnancy resolution with a sensitivity of 93% and spec. of 94% and thus D&C could be avoided but ongoing pregnancy is still possible, thus follow HCG levels.

• has Rh group & Abs been attended to with possible Anti-D administration and patient information sheet, and the need for repeat testing if recurrence of bleed after 2wks post Anti-D.
• discharge letter to LMO with clear discharge plan that patient understands
• pathology and/or radiology request forms
• work certificate if needed
• outpatient appointment if needed
• medical and expectant management options for miscarriages should only be offered when women can access a 24hr telephone advice service and emergency admission if required.
• any products of conception should be sent to histology to confirm POC rather than just a decidual cast. 
  • histology not only helps confirm miscarriage but uncommonly, it may identify hydatidiform moles, villous dysmorphic features suggesting fetal aneuploidy, chronic histiocytic intervillositis (CHI) and massive perivillous fibrin deposition and impaired trophoblast invasion. However, in most cases, morphological assessment cannot reliably determine the cause of the miscarriage or distinguish recurrent from sporadic miscarriage. ⁵⁾
• counseling about miscarriages including:
  • if needed, what to watch for if possible ectopic pregnancy
  • usual chances of miscarriage (eg. 1 in 4-5) and current chance of miscarriage given evidence to date (see here)
  • probability of normal baby despite the bleeding given normal 18wk USS, is similar to most people of ~95%.
  • if 3 or more miscarriages then consider O&G follow up.
  • advice about need for folic acid supplementation before and during pregnancy
  • advice on avoidance on medications (eg. aspirin, NSAIDs) apart from safe medicines such as paracetamol.

• Vic DHS - bleeding in early pregnancy (pdf)
• Vic DHS - miscarriage (pdf)
• SANDS