miscarriage is a common problem, occurring in ~50% of biochemical pregnancies and ~20% of recognised pregnancies
it usually presents clinically at 5-12 weeks gestation as vaginal bleeding in early pregnancy, although missed miscarriage (formerly called missed aborts) may be asymptomatic for some weeks and only discovered on a routine USS
there are no medical interventions which are effective in preventing miscarriage, however, patients with bleeding in pregnancy who are blood group Rh negative should be tested for antibodies and offered Rh antibody injection to prevent Rh isoimmunisation.
patients with severe pain and bleeding with possible cervical shock should have a VE in ED with removal of cervical products
patients with definite missed or incomplete miscarriage should be considered for either:
expectant management +/- hospital admission
medical management (eg. intravaginal misoprostol)
surgical management (eg. suction curettage or D&C)
the ED Mx of the patient with vaginal bleeding in early pregnancy can be seen here
categories of miscarriage
threatened miscarriage
this diagnosis is given to the patient who has bleeding in early pregnancy without evidence of fetal demise
this includes patients who have not yet had an USS as well as those who have had an USS which shows a viable fetus, or too early to assess viability.
those patients who have not yet had an USS have a risk of going onto miscarriage of ~50%
inevitable miscarriage
this diagnosis is sometimes given to those who have heavy PV bleeding and there is evidence of imminent miscarriage such as:
dilated cervix on VE
products of conception seen in cervical canal on USS
patients who are over 7 weeks gestation are at risk of cervical shock as products pass through the cervix
incomplete miscarriage
this diagnosis is given to those who have partly passed products of conception but whom have suspected or proven retained products of conception (RPOC)
these patients can be considered for either:
expectant Mx (particularly if < 7wks gestation)
medical Mx with misoprostol
surgical management
complete miscarriage
this diagnosis is given to those who have passed POC and in whom vaginal bleeding is settling and USS shows no RPOC
Mx is expectant
septic miscarriage
patients with RPOC remaining for many days, or those who have had instrumentation, are at risk of developing bacterial endometritis and what was formerly known as septic abortion.
these patients require admission to hospital for iv antibiotics and evacuation of RPOC.
missed miscarriage
these patients may have minimal or no PV bleeding but USS shows a non-viable gestation
serial HCG's may continue to rise for some weeks, particularly in cases of blighted ovum
NB. a blighted ovum must be distinguished from an early pregnancy gestational sac, and this is based upon sac size, expected gestation duration and progress of sac on serial USS. The HCG is largely irrelevant in these cases.
those with a fetal pole but no fetal heart detectable when it should be, often have falling HCGs
expectant Mx is usually not recommended as this could take weeks, thus these patients are usually offered either: