see also:

• vaginal bleeding in early pregnancy
• 2nd trimester miscarriage
• ectopic pregnancy
• 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

• 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
• furthermore, 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

• 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%

• 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

• 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

• 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

• 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.

• 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:
  • medical Mx
    • 400-800ug pv misoprostol
    • just over 50% of respondents to survey passed POC within 24 hours of 1st dose
    • 40% require a 2nd dose on day 2 if POC not yet passed
    • 25% made unscheduled visits for care (outside of day 1, 3 and 7 scheduled visits)
    • median duration of reported bleeding post-dose was ~10 days
    • can avoid surgical Mx in ~78% of cases of missed miscarriage < 13wks
    • only 18% indicated that they would prefer surgical Mx next time
    • overall failure rates of ~13% as determined by retained sac on USS 1 week post initial dosing, although failure rates of 20% were recorded for those who required a 2nd dose compared with 10% for those who only required 1 dose ¹⁾
    • patients should have a urine pregnancy test at 6wk follow up to exclude gestational trophoblastic disease
  • surgical Mx

• aka gestational trophoblastic disease (GTD)
• molar pregnancies present as vaginal bleeding and are detected on USS with typical findings being seen
• they are usually associated with very high HCG levels
• these patients need gynae referral for evacuation of the molar prgenancy and close follow up to ensure it does not progress to a choriocarcinoma
• see molar_pregnancy