QuestionSBA
QuestionChoice
Implantation bleeding occurs in the two weeks following conception, as the embryo implants into the endometrium. This woman is approximately 11 weeks gestation, which is after any implantation bleeding should have settled.
49901
e
Implantation bleeding
QuestionChoice
There was an intrauterine pregnancy which has now fully miscarried, with all products of conception expelled, and the uterus is now empty. The os is usually closed. The patient may have been alerted to the miscarriage by pain and bleeding.
49899
c
Complete miscarriage
QuestionChoice
This is where there are some mild symptoms of bleeding with the foetus retained within the uterus as the cervical os is closed. Hence there is the 'threat' of a miscarriage, but it is not certain. There may be little or no pain. Ultrasound reveals that the foetus is present intrauterine.
49897
a
Threatened miscarriage
QuestionChoice
The uterus still contains foetal tissue, but the foetus is no longer alive. The miscarriage is 'missed' as often the woman is asymptomatic so does not realise something is wrong. The cervical os is closed.
49900
d
Missed miscarriage
QuestionChoice
There is often heavy bleeding and pain, where the foetus is currently intrauterine but the cervical os is open. Hence it is inevitable that the foetus will be lost. Ultrasound reveals that the foetus is present intrauterine.
49898
b
Inevitable miscarriage
Concept
Chapter
# Summary
  
Miscarriage is the loss of a pregnancy before 24 weeks gestation, with over 10% of recognised pregnancies ending in miscarriage. The main clinical features are vaginal bleeding, pain and tissue loss. Differential diagnoses include ectopic pregnancy. Key investigations involve transvaginal ultrasound and potentially serial hCG measurements. Management typically involves ensuring complete removal of foetal material, either expectantly or through medical or surgical intervention. Anti-D prophylaxis may be required in rhesus negative women.
  
 
# Definition
  
 
Miscarriage is defined as the loss of a pregnancy prior to 24 weeks gestation. Just over 10% of recognised pregnancies end in miscarriage, although the total number of miscarriages is higher as some occur without the woman realising she is pregnant.
  
 
# Aetiology
  
 
The cause is often idiopathic. Known causes can be split into:
  
 
**Foetal pathology:**
 
  - Genetic disorder
  - Abnormal development
  - Placental failure
  
 
**Maternal pathology:**

  - Uterine abnormality
  - Cervical incompetence
  - Polycystic ovary syndrome
  - Poorly controlled diabetes
  - Poorly controlled thyroid disease
  - Anti-phospholipid syndrome
  

# Classification 
  
 
There are several types of miscarriage, these are:
  
 
**Threatened miscarriage**
  
 
This is where there are some mild symptoms of bleeding with the foetus retained within the uterus as the cervical os is closed. Hence there is the "threat" of a miscarriage, but it is not certain. There may be little or no pain. Ultrasound reveals that there is an intrauterine foetus present.
  
 
**Inevitable miscarriage**
  
 
There is often heavy bleeding and pain, where the foetus is currently intrauterine but the cervical os is open. Hence it is inevitable that the foetus will be lost. Ultrasound reveals that the foetus is present intrauterine.
  
 
**Complete miscarriage**
  
 
There was an intrauterine pregnancy which has now fully miscarried, with all products of conception expelled, and the uterus is now empty. The os is usually closed. The patient may have been alerted to the miscarriage by pain and bleeding.
  
 
**Missed miscarriage**
  
 
The uterus still contains foetal tissue, but the foetus is no longer alive. The miscarriage is 'missed' as often the woman is asymptomatic so does not realise something is wrong. The cervical os is closed.


# Signs and Symptoms 
  
 
  - Vaginal bleeding
  - Vaginal tissue loss
  - Abdominal/pelvic pain  
  
 
# Differential Diagnosis
  

- **Ectopic pregnancy:** Presents primarily with lower abdominal pain (may include shoulder tip pain) and also some vaginal bleeding, although classically not as much bleeding as in a miscarriage. Beta-hCG levels can help distinguish the two conditions. 
- **Hydatidiform mole:** Presents with severe nausea and vomiting, and uterus that is much larger than expected. 
- **Cystitis:** Presents with lower abdominal pain and fever, but some patients may also experience haematuria. 

  
 
# Investigations
  
**Bedside:**

* Speculum examination: Check for opening of cervix and any passage of contents. 

**Bloods:**

* Beta hCG: Serial serum hCG measurements 48 hours apart can help give an indication of the location and prognosis of the pregnancy.
    * If the levels fall then it is suggested that the foetus will not develop or there has been a miscarriage.
    *  If there is only a slight increase or a plateau in hCG levels then this may indicate an ectopic pregnancy.
    * A normal increase in hCG suggests the foetus is growing normally, but does not exclude ectopic pregnancy


**Imaging:**

  - Transvaginal ultrasound: Used to establish whether there are any foetal components within the uterine cavity and whether a foetal heartbeat can be detected.

  
 
# Management
  
 
Miscarriage often cannot be prevented or stopped. Management therefore revolves around ensuring complete removal of foetal material.

**Conservative:**

- Expectant management, i.e. allowing the products of conception to naturally expel. 
	- This is offered first-line for 7-14 days, unless: 
	    - There is an increased risk of haemorrhage (e.g. late first trimester)
	    - There are increased risks of effects of haemorrhage (e.g. coagulopathy) 
	    - Previous traumatic pregnancy experiences (e.g. miscarriage, stillbirth)
	    - There is evidence of infection. 
- Offer all women written and verbal information about expectant management of miscarriage. 
- Provide analgesia
- If there is resolution of bleeding and pain (suggesting completed miscarriage), provide the patient with a urine pregnancy test to complete 3 weeks later. If positive, to please return. 
- Offer repeat TV USS following period of expectant management if the process of bleeding and pain have not started, or if they are persisting or worsening (suggesting incomplete miscarriage). 


**Medical:**

- If this is a missed miscarriage, offer: 200 mg oral mifepristone and, 48 hours later, 800 micrograms misoprostol (vaginal, oral or sublingual)
- If incomplete miscarriage, offer: 600-800 micrograms misoprostol (vaginal, oral or sublingual) only. 
- Offer all patients anti-emetics and analgesia, as required. 
- Advise follow-up if bleeding has not started within 48h following misoprostol. 
-  Offer all women written and verbal information about medical management of miscarriage. 
-  Provide the patient with a urine pregnancy test to complete 3 weeks later. If positive, to please return. If negative but patient still symptomatic (e.g. bleeding, pain, fever), then advise to return for consideration of further management. 


**Surgical:**
  
- Offer women the choice of:
       - Manual vacuum aspiration under local anaesthetic (in outpatient or clinic setting)
       - Surgical management under general anaesthetic (in theatre)

- Usually used when medical management has failed, or if this is patient preference (e.g. due to past traumatic experiences).         
  
- If the patient is rhesus negative they may require anti-D prophylaxis.
  

# Complications 

Complications of surgical management of miscarriage: 

- Incomplete evacuation of the uterus: Caused by retained pregnancy tissue despite intervention, leading to continued vaginal bleeding and lower abdominal pain. 
- Post-uterine evacuation bleeding: This may occur following the procedure as tissue in this area is highly vascularised. 
- Asherman's Syndrome: Secondary to trauma to the endometrial lining, leading to adhesions that obstruct the uterine cavity and lead to infertility, recurrent miscarriages or high-risk pregnancy in future. 


Other complications: 

- Sepsis: May occur before or following miscarriage, especially in cases of retained products of conception. 
- Psychological impact: Very variable between patients, but offering mental health support is crucial to all patients.  
- Recurrent miscarriage: If occurs, important to investigate an underlying cause; 1-2% risk. 

 
# Recurrent miscarriage
  
 
Recurrent miscarriage is defined as the loss of 3 or more consecutive pregnancies.
  
 
**Investigations in recurrent miscarriage**
  
 
Investigations include blood tests (antiphospholipid antibodies, thrombophilia screen), cytogenetic analysis of products of conception (if abnormal then the parents should be karyotyped), and pelvic ultrasound to identify uterine abnormalities.
  
 
**Management of recurrent miscarriage**
  
 
The management is tailored to the contributing pathology:
  
 
- Genetic disorder: Refer to a clinical geneticist for genetic counselling. Options include continuing pregnancy attempts with prenatal diagnosis or use of a donor egg/sperm. 
  
-  Uterine structural abnormality: May be treated surgically. For some congenital uterine malformations there is insufficient evidence to recommend surgical treatment. 
   
- Cervical incompetence: Regular ultrasound monitoring of the cervix. May use cervical cerclage. 
  
- Polycystic ovary syndrome: Difficult to manage as pathophysiology is not fully understood. There is no consensus on the most appropriate management, especially in women who wish to conceive. Suppression of the high LH has not been found to be effective. 
  
- Antiphospholipid syndrome: Heparin or low-dose aspirin. 
  
- Thrombophilia: Heparin may increase the live birth rate. 
  
- Diabetes: Improve glycaemic control. 
  
 
# NICE Guidelines
  
[Click here for NICE CKS page on miscarriage](https://cks.nice.org.uk/topics/miscarriage/)
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Quesmed Tutorial: Obstetric Emergencies
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A 17-year-old woman presents to accident and emergency with a 4-hour history vaginal bleeding. She is approximately 11 weeks gestation. She describes the bleeding as bright red, and associated with lower abdominal cramps.

She does not complain of any unusual vaginal discharge, or any other symptoms.

On examination, her observations are normal. Her abdomen is soft and non-tender. On speculum examination, the cervical os is closed, however there is some red blood evident at the cervix.

An abdominal ultrasound scan reveals a foetus of approximately 11 weeks. A foetal heartbeat is present.

What is the diagnosis?
a