Max Brinsmead MB BS PhD

March 2016
 RCOG Greentop Guidelines The Management of
Early Pregnancy Loss October 2006
Updated September 2011

NICE Guide Ectopic Pregancy and

Miscarriage 2012
MWB Guidelines for the conduct of an Early
Pregnancy Assessment Service 2006
 Spontaneous abortion occurs for 10 - 20% of
clinical pregnancies

Traditional management was D&C for 50 yrs

More recently conservative and medical

management have been tested by RCT

They have been found to have:

Fewer risks and complications
Less cost
Greater patient satisfaction
 A systematic approach to assessment

Close follow up

Timely intervention when indicated or requested

In many hospitals this is provided by an Early

Pregnancy Assessment Unit
 Examination of the genital tract for signs of
pregnancy and miscarriage

NB POC= Products of Conception

Classified as:
Threatened = No POC passed, cervix closed & uterus
enlarged
Inevitable = No POC passed but cervix open & uterus
enlarged
Incomplete = POC passes & cervix open
Complete = POC passed & cervix closed
Missed = Pregnancy failure & cervix closed

But ultrasound has rendered this classification

obsolete
 Requires history, examination, ultrasound +/-
quantitative measure of beta HCG

Classify miscarriage as:

Threatened = PV bleeding but intrauterine fetal heart
motion seen
Incomplete = POC passed but significant POC
remaining
Complete = POC passed and uterus is empty
Early Pregnancy Failure = No POC passed but
ultrasound evidence of failed pregnancy

Note that this classification avoids the use of the confusing term
missed abortion and the unfortunately named blighted ovum
 Undiagnosed Early Pregnancy Problem

That is pain and/or PV bleeding but

US not yet performed
US unlikely to be helpful because
HCG <1500 IU/L and/or dates <5.5 weeks
amenorrhoea

Or US cannot confirm the presence of an

intrauterine pregnancy
A common condition
1-2:100 pregnancies

Can be fatal if misdiagnosed

So think of every early pregnancy as

ECTOPIC until proven otherwise

 Heterotopic Pregnancy

That is one in the uterus plus an ectopic

Quite rare unless the patient has had

assisted conception
IVF with multiple embryos transferred

Butdifficult to diagnose if ultrasound

evidence of intrauterine pregnancy is
taken to exclude ectopic pregnnacy
 When a patient is thought to be pregnant then
the doctor or nurse arranges a quantified beta
HCG and an ultrasound scan
No history, no exam just tests!

But there is no substitute for a careful history

Because it is essential for the interpretation of

some ultrasound findings

So please dont just rely on the radiologists

report!
 Is this a planned pregnancy?
Dates are more reliable if planned
Also helps to know where she is coming from

What method of family planning did you use

prior to that?
Beware of COC and Depot

When was your last pregnancy (baby)?

For how long did you breast feed?

Has the patient had time to establish a cycle?
 What was the first day of your last period?
Not the date of the first missed period
Provide suggestions e.g. before or after Xmas
Keep trying for the best estimate of a date

Was that a normal period?

Normal in timing, duration and amount

Do you have regular periods?

What do you mean by regular?
What do you mean by irregular, how early, how late?
 When did you first think you might be
pregnant?

Has your pregnancy been confirmed?

How, when and by whom?
Urine pregnant test becomes positive at the time of
the missed period (if it is a normal pregnancy)
Have you had any scans?
When did that doctor/midwife suggest your baby might
be due?

Do you still feel pregnant?

 Most patients deserve a pulse rate, BP measure
and abdominal palpation
Vaginal exam is required when...

Ultrasound is not readily available

There has been substantial bleeding
If the patient is hypotensive
It may be corrected by clearing the cervix
The patient reports passage of tissue
Clear the cervix
Collect any tissue to confirm the pregnancy
There is doubt about the source of bleeding
There is the possibility of ectopic pregnancy
But please be very gentle
 Any vaginal bleeding
Some 15 - 30% of women will have first trimester
bleeding or spotting
And 50% of patients with vaginal bleeding will have
a failed early pregnancy
Pelvicpain is not responding to simple
measures
High risk patient
History of recurrent miscarriage
High risk of ectopic esp. previous ectopic
Advanced maternal age
Patient anxiety
 Must be a vaginal scan in all cases
Mean gestational sac size > 25 mm and no
fetal heart motion detected

Embryo >7 mm seen but no fetal heart

motion detected

If in doubt...
Tell the patient
Seek a second opinion or
Rescan in 7 14 days
 Blood group (BG) and BG antibodies
HB or FBC
Quantified beta HCG
But this is pointless if sent for immediate scan
Urine PCR for Chlamydia in high risk woman
Age < 25 yrs
Relationship < 6 months or multiple partners
High Vaginal Swab and Blood C/S if septic
Routine antenatal tests if the pregnancy is
continuing
HIV in all patients is desirable
 Surgical evacuation of the uterus

Medical evacuation of the uterus

Wait and see

Recommended as first line by NICE
 The patient is febrile (>37.50 C)
After appropriate antimicrobial management

The cervix is closed and the sac > 5cm

diam

The patient has miscarried twice before

Collect tissue for chromosomes

The patient or your health facilities are

incapable of appropriate follow up
 There are fetal parts >14 weeks in size
Surgical evacuation is unsafe

The pregnancy is >10 weeks in size, the

patient elects D&C & cervix is closed
Use Misoprostol 400 mcg to ripen the cervix 3-4 hrs
prior to dilatation

There is DIC or some other

contraindication to surgery or anaesthesia
 800mcg Misoprostol into the posterior
fornix
Oral is acceptable alternative
600 mcg is sufficient for incomplete miscarriage
Must scan or evaluate clinically to confirm
that evacuation is complete
In general echogenic material >16 mm in AP diameter is
required for the US diagnosis of retained products of
conception
(better termed incomplete miscarriage)
 Repeat clinical and USS evaluation after 3
days

Then 7 days and weekly

Must telephone or come in at any hour if

pain or bleeding is unacceptable or fever
occurs
 Several weeks of follow up may be required

20 - 50% of patients request or require

curette

Some resorb the trophoblastic tissue with

little or no bleeding

Others bleed for weeks

 Anti-D is required for EP bleeding if Rh Neg

Send all tissue for histology

Provide or arrange psychological support

Patients want an explanation for the loss
And advice about the future
Or contraceptive advice
Offer referral to GP, counsellor or a Support Group
 IV Fluids are required only for hypovolaemia
Ultrasound is not appropriate if:
< 5.5 weeks amenorrhoea
>12 weeks & uterus is palpable because a Doppler by a
midwife is diagnostic of fetal viability
The patient is shocked or in pain
For vaginal examination you require:
Some experience
Privacy
A good light
Some assistance
Some instruments to swab the vagina or clear the
cervix
 Beta HCG <250 iu/L
You can watch and wait
Admit for obs if there is a strong suspicion of ectopic
Repeat quantified beta HCG in 24 - 48 hrs
A successful pregnancy will increase by at least 63% in
48 hrs and double in 48-72 hrs
Beta HCG 500 1000 iu/L
As above but laparoscopy required if there are
symptoms or signs of ectopic
Beta HCG >3000 iu/L and an empty uterus =
Ectopic Pregnancy
Beta HCG 1000 - 3000 iu/L and vaginal ultrasound
equivocal
Laparoscopy best if there is any question of ectopic
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