Miscarriage Summary

Definitions

  • Threatened: Bleeding + viable pregnancy
  • Inevitable: Bleeding + open os + non-viable
  • Incomplete: Partial tissue expulsion
  • Complete: All tissue expelled
  • Missed: Non-viable + no symptoms

Risk Factors

  • Chromosomal abnormalities (most common)
  • Advanced maternal age
  • Previous miscarriage
  • Thrombophilic disorders
  • Anatomical uterine abnormalities

Clinical Features

  • Vaginal bleeding (brown to red)
  • Lower abdominal cramping
  • Lower backache
  • Bleeding precedes pain

ED Management

  • Confirm pregnancy (urine test)
  • Rule out ectopic pregnancy
  • Refer to EPAU if ≥6 weeks
  • Expectant management if <6 weeks

Management Options

  • Expectant: First-line for incomplete/missed
  • Medical: Misoprostol if expectant fails
  • Surgical: MVA or evacuation

Investigations

  • Transvaginal ultrasound
  • Serial β-hCG monitoring
  • Rh status determination

Special Considerations

  • Anti-D for Rh-negative women
  • Psychological support
  • Follow-up pregnancy test

Miscarriage

Spontaneous loss of pregnancy before 24 weeks' gestation - Comprehensive management guide

Overview

Miscarriage is the spontaneous loss of a pregnancy before 24 weeks' gestation. About 10–24% of clinically recognised pregnancies end in miscarriage. Most miscarriages occur in the first trimester.

Epidemiology: Miscarriage is the most common complication of early pregnancy, with the majority occurring in the first 12 weeks.

Classification and Definitions

Threatened Miscarriage

  • Unprovoked vaginal bleeding
  • Viable pregnancy confirmed
  • Closed cervical os
  • First 24 weeks of gestation

Inevitable Miscarriage

  • Non-viable pregnancy confirmed
  • Bleeding has begun
  • Cervical os is open
  • Will progress to incomplete/complete

Incomplete Miscarriage

  • Non-viable pregnancy
  • Partial expulsion of tissue
  • Some products remain in uterus
  • Continued bleeding/pain

Complete Miscarriage

  • All products of conception expelled
  • Bleeding has stopped
  • Uterus empty on ultrasound
  • Resolution of symptoms

Missed Miscarriage (Silent Miscarriage)

  • Non-viable pregnancy identified on ultrasound
  • No associated pain or bleeding
  • Embryo/fetus no longer developing
  • Often discovered at routine scan

Risk Factors

Fetal Factors

  • Chromosomal abnormalities (most common cause of first trimester miscarriage)
  • Genetic abnormalities
  • Defects in placental or embryonic development

Maternal Factors

  • Previous miscarriage
  • Increasing maternal age
  • Thrombophilic abnormalities (Factor V Leiden, prothrombin gene mutation)
  • Immunological abnormalities (antiphospholipid syndrome)

Additional Maternal Risk Factors

Anatomical/Structural

  • Uterine abnormalities (septate, bicornuate, arcuate uterus)
  • Cervical incompetence
  • Uterine fibroids

Endocrinological

  • Polycystic ovarian syndrome
  • Hyperprolactinaemia
  • Thyroid disease
  • Poorly controlled diabetes mellitus

Lifestyle & Environmental

  • Smoking
  • Obesity
  • Stress
  • Heavy metals, pesticides
  • High dose radiation
  • Micronutrient deficiencies

Infective

  • Bacterial vaginosis
  • Other infections

Clinical Features

Suspect miscarriage in women who are pregnant, or with symptoms of pregnancy (amenorrhoea, missed period, breast tenderness), presenting with vaginal bleeding in the first 24 weeks of pregnancy.

Bleeding Characteristics

  • Typically scanty initially
  • Varies from brownish discharge to bright red bleeding
  • May recur over several days
  • Bleeding usually precedes pain

Associated Symptoms

  • Lower abdominal cramping pain
  • Lower backache
  • Pain usually develops after bleeding onset
  • May pass tissue/clots

Differential Diagnosis

Causes of Bleeding in Early Pregnancy

  • Miscarriage
  • Molar pregnancy
  • Urethral bleeding
  • Haemorrhoids
  • Trauma of cervix, vagina or vulva
  • Cancer of cervix, vagina or vulva
  • Vaginitis
  • Cervicitis, cervical ectropion, or cervical polyps

Causes of Pain in Early Pregnancy

  • Miscarriage
  • Ruptured ovarian corpus luteal cyst
  • Pregnancy-related degeneration of a fibroid
  • Musculoskeletal pain
  • Urinary tract infection
  • Constipation
  • Irritable bowel syndrome
  • Pelvic inflammatory disease
  • Appendicitis
  • Renal colic
  • Bowel obstruction
  • Adhesions
  • Ovarian cyst (torsion, rupture, bleeding)
  • Torsion of a fibroid
  • Pelvic vein thrombosis

Emergency Department Management

Initial Assessment Protocol
  1. Confirm pregnancy with urine pregnancy test
  2. Assess for ectopic pregnancy risk (abdominal pain, tenderness, cervical motion tenderness)
  3. Determine gestation if possible
  4. Evaluate hemodynamic stability

Management Pathways

Scenario Action
Suspected ectopic pregnancy
(pain + tenderness)		 Immediate admission to EPAU/gynaecology
≥6 weeks gestation
No signs of ectopic		 Refer to EPAU for ultrasound assessment
<6 weeks gestation
Bleeding only, no pain		 Expectant management with follow-up

Follow-up protocol for expectant management: Advise repeat urine pregnancy test after 7-10 days. Return if test positive or symptoms continue/worsen. Negative test confirms complete miscarriage.

Specialist Management

Ultrasound Assessment

  • Transvaginal ultrasound is gold standard
  • Assesses location and viability of pregnancy
  • If viability uncertain due to small size: repeat scan after ≥7 days
  • Non-viability suggested by: no growth + absent heartbeat

Management Options

Expectant Management

  • First-line for incomplete or missed miscarriage
  • Duration: 7-14 days
  • Provide: Information, analgesia advice, emergency contact
  • Success rate: 80-90% for incomplete miscarriage
  • Follow-up: Urine pregnancy test after 3 weeks

Medical Management

  • Indicated if expectant management inappropriate or fails
  • Misoprostol (vaginal or oral)
  • Stimulates uterine expulsion of products
  • Follow-up: Pregnancy test after 3 weeks
  • Success rate: 85-95%

Surgical Management

  • Indications: Failed medical treatment, ongoing symptoms, patient choice
  • Options:
    • Manual vacuum aspiration (local anaesthetic)
    • Surgical evacuation (general anaesthetic)
  • Anti-D immunoglobulin for all Rh-negative women
  • Success rate: >95%

Follow-up and Monitoring

Post-Management Protocol
  1. Urine pregnancy test after 3 weeks
  2. Return if test positive (suggests retained products)
  3. Rh testing and Anti-D administration if indicated
  4. Psychological support and counselling
  5. Contraception advice if desired
  6. Future pregnancy planning discussion

Complications and Special Considerations

Immediate Complications

  • Heavy bleeding (hemorrhage)
  • Infection (septic miscarriage)
  • Retained products of conception
  • Uterine perforation (surgical complication)

Long-term Considerations

  • Asherman's syndrome (uterine adhesions)
  • Psychological impact
  • Recurrent miscarriage evaluation
  • Future pregnancy anxiety

Psychological Support: Miscarriage can have significant psychological impact. Provide empathetic care, offer counselling services, and validate the emotional experience of pregnancy loss.