Miscarriage

Defined as the loss of an intra-uterine pregnancy at less than 24 weeks' gestation

• Early miscarriage <12 weeks
• Late miscarriage 12-24 weeks

Incidence

• About 20% of all pregnancies
• Highly influenced by maternal age, reaching about 50% in a 45 year old woman

Presentation

• Threatened miscarriage: vaginal bleeding with closed os
• Inevitable miscarriage: bleeding, cramps, open os
• Complete miscarriage: empty uterus
• Incomplete miscarriage: retained products of conception
• Missed miscarriage: no fetal heart beat, but no clinical signs of miscarriage

Differential diagnosis of vaginal bleeding in pregnancy:

• Cervical lesion
• Trauma

Imaging

• Diagnosed based on transvaginal scan with absent fetal heart beat and a crown-rump length of 7mm or more; or, in the absence of a fetal pole in the presence of a mean gestational sac diameter of 25mm or more

Management

• Expectant
• Medical
  • Prostaglandins (supports uterine contractions and cervical softening)
• Surgical
  • Indications:
    • Persistent excessive bleeding
    • Haemodynamic instability
    • Evidence of retained tissue
    • Suspected gestational trophoblastic disease
  • Vacuum pump aspiration
  • Suction curette (GA)
  • Consider rhesus status