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Obstetrics & Gynaecology Series: Miscarriage | David CahillMiscarriage Clinical Assessment & Diagnosis Counselling & Emotional Support Decision-Making in Complex Scenarios Interprofessional Collaboration Tailored Patient EducationClinical Assessment & Diagnosis • Pulse, blood pressure, respiratory rate, evidence of shock • Relevant history – nausea, vomiting, nocturia, constipation, • LMP • When? • Amount? • Pain? • Timing of PainExamination • ABC (vital signs) – as on the last slide – SO IMPORTANT • Abdominal – mass to palpate • Vaginal (speculum) • Cervical state - open/closed; tissue in the os? – what to do with it? • Amount of bleeding Terms • Threatened miscarriage Vaginal bleeding at < 24 weeks gestation • Delayed (Missed) miscarriage Gestational sac with/without fetus present (but no FH) • Inevitable miscarriage Could still be a fetus +/- FH but the cervical os is open and there is no likelihood of the miscarriage not proceedingMiscarriage • Approximately 30% of pregnant women will experience bleeding in early pregnancy • At least 50% of women with threatened miscarriage will have continuing pregnancy • Miscarriage occurs in 15-20% of clinically diagnosed pregnanciesInvestigations Ideally in an ‘Early Pregnancy Assessment Unit’ if its available • Ultrasound • Measurement of serum βhCG • Determination of blood & Rhesus group – and anti-D if RH -ve • FBC, G&S and admit if significant bleeding • Psychological supportUltrasound • Expect to see viable fetus from around 6.5 weeks transabdominally, 5.5 weeks transvaginally • Diagnosis can be made on TVS only • CRL ≥ 7mm • Empty GS with a mean diameter ≥ 25 mm Measurement of βhCG • Not necessary if diagnosis unequivocal on scan (fetus with FH in uterus) • pregnancy part of investigations to diagnose / exclude extrauterine • Doubling time approx 2 days in viable pregnancy (actually 66%) • Halving time 1-2 days in complete miscarriage • Should see fetal pole with βhCG of 1500-2000 Management • Expectant First line approach, stable, apyrexial, uncomplicated • Medical missed miscarriage, 800 mg misoprostol orally / vaginally incomplete miscarriage 600 mg misoprostol orally / vaginally • Surgical Evacuation of uterus – manual aspiration in clinic without GA Surgical aspiration with GA Products should go for histological assessment - why?? • Major haemorrhage check the os if there are products; empty the uterus surgically as soon as you can; give some uterotonic drug if possible – ergometrine is the best Counselling & Emotional Support Always a major blow for a woman Whether the pregnancy was wanted or it this was a first or a fifth pregnancy What will a woman ask? What did I do to make it happen Will it happen again Can you do any testsDecision-Making in Complex Scenarios A woman presents with 8 weeks amenorrhoea. She says she no longer felt pregnant two weeks ago. Her test is now negative. How would you manage her? A woman had a miscarriage two weeks ago and has continued to bleed since then. Her pregnancy test is still positive. How would you manage her? A woman had a miscarriage two weeks ago and has continued to bleed since then. Her pregnancy test is negative, and she feels unwell and shivery. How would you manage her?Interprofessional Collaboration • Who will you interact with in the management of miscarriage? Ultrasonographer Theatre staff Biochemistry staff Gynaecology nurses Blood bankT ailored Patient Education • How long will I bleed for? • What do I do if I don’t stop bleeding? • When can I get pregnant again? • How likely is it to happen again?What else might it be? Knowledge assessment 1 For this patient, select the most likely diagnosis from the list below: weeks pregnant by her menstrual dates. She reports lower abdominal 7 pain, worse on the right side. She has only had minimal brown discharge vaginally. In her past medical history, she was treated for Chlamydia at age 18 years. 1. Hydatitiform mole 2. Anembryonic or missed miscarriage 3. Complete miscarriage 4. Ectopic pregnancy 5. Threatened miscarriageKnowledge assessment 2 For this patient, select the most likely diagnosis from the list below: A 25-year-old women presents via Accident and Emergency with a history of heavy vaginal bleeding and a positive pregnancy test. She has been passing clots associated with some lower abdominal cramping-like pain. She has no relevant past medical history. On moderate vaginal bleeding, There is a small amount of tissue seen protruding through the cervix which is removed. A scan shows retained products of conception in the uterus. 1. Hydatidiform mole 2. Complete miscarriage 3. Missed miscarriage 4. Threatened miscarriage 5. Incomplete miscarriageKnowledge assessment 3 For this patient, select the most likely diagnosis from the list below: An 18 year old women is referred to the early pregnancy clinic with bleeding at 8 weeks gestation. Her only other symptoms are of nausea and vomiting. She is otherwise fit and well. Her scan showed an enlarged uterus at 12 weeks size with a heterogeneous mass within with “grape- like” structures within. 1. Hydatidiform mole 2. Anembryonic or missed miscarriage 3. Complete miscarriage 4. Ectopic pregnancy 5. Threatened miscarriage