🔑 Key Learning

  • Miscarriage is the spontaneous loss of pregnancy before 24 weeks.
  • Can present as missed, incomplete, inevitable, complete or threatened.
  • Management options include expectant, medical, or surgical.
  • Always assess haemodynamic stability and exclude ectopic pregnancy.
  • Progesterone can reduce miscarriage risk in threatened cases.

🧬 Terminology & Classification

  • Missed miscarriage – foetus not viable, no symptoms
  • Threatened miscarriage – PV bleeding, closed cervix, viable pregnancy
  • Inevitable miscarriage – open os with bleeding, pregnancy non-viable
  • Incomplete miscarriage – retained products of conception (POC)
  • Complete miscarriage – all POC expelled

👀 Clinical Features

  • Amenorrhoea / pregnancy symptoms
  • PV bleeding
  • Crampy lower abdominal pain ± back pain

🧪 Investigations

  • Transvaginal ultrasound is 1st line
  • May show no heartbeat or no foetal pole
  • Consider beta-hCG and FBC if heavy bleeding

💊 Management Overview

  • If unstable or high bleeding – admit or refer EPAU urgently
  • If < 6 weeks with mild bleeding and no pain – consider expectant management with urine pregnancy test in 7–10 days - return if positive or bleeding continues/pain develops --> EPAU

💊 Threatened Miscarriage

  • If foetal heartbeat seen with closed cervix:
    • Vaginal progesterone 400 mg BD until 16 weeks
    • Reassess if bleeding persists > 14 days

💊 Missed or Incomplete Miscarriage

Expectant Management (1st line)

  • Suitable if low risk and no infection, haemorrhage or adverse history
  • Repeat urine pregnancy test at 3 weeks
  • Refer if ongoing symptoms or positive test

Medical Management

  • Indicated if symptoms persist > 14 days or high-risk features
  • Missed miscarriage:
    • 200mg oral mifepristone → 800mcg misoprostol 48h later (oral, vaginal or sublingual)
  • Incomplete miscarriage:
    • Single 600–800mcg misoprostol (oral, vaginal or sublingual)
  • Advise pregnancy test after 3 weeks

Surgical Management

  • Indicated if:
    • Retained products after medical mx
    • Woman declines other options
    • Severe symptoms
  • Options:
    • Manual vacuum aspiration (local anaesthetic)
    • Surgical management (general anaesthetic)

📝 Exam Clues & Clinchers

  • Painless PV bleeding + foetal heartbeat → threatened miscarriage
    • Vaginal progesterone 400 mg BD until 16 weeks
  • Open cervix + bleeding → inevitable miscarriage
  • No symptoms, no heartbeat on scan → missed miscarriage
    • Expectant management 1st line if low risk
  • Miscarriage + retained tissue → incomplete
  • Rh-negative woman undergoing surgical management → give anti-D

🔗 Useful Links and References