Miscarriage is a term used for a pregnancy that ends on its own, within the first 20 weeks of gestation.
Common in early pregnancy (20-40%).
Several stages recognized:
1. Threatened- bleeding but cervical os remains closed,
2. Incomplete- Products Of Conception in uterus, cervix or vagina, with an open os
3. Complete- All Products Of Conception expelled & os closed.
Presents with vaginal bleeding (spotting, heavy or with clots & gestational tissue).
Midline, colicky discomfort usually starts after the bleeding.
Establish if they have had an USS yet in this pregnancy- confirming the presence of an intrauterine pregnancy & dates.
1. ABC’s & resuscitation as appropriate,
2. Baseline observations,
3. IV access & fluids as appropriate,
4. FBC, Group & Retain (for Rhesus status)
5. Confirm pregnant with urinary HCG
6. If above positive, check quantitative
7. Shock or bradycardia can occur with clots or POC in the cervical os. If present inspect cervix & look for this & gently remove them,
8. Rh. (Anti-D) immunoglobulin 250- IU IM (for singleton pregnancy <12/40), 625 IU IM (if multiple pregnancy or gestational age >12/40 or unknown) to all Rhesus negative patients who have not received it within the last 6 weeks (e.g for previous threatened miscarriages)
9. Occasionally uterine compression, vaginal packs or Ergometrine 0.5 mg IM or Oxytocin may be required to control bleeding
10. USS is confirms the viability & diagnosis definitely
11. Incomplete or inevitablemiscarriage will probably require D&C & admission – discuss with Medical Officer.
Generally, patients can go home (after discussion with their Medical Officer) until their USS is performed unless:
· They are in any way unstable
· They are bleeding more than the equivalent of about twice their normal period
· There is any possibility they might have ectopic.
All patients will need review after the USS with appropriate management.
During daylight hours it might be possible to arrange an expedient USS.
Discuss with Medical Officer those patients with a positive pregnancy test where no intrauterine pregnancy or adenexal mass/fluid has been identified on USS. Generally these patients can be discharged & have serial assays in two days. If the levels are falling miscarriage is confirmed, if levels are doubling repeat USS.
Ensure that all patients who have had a miscarriage are referred to their Medical Officer/ appropriate medical or social support for grievance counseling & follow-up.