Miscarriage, Early Pregnancy Bleeding and Termination of Pregnancy

Definition: Miscarriage
The spontaneous loss of pregnancy before viability. (Usually <20 weeks gestation).
Miscarriage Classifications
Complete miscarriage
Missed miscarriage
Incomplete miscarriage
Definition: Complete Miscarriage
All products of pregnancy have been expelled and the uterine cavity is empty.
Definition: Missed Miscarriage
Products of conception still in the uterus but non-viable.

Defined by ultrasound appearance of intrauterine pregnancy with reproducible evidence of:
a) absent or lost fetal heart activity
b) failure of crown-rump length to increase over 1 week
c) persisting presence of an empty sac at less than 12 weeks gestation

Usually asymptomatic, diagnosed at routine dating scan.

Other terminology – delayed miscarriage, “silent” miscarriage

Definition: Incomplete miscarriage
Partial passage of products of conception but some remain.

Vaginal bleeding/pain present, cervix is dilated and products of conception are found within the cervical canal on examination.
i.e. some products of conception still in t

Indications for histological investigation in miscarriage
Uncertain preoperative diagnosis
Suspicious operative findings
Suspect molar pregnancy, ectopic pregnancy
Factors affecting success rates of expectant or medical management in miscarriage
Presence of vaginal bleeding
Presence of intervillous blood flow
Low serum biochemical markers (hCG, progesterone)
Management options in miscarriage
Expectant – wait for pregnancy to resolve spontaneously
Medical – prostaglandins administered
Surgical – excavation of retained products of conception

Infection risks similar with all treatment options

Principles of expectant management in miscarriage
Wait for pregnancy to resolve spontaneously, may take up to 8 weeks.
Can continue as long as no evidence of infection and woman wishes to continue.
Success rate incomplete > missed
Women should be aware of significantly higher risk of requiring surgical intervention, possibly as an emergency procedure
Advantages/disadvantages – expectant management of miscarriage
Advantages: Avoidance of GA and invasive surgery, control over situation

Disadvantages: Unpredictable outcome and timescale, bleeding may be heavy and painful, surgical management may be necessary in emergency or in absence of spont resolution

Principles of medical management in miscarriage
Prostaglandins administered (vaginally, less often orally)
Higher dose in missed miscarriage
Benefit of medical management uncertain (MIST study vs systematic reviews), except in improving success rate in missed miscarriage
Can be offered as an outpatient intervention
Advantages/disadvantages – medical management of miscarriage
Advantages: avoidance of GA and invasive surgery, faster completion of pregnancy than expectant management.

Disadvantages: Pain, increased analgesia, increased duration of bleeding, GI/other side effects associated with prostaglandin use, unpredictability, surgical managment may be necessary in an emergency or in absence of spont resolution in up to 36%

Principles of surgical management in miscarriage
Evacuation of retained products of conception – dilatation of cervix to allow uterine cavity to be instrumented and removal of products through suction.
Performed under GA or with regional anaesthesia. Conscious sedation may also be used.
Pre-op priming of cervix with misoprostol
Advantages/disadvantages – surgical management of miscarriage
Advantages: predictable, low risk of needing further treatment, reduced duration of bleeding.

Disadvantages: Usually requires GA, increased risk of surgical complications – perforation, cervical damage and intrauterine adhesions.

What percentage of pregnancies end in miscarriage?
Between 10-20%.
List key elements of service delivery and follow up for women who have experienced a miscarriage.
Care by supportive, informed and empathetic staff (and appropriate care i.e. not admitted to postnatal ward), acknowledge loss
Assessment
Provision of information
Routine phone follow up
Risk assessment
Support during subsequent pregnancies
What steps must occur in consultations regarding abortion to comply with abortion law in WA?
1) Provide counselling about medical risks of having a termination and of continuing the pregnancy.
2) Offer the opportunity of referral to counselling related to termination and continuing the pregnancy.
3) Inform of the availability of post-abortion or post-delivery counselling.