Fast Facts & Helpful Hints
Definition: the death or expulsion of an embryo or fetus of up to 24 weeks' gestation
Miscarriages are common; 20% of all pregnancies will end this way. The vast majority occur before 12 weeks gestation. >60% miscarriages are due to chromosomal abnormalities.
Emotional stress, heavy exercise and sexual intercourse DO NOT cause miscarriage.
Types of Miscarriage
Bleeding is a usual feature, unless a missed miscarriage is incidentally discovered on ultrasound scan (USS). Pain from uterine contractions may be present but generalised uterine tenderness is uncommon.
- Date of last menstrual period?
- Was the last period "normal"?
- Date of first positive pregnancy test?
- First pregnancy? If not, take a full obstetric history (including any previous miscarriages, TOPs)
- Any other problems during this pregnancy?
- Onset and type of bleeding - ask about colour of blood, passage of clots and whether any fetal tissue has been seen
- Amount of bleeding - more or less than a "normal" period? How regularly is she changing pads?
- Any history of SOB, dizziness or fainting? (assesses haemodynamic stability)
- Onset and type of pain (if relevant). Remember to ask about shoulder-tip pain (when thinking about possible ectopic pregnancy)
- Any fever, dysuria or bowel symptoms? (again, important when considering ectopic pregnancy)
- Past medical/gynaecological history (including STIs, smear tests [up to date? results?], pelvic surgery)
- Drug history: current medications, including any allergies
- Baseline observations, to exclude haemodynamic compromise and/or infection
- Abdominal examination
- Speculum examination to assess the state of the os and the degree of bleeding
- Digital vaginal examination to assess for cervical excitation and adnexal tenderness (to help rule out ectopic pregnancy.
As always, informed consent is required before undertaking the above examinations and a chaperone should be present for any internal examination.
- Urine dip
- Urinary pregnancy test
- Bloods: FBC, beta-HCG, Group & Save (indicated in heavy bleeding)
- High vaginal swab (especially important if there is evidence of infection)
- An ultrasound scan may be indicated if the beta-HCG is > 1000 to assess fetal viability (and to exclude ectopic pregnancy - very unlikely if an intrauterine pregnancy is seen)
Management of Miscarriage
250 IU i.m. Anti D should be given to all rhesus negative women at a gestation of < 12 weeks in cases of medical and surgical uterine evacuation (NB Anti D is not necessary for women with a threatened miscarriage at < 12 weeks, but is required for all non-sensitised rhesus negative women with bleeding over 12 weeks' gestation)
All women should be offered written information, appropriate support and the option of counselling.
When three or more miscarriages occur in succession, the description 'recurrent miscarriage' is used. Further investigation is indicated to look for:
- autoimmune disease
- anatomical factors
- chromosomal defects