Miscarriage

🩸 Miscarriage (spontaneous abortion or pregnancy loss) is the natural death of an embryo or fetus before it can survive independently. It occurs in 10–20% of clinical pregnancies and accounts for ~50,000 hospital admissions per year in the UK.

📖 About

• 🧑‍🍼 Cut-off: before 20 weeks (sometimes extended to 24 weeks in definitions).
• 🕑 Types: Early miscarriage (<12 weeks) and Late miscarriage (12–24 weeks).

⚠️ Risk Factors

• 👩 Maternal age >30 (higher after 35).
• 🚬 Smoking, 🍷 alcohol, 💊 illicit drugs, low BMI.
• 👨 Paternal age >45.
• ⚕️ Fertility problems, prior uterine surgery, uncontrolled diabetes.
• 😔 High stress or traumatic events.

🩺 Clinical Features

• 🔴 Vaginal bleeding ± abdominal cramps.
• ⏳ Pain may be variable; some miscarriages are silent (missed miscarriage).

🧾 Types of Miscarriage

• Threatened: Mild bleeding, cervix closed, fetal heartbeat seen → pregnancy often continues.
• Inevitable: Heavy bleeding + pain, cervix open → pregnancy cannot continue.
• Incomplete: Bleeding + retained tissue in uterus (USS shows products of conception).
• Complete: Severe pain + heavy bleeding, uterus empty on USS (endometrial thickness <15 mm).
• Missed: Non-viable pregnancy with no heartbeat, often no bleeding or pain.
• Recurrent: ≥3 consecutive miscarriages → requires investigations.

🔍 Investigations

• 🩸 FBC: Check for anaemia.
• 🖥️ Ultrasound: Confirm viability, detect retained products.
• 📉 Beta-hCG: Declining levels → confirms pregnancy loss.

🛠️ Management Options

• ⏳ Expectant: Wait for spontaneous passage (70–80% success).
• 💊 Medical: Mifepristone + misoprostol (800 mcg PV, NICE guideline). ~80% success.
• 🩺 Surgical: ERPC or manual vacuum aspiration. ~95% success.

📌 Management Details

• Medical: Mifepristone followed by misoprostol. If no bleeding within 24 hrs → seek review.
• Surgical: Vacuum aspiration (local or GA). Prostaglandins may reduce surgical complications.

🔄 Recurrent Miscarriage

• Definition: ≥3 consecutive miscarriages.
• Causes: Genetic (3–5%), PCOS, antiphospholipid syndrome (APS), thrombophilia.
• Investigations: Thrombophilia screen, antiphospholipid antibodies, genetic referral.
• Management: APS → Aspirin 75 mg + Heparin until 34 weeks. PCOS → weight management improves outcomes.

Cases - Miscarriage

• Case 1 - Threatened miscarriage ⚠️: A 29-year-old woman at 9 weeks’ gestation presents with vaginal spotting and mild cramping. Cervix closed, uterus appropriate size. Ultrasound: viable intrauterine pregnancy with fetal heartbeat. Diagnosis: threatened miscarriage. Managed conservatively with reassurance and follow-up scan.
• Case 2 - Inevitable miscarriage 🚨: A 32-year-old woman at 11 weeks presents with heavy vaginal bleeding and severe crampy pain. Speculum exam: open cervix with visible products of conception. Ultrasound: intrauterine pregnancy sac low in uterus, no fetal heart activity. Diagnosis: inevitable miscarriage. Managed with expectant, medical, or surgical evacuation depending on stability and preference.
• Case 3 - Incomplete miscarriage 🩸: A 36-year-old woman at 10 weeks presents with profuse vaginal bleeding, abdominal pain, and dizziness. Exam: cervix open, partial products seen at os. Ultrasound: retained tissue in endometrial cavity. Diagnosis: incomplete miscarriage. Managed with IV fluids, misoprostol, or surgical evacuation (MVA/ERPC) if unstable or heavy bleeding.
• Case 4 - Missed miscarriage ❌: A 30-year-old woman attends for routine 12-week scan. She has had no bleeding or pain. Ultrasound: intrauterine sac with absent fetal heart activity (fetal pole measuring 9 weeks). Cervix closed. Diagnosis: missed miscarriage. Managed with expectant, medical (misoprostol), or surgical evacuation after counselling.

Teaching Point 🩺: Miscarriage = spontaneous pregnancy loss <24 weeks. Subtypes: threatened, inevitable, incomplete, missed. Always confirm with ultrasound, check haemodynamic stability, and offer expectant, medical, or surgical management. Anti-D should be given to all Rh-negative women after miscarriage with bleeding or intervention.