1. Max Brinsmead MB BS PhD June 2015

2.  RCOG Greentop Guidelines “The Management of Early Pregnancy Loss” October 2006 Updated September 2011  NICE Guide “Ectopic Pregancy and Miscarriage” 2012  MWB Guidelines for the conduct of an Early Pregnancy Assessment Service 2006

3.  Spontaneous abortion occurs for 10 - 20% of clinical pregnancies  Traditional management was “D&C” for 50 yrs  More recently conservative and medical management have been tested by RCT  They have been found to have:  Fewer risks and complications  Less cost  Greater patient satisfaction

4.  A systematic approach to assessment  Close follow up  Timely intervention when indicated or requested  In many hospitals this is provided by an “Early Pregnancy Assessment Unit”

5.  Examination of the genital tract for signs of pregnancy and miscarriage  Classified as:  Threatened = No POC passed, cervix closed & uterus enlarged  Inevitable = No POC passed but cervix open & uterus enlarged  Incomplete = POC passes & cervix open  Complete = POC passed & cervix closed  Missed = Pregnancy failure & cervix closed  But high resolution ultrasound has rendered this classification obsolete

6.  Requires history, examination, ultrasound +/- quantitative measure of beta HCG  Classify miscarriage as:  Threatened = PV bleeding but intrauterine FH seen  Incomplete = POC passed but significant POC remaining  Complete = POC passed and uterus is empty  Early Pregnancy Failure = No POC passed but ultrasound evidence of failed pregnancy  Note that this classification avoids the use of the confusing term “missed abortion” and the unfortunately named “blighted ovum”

7.  Undiagnosed Early Pregnancy Problem  That is pain and/or PV bleeding but…  US not yet performed  US unlikely to be helpful because  HCG <1500 IU/L and/or dates <5.5 weeks amenorrhoea  Or US cannot confirm the presence of an intrauterine pregnancy

8.  A common condition 1-2:100 pregnancies  Can be fatal if misdiagnosed  So think of every early pregnancy as…  ECTOPIC until proven otherwise

9.  Heterotopic Pregnancy  That is one in the uterus plus an ectopic  Quite rare unless the patient has had assisted conception  IVF with multiple embryos transferred  But difficult to diagnose if ultrasound evidence of intrauterine pregnancy is taken to exclude ectopic pregnnacy

10.  When a patient is thought to be pregnant then the doctor or nurse arranges a quantified beta HCG and an ultrasound scan  No history, no exam just tests!  But there is no substitute for a careful history  Because it is essential for the interpretation of some ultrasound findings  So please don’t just rely on the radiologist’s report!

11.  Is this a planned pregnancy?  Dates are more reliable if planned  Also helps to know “where she is coming from”  What method of family planning did you use prior to that?  Beware of COC and Depot  When was your last pregnancy (baby)?  For how long did you breast feed?  Has the patient had time to establish a cycle?

12.  What was the first day of your last period?  Not the date of the first missed period  Provide suggestions e.g. “before or after Xmas”  Keep trying for the best estimate of a date  Was that a normal period?  Normal in timing, duration and amount  Do you have regular periods?  What do you mean by regular?  What do you mean by irregular, how early, how late?

13.  When did you first think you might be pregnant?  Has your pregnancy been confirmed?  How, when and by whom?  Urine pregnant test becomes positive at the time of the missed period (if it is a normal pregnancy)  Have you had any scans?  When did that doctor/midwife suggest your baby might be due?  Do you still feel pregnant?

14.  Most patients deserve a pulse rate, BP measure and abdominal palpation  Vaginal exam is required when...  Ultrasound is not readily available  There has been substantial bleeding  If the patient is hypotensive  It may be corrected by clearing the cervix  The patient reports passage of tissue  Clear the cervix  Collect any tissue to confirm the pregnancy  Th ere is doubt about the source of bleeding  There is the possibility of ectopic pregnancy  But please be very gentle

15.  Any vaginal bleeding  Some 15 - 30% of women will have first trimester bleeding or spotting  And 50% of patients with vaginal bleeding will have a failed early pregnancy  Pelvic pain is not responding to simple measures  High risk patient  History of recurrent miscarriage  High risk of ectopic esp. previous ectopic  Advanced maternal age  Patient anxiety

16.  Must be a vaginal scan in all cases  Mean gestational sac size > 25 mm and no fetal heart motion detected  Embryo >7 mm seen but no fetal heart motion detected  If in doubt...  Tell the patient  Seek a second opinion or  Rescan in 7 – 14 days

17.  Blood group (BG) and BG antibodies  HB or FBC  Quantified beta HCG But this is pointless if sent for immediate scan  Urine PCR for Chlamydia in high risk woman  Age < 25 yrs  Relationship < 6 months or multiple partners  High Vaginal Swab and Blood C/S if septic  Routine antenatal tests if the pregnancy is continuing  HIV in all patients is desirable

18.  Surgical evacuation of the uterus  Medical evacuation of the uterus  Wait and see Recommended as first line by NICE

19.  The patient is febrile (>37.5 0 C) After appropriate antimicrobial management  The cervix is closed and the sac > 5cm diam  The patient has miscarried twice before Collect tissue for chromosomes  The patient or your health facilities are incapable of appropriate follow up

20.  There are fetal parts >14 weeks in size Surgical evacuation is unsafe  The pregnancy is >10 weeks in size, the patient elects D&C & cervix is closed Use Misoprostol 400 mcg to ripen the cervix 3-4 hrs prior to dilatation  There is DIC or some other contraindication to surgery or anaesthesia

21.  800 mcg Misoprostol into the posterior fornix Oral is acceptable alternative 600 mcg is sufficient for incomplete miscarriage  Must scan or evaluate clinically to confirm that evacuation is complete  In general echogenic material >16 mm in AP diameter is required for the US diagnosis of retained products of conception  (better termed incomplete miscarriage)

22.  Repeat clinical and USS evaluation after 3 days  Then 7 days and weekly  Must telephone or come in at any hour if pain or bleeding is unacceptable or fever occurs

23.  Several weeks of follow up may be required  20 - 50% of patients request or require curette  Some resorb the trophoblastic tissue with little or no bleeding  Others bleed for weeks

24.  Anti-D is required for EP bleeding if Rh Neg  Send all tissue for histology  Provide or arrange psychological support  Patients want an explanation for the loss  And advice about the future  Or contraceptive advice  Offer referral to GP, counsellor or a Support Group

25.  IV Fluids are required only for hypovolaemia  Ultrasound is not appropriate if:  < 5.5 weeks amenorrhoea  >12 weeks & uterus is palpable because a Doppler by a midwife is diagnostic of fetal viability  The patient is shocked or in pain  For vaginal examination you require:  Some experience  Privacy  A good light  Some assistance  Some instruments to swab the vagina or clear the cervix

26.  Beta HCG <250 iu/L  You can watch and wait  Admit for obs if there is a strong suspicion of ectopic  Repeat quantified beta HCG in 24 - 48 hrs  A successful pregnancy will increase by at least 63% in 48 hrs and double in 48-72 hrs  Beta HCG 500 – 1000 iu/L  As above but laparoscopy required if there are symptoms or signs of ectopic  Beta HCG >3000 iu/L and an empty uterus = Ectopic Pregnancy  Beta HCG 1000 - 3000 iu/L and vaginal ultrasound equivocal  Laparoscopy best if there is any question of ectopic

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