Miscarriage, Early Pregnancy Bleeding and Termination of Pregnancy
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
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
Suspicious operative findings
Suspect molar pregnancy, ectopic pregnancy
Presence of intervillous blood flow
Low serum biochemical markers (hCG, progesterone)
Medical – prostaglandins administered
Surgical – excavation of retained products of conception
Infection risks similar with all treatment options
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
Disadvantages: Unpredictable outcome and timescale, bleeding may be heavy and painful, surgical management may be necessary in emergency or in absence of spont resolution
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
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%
Performed under GA or with regional anaesthesia. Conscious sedation may also be used.
Pre-op priming of cervix with misoprostol
Disadvantages: Usually requires GA, increased risk of surgical complications – perforation, cervical damage and intrauterine adhesions.
Provision of information
Routine phone follow up
Support during subsequent pregnancies
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.
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