Obstetrics & Gynaecology
Question 133 of 180
A 19 year old woman presents to the Emergency Department with a 4 hour history of cramping lower abdominal pain and spotting. She tells you a home pregnancy test was positive 2 weeks ago. She has no past medical or obstetric history. On examination you find her abdomen is soft and non-tender. Her observations are recorded as:
- Heart rate: 87 beats per minute
- Blood pressure: 134/89 mmHg
- Respiratory rate: 18 breaths per minute
- Temperature: 37.1°C
What is the single most likely diagnosis?
Answer:
Suspect a miscarriage in women who are pregnant, or with symptoms of pregnancy (amenorrhoea, missed period, breast tenderness), presenting with vaginal bleeding in the first 24 weeks of pregnancy. Bleeding is typically scanty, varying from a brownish discharge to bright red bleeding, and may recur over several days. Lower abdominal cramping pain or lower backache, when it occurs, usually develops after the onset of bleeding.Miscarriage
Obstetrics & Gynaecology
Last Updated: 8th January 2022
Miscarriage is the spontaneous loss of a pregnancy before 24 weeks’ gestation. About 10–24% of clinically recognised pregnancies end in miscarriage. Most miscarriages occur in the first trimester.
Definitions
Miscarriage is classified as complete, incomplete, missed, threatened, or inevitable on the basis of clinical history and findings on speculum and digital pelvic examination:
- Threatened miscarriage is diagnosed when there is unprovoked vaginal bleeding in the presence of a viable pregnancy in the first 24 weeks of gestation.
- Inevitable miscarriage is a diagnosed non-viable pregnancy in which bleeding has begun and the cervical os is open. The pregnancy will proceed to incomplete or complete miscarriage.
- Incomplete miscarriage is a diagnosed non-viable pregnancy in which early pregnancy tissue has been partially expelled, but where some pregnancy tissue remains in the uterus.
- Complete miscarriage is when all the products of conception have been expelled from the uterus and bleeding has stopped.
- Missed miscarriage (also known as delayed or silent miscarriage) is diagnosed when a non-viable pregnancy is identified on ultrasound scan, without associated pain and bleeding.
Risk factors
Risk factors for miscarriage include:
- Fetal factors
- Chromosomal abnormalities (most common cause of first trimester miscarriage)
- Genetic abnormalities
- Defects in the development of the placenta or embryo
- Maternal factors
- Previous miscarriage
- Increasing maternal age
- Thrombophilic abnormalities (including factor V Leiden (FVL) mutation and prothrombin gene mutation)
- Immunological abnormalities (e.g. antiphospholipid syndrome)
- Anatomical or structural causes (including uterine abnormalities (such as eptate, bicornuate, or arcuate uterus) and cervical abnormalities (such as cervical incompetence))
- Endocrinological causes (including polycystic ovarian syndrome, hyperprolactinaemia, thyroid disease, and poorly controlled diabetes mellitus)
- Infective causes (e.g. bacterial vaginosis)
- Occupational and environmental factors (such as heavy metals, pesticide, high dose radiation, and lack of micronutrients).
- Lifestyle factors, such as stress, obesity, and smoking
Clinical features
Suspect a miscarriage in women who are pregnant, or with symptoms of pregnancy (amenorrhoea, missed period, breast tenderness), presenting with vaginal bleeding in the first 24 weeks of pregnancy. Bleeding is typically scanty, varying from a brownish discharge to bright red bleeding, and may recur over several days. Lower abdominal cramping pain or lower backache, when it occurs, usually develops after the onset of bleeding.
Differential diagnosis
- Conditions that can cause bleeding in early pregnancy
- Miscarriage
- Molar pregnancy
- Urethral bleeding
- Haemorrhoids
- Trauma of cervix, vagina or vulva
- Cancer of cervix, vagina or vulva
- Vaginitis
- Cervicitis, cervical ectropion, or cervical polyps
- Conditions that can cause pain in early pregnancy
- Miscarriage
- Ruptured ovarian corpus luteal cyst
- Pregnancy-related degeneration of a fibroid
- Musculoskeletal pain.
- Urinary tract infection
- Constipation
- Irritable bowel syndrome
- Pelvic inflammatory disease
- Appendicitis
- Renal colic
- Bowel obstruction
- Adhesions
- Ovarian cyst (due to torsion, rupture, or bleeding)
- Torsion of a fibroid
- Pelvic vein thrombosis
ED management
- Confirm pregnancy with a urine pregnancy test.
- If pregnancy is confirmed in a woman with symptoms or signs of an ectopic pregnancy (abdominal pain and tenderness or pelvic tenderness or cervical motion tenderness), arrange immediate admission to an early pregnancy assessment unit (EPAU) or out-of-hours gynaecology service.
- If there is no abdominal pain and tenderness, pelvic tenderness, or cervical motion tenderness and the woman is 6 or more weeks pregnant or of uncertain gestation, refer to an EPAU or out-of-hours gynaecology service for further investigation to determine the cause of symptoms. The urgency of the referral should depend on the clinical situation.
- If the woman is less than 6 weeks pregnant and is bleeding but not in pain, consider expectant management. Advise the woman to repeat a urine pregnancy test after 7–10 days and to return if the test is positive or if her symptoms continue or worsen. Refer women with a positive urine pregnancy test, or continuing or worsening symptoms to an EPAU or out-of-hours gynaecology service. The decision on whether she should be seen immediately or within 24 hours will depend on the clinical situation. A negative pregnancy test means that the pregnancy has miscarried.
Speciality management
- Ultrasound
- Ultrasonography (usually a transvaginal ultrasound scan) is used to assess the location and viability of the pregnancy.
- If the viability of an intrauterine pregnancy cannot be established because the fetus is of insufficient size for a heartbeat to be visualised, measurements are made and the scan repeated after a minimum of 7 days. A non-viable pregnancy is strongly suggested by a lack of growth and the continuing absence of a detectable heartbeat.
- Expectant management
- Expectant management is offered first line if the woman has a confirmed diagnosis of incomplete or missed miscarriage.
- Expectant management lasts for 7–14 days, and all women are given information on what to expect, advice on analgesia, and advice on how to get help in an emergency.
- If the bleeding and pain settle (suggesting complete miscarriage), the woman will be advised to take a urine pregnancy test after 3 weeks and to return to the hospital if it is positive.
- If the bleeding and pain persist or are increasing (suggesting incomplete miscarriage), or if bleeding and pain has not started (suggesting a missed miscarriage), a repeat scan is done and expectant, medical, and surgical options are discussed.
- Medical management
- Medical management is offered if expectant management is not clinically appropriate or a woman has ongoing symptoms after 14 days of expectant management.
- Vaginal or oral misoprostol is used for the treatment of missed or incomplete miscarriage to stimulate uterine expulsion of the products of conception.
- Women are advised to do a pregnancy test after 3 weeks and return if it is positive.
- Surgical management
- Surgical intervention may be required if products of conception are retained despite medical treatment, or offered if the woman has ongoing symptoms after 14 days of expectant management.
- Women with a missed or incomplete miscarriage are offered a choice of manual vacuum aspiration under local anaesthetic or surgical management under a general anaesthetic.
- Anti-D immunoglobulin is offered to all rhesus-negative women who have had a surgical procedure to manage a miscarriage.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
