INFORMATION FOR CANDIDATE

Your next patient in an emergency department is a 24 year old

Mrs. Chang who comes in with her husband. She is 9 weeks
pregnant and developed sudden onset of crampy lower
abdominal pains about 3 hours ago, followed by loosing quite a
bit of blood when she went to the toilet 30 minutes ago.
YOUR TASKS ARE:

To take a further history

Examine the patient
Organise appropriate investigations
Discuss the diagnosis and management with the husband
(his wife has given permission)

HOPC: This is Mrs. Changs first pregnancy and about three hours ago, she rested in bed but
then she had to go to the toilet and she lost a lot of blood. She was quite scared and very worried
to perhaps have lost the baby and her husband brought her to the ED.
PHx. + FHx.: unremarkable
O+G Hx.: unremarkable, Rh ve!!!!
SHx.: married secretary, non drinker, non smoker, NKA, no medication
EXAMINATION: very upset young woman, mildly pale looking, BP 120/75, P 88/min, RR 22,
SaO2 98% on RA, afebrile.
Abdomen: mildy tender suprapubically, otherwise NAD
Pelvic examination: enlarged uterus (9 weeks), cervical os is open, but no product of conception
is seen in the os.
INVESTIGATIONS:

FBE, U+Es, clotting profile, blood group and Rh factor!

Serial Beta HCG (has dropped significantly)

Cervical swab

U/S to verify the diagnosis (confirms an empty uterus!)

DIAGNOSIS: COMPLETE SPONTANEOUS MISCARRIAGE (abortion)

Spontaneous miscarriage refers to a pregnancy that ends spontaneously before the fetus has
reached a viable gestational age. The World Health Organization defines it as expulsion or
extraction of an embryo or fetus weighing 500 g or less from its mother. This typically
corresponds to a gestational age of 20 to 22 weeks or less. It is the most common complication of
early pregnancy. Twenty percent of clinically recognized pregnancies under 20 weeks of
gestation will undergo spontaneous miscarriage.
Other spontaneous miscarriages are:
1. THREATENED MISCARRIAGE
2. INEVITABLE MISCARRIAGE
3. INCOMPLETE MISCARRIAGE
RISK FACTORS:
Age Advancing maternal age is the most important risk factor for spontaneous miscarriage in
healthy women.
Previous spontaneous abortion Past obstetrical history is an important predictor of
subsequent pregnancy outcome.
Smoking Heavy smoking (greater than 10 cigarettes per day) is associated with an increased
risk of pregnancy loss.
Alcohol Observational studies have generally, but not consistently, reported that moderate to
high alcohol consumption increases the risk.
Cocaine Use of cocaine is associated with preterm birth, and may also be a risk factor for
spontaneous abortion.
Nonsteroidal antiinflammatory drugs The use of nonsteroidal antiinflammatory drugs
(NSAIDs), but not acetaminophen, may be associated with an increased risk of miscarriage if
used around the time of conception. The postulated mechanism is that prostaglandin inhibitors
interfere with the role prostaglandins play in implantation, thus potentially leading to abnormal

implantation and pregnancy failure.

Fever Fevers of 37.78 C or more may increase the risk of miscarriage, but the only two large
studies have been contradictory and inconclusive.
Caffeine Meta-analyses of controlled studies have reported an association between caffeine
intake and spontaneous miscarriage , mostly at high levels of consumption.
Low-folate level A well-designed, population-based, case-control study showed low plasma
folate levels (2.19 ng/mL [4.9 nmol/L]) were associated with an increased risk of spontaneous
miscarriage at 6 to 12 weeks of gestation, but only when the fetal karyotype was abnormal .
There is no evidence that vitamin supplementation prevents miscarriage. However, folate
supplements are routinely recommended for all pregnant women anyway for prevention of
neural tube defects.
Maternal weight Prepregnancy body mass index less than 18.5 or above 25 kg/m2 has been
associated with an increased risk of infertilty and spontameous miscarriage.
ETIOLOGY One-third of the products of conception from spontaneous miscarriages
occurring at or before 8 weeks of gestation are "blighted" or anembryonic (ie, no embryo or yolk
sac is found in the gestational sac). In the two-thirds of cases in which an embryo is found,
approximately 50 percent are abnormal, dysmorphic, stunted, or too macerated for examination.
Blighted or otherwise abnormal embryos may result from chromosomal abnormalities or
exposure to teratogens.
Chromosomal abnormalities Chromosomal abnormalities account for approximately 50
percent of all miscarriages. The earlier the gestational age at miscarriage, the higher the
incidence of cytogenetic defects: the incidence of abnormal fetal karyotype is 90 percent in
anembryonic products of conception, 50 percent for abortuses at 8 to 11 weeks of gestation, but
decreases to 30 percent of abortuses at 16 to 19 weeks.
Congenital anomalies Congenital anomalies are caused by genetic or chromosomal
abnormalities, extrinsic factors (eg, amniotic bands), and exposure to teratogens. Potential
teratogens include maternal disorders (eg, diabetes mellitus with poor glycemic control), drugs
(eg, isotretinoin), physical stresses (eg, fever), and environmental chemicals (eg, mercury).
Trauma Invasive intrauterine procedures/trauma, such as chorionic villus sampling and
amniocentesis, increase the risk of abortion. In contrast, the early gestational age uterus is
generally protected from blunt trauma to the maternal abdomen .
Host factors Pregnancy loss may also be related to the host environment. As an example,
congenital or acquired uterine abnormalities (eg, uterine septum, submucosal leiomyoma,
intrauterine adhesions) can interfere with optimal implantation and growth.
Acute maternal infection with any of a large number of organisms (eg, Listeria monocytogenes,
Toxoplasma gondii, parvovirus B19, rubella, herpes simplex, cytomegalovirus, lymphocytic
choriomeningitis virus [62] ) can lead to miscarriage from fetal or placental infection.
Maternal endocrinopathies (eg, thyroid dysfunction, Cushing's syndrome, polycystic ovary
syndrome) can also contribute to a suboptimal host environment.
DIFFERENTIAL DIAGNOSIS The cardinal clinical sign of miscarriage is vaginal
bleeding. Bleeding in the first trimester may be light, heavy, intermittent, or constant and it may
be painless or painful. The four major causes of bleeding early in pregnancy are:

Physiologic (ie, believed to be related to implantation)

Ectopic pregnancy
Impending miscarriage
Cervical, vaginal, or uterine pathology

MANAGEMENT:
If a complete miscarriage has been confirmed the patient and partner must be reassured, possibly
counseling services can be offered.
The bleeding will stop within 10 days.
In a woman who is Rhesus negative a Kleihauer test should be performed to determine the
amount of fetal blood cells in the circulation and then a prophylactic injection of anti-D
gammaglobulin should be given.