INFORMATION FOR CANDIDATE:

Your next patient in general practice is a 29 year

old Miriam Snowdon who is 8 weeks pregnant
complaining about 12 hours of crampy lower
abdominal pains and this morning she started to
have some pv blood loss with what looked like
clots although she is now pain free and does not
feel any contractions anymore.
YOUR TASK IS TO:
Take a brief further history
Examine the patient
Arrange for appropriate investigations
Discuss the most likely diagnosis and
management with the patient

HOPC: Miriam Snowdon is 8 weeks pregnant complaining about 12 hours of crampy

lower abdominal pains and this morning she started to have some pv blood loss with what
looked like clots although she is now pain free and does not feel any contractions
anymore. This is her first, wanted pregnancy previously confirmed with a positive urine
beta HCG.
O+G Hx.; menarche age 13, regular periods, stable relationship, no STDs, has been on
the OCP for 5 years but wanted to start a family.
PHx. + FHx.: unremarkble
SHx: married social worker, non drinker, non smoker, no medication, NKA/
EXAMINATION: actually well looking lady, normal BMI, BP 120/80, P 72/min. RR 16,
SaO2 98% on RA, afebrile.
Abdomen: NAD
Normal external genitalia, pelvic examination unremarkable with os closed and non
tender, no other pathological findings.
INVESTIGATIONS:
Beta HCG and follow-up
DIAGNOSIS: complete, spontaneous miscarriage
Spontaneous miscarriage is a non induced embryonic or fetal death or passage of
products of conception before 20 wk gestation of usually unknown cause, although one
has to consider problems with either:
Implantation (20%)
Ovofetal (70%, improper development, mainly chromosomal abnormalities)
Maternal (systemic diseases like SLE, viral diseases like cytomegalovirus,
herpesvirus, parvovirus, and rubella virus)
Risk factors include
Age > 35
History of spontaneous abortion
Cigarette smoking
Use of certain drugs (eg, cocaine, alcohol, high doses of caffeine)
Uterine abnormalities (eg, leiomyoma, adhesions)
Stopping of bleeding and crampy pains after the expulsion of products of conception
(POC) is the typical scenario of a complete miscarriage!

MANAGEMENT:
Reassurance
Follow-up with serial beta HCG tests which should half every 48 hours which is
almost diagnostic that all tissue has been expelled
!

MISCARRIAGE HISTORY
Threatened
Bleeding +/contractions
Inevitable
Bleeding +
strong
contractions
Incomplete
Bleeding +
contractions+
loss of parts

SYMPTOMS
No loss of
tissue
No loss of
tissue

Complete

Bleeding +
contractions+
Loss of POC

POC passed
completely

Missed

Bleeding +
contractions+
ongoing
brown
discharge
Successive
miscarriages
Malodorous,
pink
discharge,
pyrexia

Embryo or
fetus died and
still in uterus

Recurrent
Septic

Parts of POC
still in uterus
or in cervix

Recurrent
miscarriages
With any
spontansous
miscarriage

FINDINGS
Os closed
Cervix dilated
with POC
visible
Os open, POC
partially
expelled

Os open or
closed again,
POC totally
expelled
Os closed,
uterus fails to
grow

As per type of
miscarriage +
fever,
tachycardia

Mx
U/S, rest +
reassurance
Admit, U/S,
D+C or
expectant
Admit, U/S,
remove POC
in cervical
canal, D+C

PROGNOSIS
98% if normal
U/S
0%

U/S,
reassurance

0%

0%

U/S, expectant 0%
( spontaneous
misc.), induced
abortion
?cervical
cerclage
Swabs, blood
culture,
antibiotics

80%
0%