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14.03.12 Miscarriage and antepartum haemorrhage

  • Miscarriage = Loss of a pregnancy before 24 weeks of gestation
    • But ectopic pregnancy and gestational trophoblastic disease are not included
  • Bleeding after 24 weeks is 'antepartum haemorrhage'

Miscarriage classification
  • Threatened 
    • Mild symptoms of bleeding
    • Little or no pain
    • Cervical os closed
  • Inevitable 
    • Heavy bleeding with clots and pain
    • Cervical os open
    • Will proceed to incomplete or complete miscarriage
  • Incomplete 
    • Products of conception partially expelled
    • Many incomplete miscarriages can be unrecognised missed miscarriages
  • Missed 
    • Fetus is dead but retained
    • Uterus small for dates
    • Pregnancy test can remain positive for several days
    • Presents with a history of threatened miscarriage and persistent, dirty brown discharge
    • Early pregnancy symptoms may have decreased or gone
  • Habitual / recurrent
    • Three or more consecutive miscarriages

Differential diagnosis
  • Ectopic pregnancy
    • Pain is usually greater, may be unilateral and usually precedes the bleeding
    • Blood loss is usually less heavy and darker - almost black in some cases
    • Acute pain on manipulating the cervix (cervical excitation)
  • Neoplasia
  • Hydatiform mole
  • Chorionic cyst
  • Subchorionic haemorrhage

Antepartum haemorrhage
  • Placenta previa
  • Placental abruption
  • Uterine rupture
  • Fetal vessel rupture