14.03.12 Miscarriage and antepartum haemorrhage

Terminology

• 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