Assessment of recurrent miscarriage

The following conditions may occur in people with recurrent miscarriage or present similarly to recurrent miscarriage. They have the potential to be life-threatening, due to severe bleeding and haemodynamic shock.

Ectopic pregnancy

Ruptured ectopic pregnancies are still a cause of maternal mortality. A pregnant patient with vaginal blood loss and pelvic pain should be considered a patient with an ectopic pregnancy until proven otherwise. Severe haemodynamic shock can occur, so patients should be regularly monitored. Resuscitation measures (ABC) should be administered immediately if this occurs. Intravenous access should be secured and intravenous fluids (either Hartmann's solution or normal saline) administered. Blood transfusion will be required if blood loss is excessive. Blood should be sent for urgent investigations including:

• FBC

• Serum electrolytes

• Clotting studies (prothrombin time and activated partial thromboplastin time)

• Blood grouping and cross-matching for at least 4 units of blood.

When a patient is stable, serum hCG should be ordered and an ultrasound (transvaginal or transabdominal if transvaginal is unacceptable to the woman or if the woman has an enlarged uterus or other pelvic pathology) done to verify the location and viability of the pregnancy.[66]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Aug 2023 [internet publication]. https://www.nice.org.uk/guidance/ng126 In pregnancies of unknown location, there is evidence that shows that a 53% rise in hCG level over 48 hours is associated with an intrauterine pregnancy.[67]Barnhart KT, Sammel MD, Rinaudo PF, et al. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol. 2004 Jul;104(1):50-5. http://www.ncbi.nlm.nih.gov/pubmed/15229000?tool=bestpractice.com Consideration needs to be given to the possibility of a heterotopic pregnancy (an intrauterine pregnancy coexistent with an ectopic pregnancy).

When an ectopic pregnancy is confirmed and the patient remains well, she can be offered either conservative management, medical treatment with methotrexate, or surgical management, depending on the clinical symptoms, serum hCG levels, ultrasound findings, and patient choice.[68]Royal College of Obstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy. Green-top guideline no. 21. November 2016 [internet publication]. https://onlinelibrary.wiley.com/doi/10.1111/1471-0528.14189/epdf [66]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Aug 2023 [internet publication]. https://www.nice.org.uk/guidance/ng126 If the patient is unwell, arrangements need to be made for urgent laparotomy and salpingectomy to remove the ectopic pregnancy and stop the bleeding after stabilising the patient.

Incomplete miscarriage

Incomplete miscarriage occurs when the uterus is still not emptied of all products of conception. These patients are at risk of shock if the blood loss is excessive. Quick and efficient management is required, as significant blood loss resulting in circulatory compromise and anaemia can occur in a short period of time. Resuscitation (ABC) measures are needed if there is haemodynamic instability. If bleeding continues, an emergency surgical evacuation of the uterus to remove all retained products of conception needs to be performed.

For patients who can be stabilised, a vaginal examination is performed to assess for the presence of any products of conception at the cervical os. A transvaginal ultrasound should be offered to establish whether there are signs of retained products of conception. However, clinical assessment is most important. If the diagnosis of a miscarriage has not been made previously on ultrasound, fetal viability needs to be checked.

Expectant care or medical management with misoprostol are alternatives to routine surgical evacuation in women who are haemodynamically stable and have a non-viable fetus.[69]Kim C, Barnard S, Neilson JP, et al. Medical treatments for incomplete miscarriage. Cochrane Database Syst Rev. 2017 Jan 31;1:CD007223. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007223.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/28138973?tool=bestpractice.com [66]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Aug 2023 [internet publication]. https://www.nice.org.uk/guidance/ng126

Septic miscarriage

Although more common in countries with poor healthcare resources, women can still die from undiagnosed sepsis secondary to infected retained products of conception. If a patient presents with signs and symptoms of sepsis and is known to have a non-viable fetus, she should be immediately reviewed, treated with antibiotics accordingly, and advised to have a surgical evacuation to remove the infected tissue.

Pregnancy of unknown location (PUL)

Patients who present with a positive pregnancy test and either vaginal spotting or abdominal pain need to have the location of their pregnancy identified with an ultrasound scan (transvaginal or transabdominal if transvaginal is unacceptable to the woman or if the woman has an enlarged uterus or other pelvic pathology). If the ultrasound scan is inconclusive, serial serum hCG measurements are needed. A rise of more than 53% in 48 hours is commonly associated with an intrauterine pregnancy. A follow-up pelvic ultrasound scan can be arranged in one week to confirm the presence of an intrauterine gestational sac. However, if the rise is suboptimal, further investigations such as another serum hCG, repeat pelvic ultrasound scan, or even diagnostic laparoscopy need to be considered to confirm the location of the pregnancy.