Miscarriage & Recurrent Pregnancy Loss — Viva

Q1: Definition & classification (2 min)

"Define miscarriage and classify the clinical types."

[1]

• Miscarriage (spontaneous abortion) = pregnancy loss before 24 weeks of gestation (UK viability).
• Affects about 1 in 5 (15 to 20 percent) of clinically recognised pregnancies; far more including biochemical losses.
• Types — the discriminator is the cervical os:
  • Threatened — bleeding, closed os, viable fetus.
  • Inevitable — bleeding, open os, products not passed.
  • Incomplete — partial passage, open os, ongoing/heavy bleeding (commonest acute).
  • Complete — all products passed, closed os, bleeding settled.
  • Missed — fetal demise, retained products, closed os, minimal/no bleeding.
  • Septic — infection (fever, pain, discharge, tender uterus) — emergency.
• Recurrent pregnancy loss (RPL) = 3+ consecutive first-trimester losses (ASRM: 2+ consecutive failed pregnancies).[1][2]

Q2: Diagnosis (2 min)

"A woman at 9 weeks presents with bleeding. How do you confirm viability?"

[1]

• Transvaginal ultrasound (TVS) is the diagnostic gold standard — assesses viability, gestational sac, fetal pole and heartbeat.
• NICE non-viability criteria (to avoid false positives):
  • Crown-rump length (CRL) at least 7 mm with no fetal heartbeat.
  • Mean sac diameter (MSD) at least 25 mm with no embryo.
  • No heartbeat on two scans at least 7 days apart.
• Serial quantitative beta-hCG — failure to rise appropriately (less than 63 percent rise in 48 hours in early viable pregnancy) suggests non-viable or ectopic.
• Always exclude ectopic (empty uterus + adnexal mass/free fluid).[1]

Q3: Management of a missed miscarriage (3 min)

"A stable woman has a confirmed missed miscarriage at 9 weeks. What are the management options?"

[1]

Three options — patient choice drives selection; counsel on success and risks:

[1]

• (1) Expectant — allow natural passage over 7 to 14 days; success over 50 to 80 percent in early loss. Suitable if stable and small.

• (2) Medical — mifepristone 200 mg oral followed 1 to 2 hours later by misoprostol 800 microgram vaginal (or 600 microgram sublingual); repeat misoprostol after 24 hours if needed. Mifepristone pretreatment improves success (Schreiber, NEJM 2018).

• (3) Surgical — suction evacuation / ERPC (electric vacuum or manual vacuum aspiration). Preferred if heavy bleeding, sepsis, persistent bleeding, or patient preference; cervical priming with misoprostol pre-op.[1]

• Always: anti-D 250 IU IM within 72 hours if Rh-negative.

• Heavy bleeding or haemodynamic instability — IV access, group and save, urgent surgical evacuation.[2]

Q4: Recurrent pregnancy loss (3 min)

"She has now had 3 consecutive losses. Outline the workup and the treatable cause."

[1]

• Workup:
  • Parental peripheral blood karyotype — balanced translocation (3 to 5 percent).
  • APS screen — lupus anticoagulant, anticardiolipin, anti-beta-2-glycoprotein-I (repeat at 12 weeks).
  • Uterine assessment — 3D ultrasound / sonohysterography / hysteroscopy (septum).
  • Endocrine — TSH, HbA1c.
  • Inherited thrombophilia screen (especially after late losses).
• Most important treatable cause: APS.
• Management of APS: low-dose aspirin 75 mg + prophylactic LMWH (e.g. enoxaparin) from confirmation of viable pregnancy to 6 weeks postpartum — improves live birth.
• Even unexplained RPL has a good prognosis — over 55 to 75 percent chance of a live birth next pregnancy with supportive care alone.[1][2]

Q5: Septic miscarriage (1 min)

"What are the red flags and immediate management of septic miscarriage?"

[1]

• Red flags: fever, uterine tenderness, foul-smelling discharge, tachycardia, history of unsafe procedure.
• Management: IV broad-spectrum antibiotics (cover gram-negative and anaerobes — e.g. piperacillin-tazobactam + gentamicin +/- metronidazole) + urgent surgical evacuation (source control); manage sepsis (fluids, cultures, ICU if shock); anti-D if Rh-negative.[2]

References

1. [1]Deng T, Liao X, Zhu S. Recent Advances in Treatment of Recurrent Spontaneous Abortion. Obstetrical and Gynecological Survey, 2022.PMID 35672876
2. [2]Jeve YB, Davies W. Evidence-based management of recurrent miscarriages. Journal of Human Reproductive Sciences, 2014.PMID 25395740
3. [3]Chu JJ, Devall AJ, Beeson LE, et al. Mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage (MifeMiso): a randomised, double-blind, placebo-controlled trial. The Lancet, 2020.PMID 32853559
4. [4]Coomarasamy A, Devall AJ, Cheed V, et al. A Randomized Trial of Progesterone in Women with Bleeding in Early Pregnancy. New England Journal of Medicine, 2019.PMID 31067371
5. [5]Quenby S, Booth K, Hiller L, et al. Heparin for women with recurrent miscarriage and inherited thrombophilia (ALIFE2): an international open-label, randomised controlled trial. The Lancet, 2023.PMID 37271152