Miscarriage

Miscarriage is the loss of a pregnancy before 23 completed weeks. Early miscarriage is more precisely defined as pregnancy loss in the first 12 weeks and late miscarriage as pregnancy loss thereafter.

Since 1997 the RCOG has encouraged the use of the term ‘miscarriage’ rather than (spontaneous) abortion.

Subdivision of miscarriage

Miscarriage is subdivided as follows:

Threatened miscarriage: bleeding or cramping in a continuing pregnancy. [6]  The cervical os is closed. An ultrasound scan is required to confirm fetal heart activity.

Complete miscarriage: all the fetal material has passed and the uterus is empty. [6] The cervical os will be closed and where there has not previously been an US scan, one should be performed together with serum βhCG to confirm pregnancy failure. [7]

Incomplete miscarriage: there is retained products of conception within the uterus and the os remains open. The patient is at risk of haemorrhage and infection.

Early embryonic/fetal demise (previously known as missed/anembryonic pregnancy/blighted ovum): a non-viable pregnancy at 12 weeks where the products of conception have not been passed.

Miscarriage with infection (previously referred to as septic): this is secondary to either a spontaneous miscarriage or induced termination. Presentation is with fever and foul-smelling discharge.

Causative factors

Causative factors include [8]:

• Chromosomal abnormalities
• Increasing maternal age
• Smoking
• Alcohol
• Uterine abnormalities
• Maternal infection
• Co-morbidity

Presentation

• Vaginal bleeding ranging from ‘occasional spotting’ to significant haemorrhage or cervical shock
• Abdominal pain

The psychological aspect of miscarriage is often overlooked in busy emergency departments. For patients and their partners, miscarriage can be distressing and lonely. Please consider that your patient maybe finding it emotionally difficult to sit in a crowded waiting area. They may feel embarrassed if they are bleeding heavily and they are likely to be in pain. Addressing these needs may make a huge difference to their experience. Offer analgesia, sanitary towels, blankets and if possible, a place of privacy. Your patient may not need admission, or Early Pregnancy Unit services may not immediately be available, or ultrasound imaging at the time may not be clinically appropriate. When explaining this to patients, remember they may feel that faster management could save their pregnancy. [9]

This ‘wait’ understandably can cause more distress.

In terms of language to use, patients and their partners are sensitive to the words we use. If you’re not sure what term to use, mirror what the patient uses (baby, fetus, pregnancy).

The miscarriage association has a good practice guide for the emergency department.