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MRCOG PART 2 SBAs and EMQs

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ESSAY 271 - Miscarriage

Posted by Farina A.

A)Initial clinical assessment includes checking her vital signs, abdomen for any sign of tenderness and per vaginal examination to estimate the amount of bleeding and the state of internal os. When the os is open with products of conception still inside, a diagnosis of incomplete miscarriage can be made however if os is closed and there is minimal bleeding a diagnosis of complete miscarriage can be made. Her state of consciousness is important to consider as sometimes pts go in hypovolemic or vasovagal shock .If the pt is well I would like to know about the previous miscarriages there gestational ages and results of histopathology and karyotyping if any.

B) I would like to check her HB, WBC and blood group, in order to have an idea about the degree of anemia, presence of infection and need of blood transfusion and ant-D prophylaxis respectively. If the situation allows I would like to do a scan to determine the retained products of conception. Coagulation profile can be done in order to rule out DIC. The products she passed should be sent for histopathology and karyotyping.

C) As this pt suffered from recurrent miscarriages her emotional and psychiatric status should be assessed and dealt with empathetically. I would like to reassure her as she is expected to be in a state of grief. I would like to tell her that there is nothing on part of her responsible for this sad event. I would like to tell her about the common causes of recurrent miscarriages including chromosomal abnormalities, PCOS and APS besides that I would like to tell that majority of recurrent miscarriages are unexplained and has a very good prognosis. If a cause is detected most of them are treatable and has good pregnancy outcome. Like achieving a successful out come of pregnancy is more than 75% in case APS is treated with heparin and aspirin. PCOS can be treated effectively with a good pregnancy outcome. Only 3-5% of cases of recurrent miscarriages is due to chromosomal abnormalities and may need a referral to the geneticist after parental karyotyping. However conditions like uterine anomalies and fibroids are less likely to improve fertility after surgery. Conditions like diabeties, thyroid disease and TORCH need not to be screened. Empirical treatments with progesterone and hcg for luetal support is not been proven by RCTs. She is should be provided with an appointment to the clinic after 6wks for further investigations and reports of histopathology and karyotyping along with written information and addresses of support groups.
Posted by hoping ..

This patient unfortunately has had third consecutive early pregnancy loss. As she has heavy bleeding and severe pain she may be in shock, thus quick assesment of her airway and breathing should be established. Her pulse and blood pressure should be checked as she may be hypovolemic. Her temprature should be recorded to check for hypothermia associated with hypovolemic shock. Hyperthermia may indicate septicaemia. Presence and degree of pallor should be recorded. Her abdomen should be palpated to check for tenderness associated with infection. Speculum examination to asses bleeding should be undertaken, this also facilitates removal of any remaining products visible at cervical os. Bimanual examination to asses uterine size and tenderness may reveal uterine size larger than 12 weeks which raises possibility of molar pregnancy or fibroid uterus. Associated tenderness would indicate infection. Smaller uterus usually means miscarriage occured at earlier gestation. Internal cervical os if open suggests incomplete miscarriage.
Fullblood count should be sent to check for haemoglobin level as she had heavy bleed. Blood group should be determined as anti-D will be required if she is rhesus negative as she had severe pain and heavy bleeding. Blood should be saved as she may require blood transfusion. If she appears to have severe pallor or signs of haemodynamic compromise or persistent bleeding crossmatching 4 units should be requested. Her coagulation status should be checked as severe bleeding could lead to derangement. Infection may precipitate coagulopathy.If she is pyrexial urea, elctrolytes should also be checked. If pateint consents products should be sent for histopathological examination to rule out molar changes. Cytogenetic testing should also be suggested to rule out chromosomal problems as she has reccurent miscarriage.
Patient should be reviwed prior to discharge to discuss events and answer her queries if any. Pscychological trauma due to pregnancy loss can be significant and couple should be offered counselling and support. She should be provided with information of local and national support groups. She should be informed of investigations done and time and method of communication of results. She should be reviwed in gynae clinic or ideally pregnancy loss clinic in 6 weeks or more according to her suitability. Further investigations to diagnose etiology should be offered in clinc,these include karyotyping of both partners and products of conception. If abnormality is discovered then prompt geneticist referal should be arranged. Pelvic scan to rule out uterine anamolies and polycystic ovaries may reveal such pathology but benfit of surgical correction is limited apart from Ashermans syndrome.Antiphospholipid antibody testing if identifies lupus anticoagulant or anticardiolipin antibodies aspirin and heparin improve pregnancy success rates to 70% from 10%. Thrombophilia screening should be considered as heparin and aspirin may improve pregancy outcome with thrombophilias especially factor v leiden deficiency. If patient has symptoms of thyroid dysfunction or diabetes then screening for these should be offered. She should be informed that most recuurent miscarriages have no know etiology and are unexplained. With unexplained miscarriages chances of future succesful pregnancy are 70%. She should be offered contraception if she wishes to use meanwhile until investigations are completed and mangement plan for future pregnancy derived. she should be given discharge letter and her General practitioner should be informed. If she is already booked for antenatal care her future appointments haould be cancelled.

Posted by San S.
(a) Justify your initial clinical assessment [5 marks].
General assessment of patient should be undertaken and basic resuscitation should be carried out if she is haemodynamically unstable. History of onset of bleeding and amount of bleeding is important. It is also important to enquire regarding onset, site, radiation and severity pain. Other associated symptoms e.g. fainting episodes, shoulder tip pain may suggest coexist ectopic pregnancy and previous scan to confirm intrauterine pregnancy would mean that this unlikely to be the case.
Her vitals including pulse, BP and temperature should be measured to assess her haemodynamic status. Oxygen should be administrated and IV access gained with large bore cannula for bloods i.e. FBC group+save and crossmatch if haemodynamically unstable and administration of colloids or crystalloids. Analgesia should be given to relieve her symptoms. Her abdomen should be examined for abdominal distension, tenderness and peritonism. Speculum and vaginal examination should be carried out to assess if her cervix is open or close and products of conceptions should be removed and ergometrine administered if she is bleeding heavily. She should be kept nil by mouth in case of the need for evacuation of retained products of conception under general anaesthetic if bleeding doesn\'t settle. This should be liase with anaesthetist, consultant oncall, ward and theatre staffs.

(b) Which investigations will you undertake in the emergency gynaecology clinic? [5 marks]
FBC and group and save should be taken to assess the extend of blood loss. Haemacue may be useful in estimating Hb in haemodynamically unstable patient. Cross match and clottings should be requested in massive haemorrhage. Rhesus status could be obtained as antiD should be administrated in rhesus negative patient. CRP and WCC should be requested if coexisting infection suspected clinically. BHCG is useful in suspected ectopic pregnancy.
Triple swabs should be taken during speculum examination to rule out infection and products and gestational sac sent for histological examination as recommended in CEMACH report. Cytogenetics for products of conception should be considered if patient consent to this.
Ultrasound is useful to asess retained products of conception once patient is haemodynamically stable.

(c) Which information will you give her before discharge? [10 marks]
I would debrief her regardng the event. I would explain that the risk of miscarriage in first trimester is common (1in 5 pregnancy). However, being this her third miscarriage, I would offer her investigations to rule out other causes of recurrent miscarriages.
This would include parental karyotypes to rule out chromosomal abnormalities. Cytogenetics of products of conception can assess fetal chromosomes. Thrombophilia screen, anticoagulant and anticardiolipin antibodies can be used to rule out clotting and autoimmune disorders that could cause recurrent miscarriages. Thyroid function test is only carried out if clinically indicated. She can be offered ultrasound scan to assess her pelvic organs to rule out anatomical cause of miscarriage e.g. fibroids, bicornuate uterus. She should be follow up at gynaecology outpatient in 6 to 8 weeks with these results.
If all the tests were normal, she has a good prognosis and chance of successful pregnancy in the future. She should contact EPAC or GP to arrange a scan early in the pregnancy to confirm viability and reassurance.
She would be expecting period like bleeding for the next 2 to3 weeks. She should have open access to the ward if she has severe bleeding, temperature, unwell or pain in the next few weeks. This would include the ward and EPAC contact numbers. She should be given information and leaflets about miscarriage and support groups available.
Information and advices on contraception should be provided if patient wishes to.
If she has pre-existing medical problems e.g. diabetes, thyroid disease,epilepsy she should be advised to delay pregnancy with effective contraception until conditions are well-controlled. Same apply if she is morbidly obese. Prepregnancy folic acid is beneficial and should be started 12 weeks prior to pregnancy and to be continue up to 12 weeks gestation.
Posted by Manoj M.
A)As the patient has just miscarried she is at a high risk of bleeding. Her haemodynamic status must be assessed. Her observations like pulse, blood pressure and temperature must be taken to ensure she is stable. Her abdomen must be palpated for signs of tenderness which is present in most of the miscarriages. Verbal consent must be taken before speculum examination. A speculum examination must be carried out to assess the state of the external os whether open or closed. Presence of active bleeding must be noted. An open os with active bleeding suggests retained products. Any foul smell along with bleeding suggests sepsis. A bimanual examination of the uterus is necessary to assess the tenderness and as to whether the uterus has contracted after the miscarriage.

B) A full blood count is necessary to assess the haemoglobin level and the degree of anaemia. A grouping and saving of serum is important for her Rhesus status. If bleeding is very heavy then cross-matching would be necessary. A high vaginal swab at the time of speculum is necessary to rule out infection. If bleeding is uncontrollable then there is no role for ultrasound. However if bleeding is moderate and if the patient is haemodynamically stable, then an ultrasound can be done to rule out retained products. Additionally if there is suspicion of sepsis a C- reactive protein can be done. Renal function needs to be tested if there is massive haemorrhage.
C) Before the discharge of this patient she must be sensitively counselled as she has had recurrent miscarriages. She must be informed that out of 10% to 15% of all clinical miscarriages there is a1% risk of recurrent miscarriage. If she wished to then she can undergo tests for certain conditions; however by ruling out any of these conditions it is not possible to guarantee the success of future pregnancy. But if any of these tests are positive then some interventions can result in successful ongoing prenancy. These tests would involve blood tests to check for karyotyping abnormalities for both her and her partner. Any karyotypic abnormalities or unbalanced tranlocations can be identified by this. She can be informed that the products that she has passed may be sent for cytogenetic testing. She can be informed that by doing an ultrasound uterine abnormalities which could cause miscarriages can be ruled out. She can be enquired for medical problems and she can be informed that she can have blood tests to rule out any associated diabetes or thyroid problems( depending on the medical history). She should be counselled regarding anti phospholipid antibody syndrome as being one of the important causes of recurrent miscarriage. To test for this should have 2 blood tests 6 weeks apart. The significance of this condition is that by giving medications like aspirin and heparin there succesful pregnancy and delivery can be achieved. She should also be informed regarding testing for thrombophilia to rule out causes like Factor V Leiden mutation. She also needs to be informed regaring bacterial vaginosis as one of the causes and the swab will give the result of the same. She should be given numbers for support droups and miscarriage association. Leaflet on recurrent miscarriage sholud be given. If she wishes to and if there are provisions of recurrent miscarriage clinic then she can be offered an appointment for this.

Posted by Sam M.
a.Initial clinical assessment will be based on history and examination .As she is passing heavey clots a general assessment will be done to asses the haemodynamic stability.If she is not stable basicresuscitation will be given to her.Detailed history of eisode of pain and bleeding that when it stated and an estimated blood loss will be assessed .During this pregnancy any episode of pain and bleeding earlier she had and if needed a hospital admission or treatment.when she had her dating scane and information obtained from that for example multiple pregnancies ,or molar .History of previous pregnancies ,if any completed one and about miscarriages ,investigations done so far to diagnose the cause of miscarriages is important.Past history of hospital admission anesthseia and blood transfusion ,allergies to drugs or transfusion reactions .
On examination her blood pressure ,pulse temperature will be recorded ,chest be examined.
On abdominal examination for any other causes for tenderness as very rarely heterotopic pregnancy may co exist. Vaginal speculum examination to see for any products conception coming out of cervical os or clots. Bimannual pelvis examination ,cervical os closed or not ,cerbvical excitation for co pathologies,uterine size and adnexa .If os is closed and uterine size is normal then it is more likely complete miscarriage which will be confirmed later on by ultrasonography.
b..Her intravenous lines will be secured with 2 wide bore cannula and blood will be sent for complete examination ,rh factor and blood grouping ,as for non immune rh positive mother having abdominal pain in association with miscarriage she will need an anti D Immunoglobulin prophylaxis .MSU for microscopy.pelvic ultrasound for retained products of conception.i will try to make arrangements to send products of conception for histopatholgy as early as possible.
c..she will be told that if she had 3 miscarriage consecutively ,then her case falls under the category of recurrent miscarriges ,.She needs to have some investigations to find cause.15% cases of recurrent miscarriages are because of antiphospholipid syndrome .She should have anticardiolipn anti body and lupus anti coagulants twice 6 weeks apart.if she is diagnosed to be positive ,then in ner next pregnancy heparin and low dose aspirin need to started early in pregnancy till 34 weeks of gestation ,This will improve pregnancy out come.30 %are because of luteal insufficiency but treatment with progestogens and HCG is not supported by evidence .3% because of chromosomal abnormalities and paternal karyotyping testing will be done to diagnose this.1 to 3 5 had congenital uterine abnormalities ,unfortunately corrective surgery doesnot improve out come .Cause could not be find out in 40% of cases designated as unexplained miscarriages and they have preganacy out come around 70% in 3 years.For
Uncontrolled diabestes good glycemic control before pregnancy is important to reduce incidence of miscarriage.thyroid function test can be done if sign and symptoms suggest. Routine screening for torch infection if not recommended.she will be given information leaflet to take home .if she wants that all her investigations prior to next preganancy are done then appropriate contracentive advice will also given.

Posted by Priti T.
a]Patient should be assessed initially for the haemodynamic instability in view of the inevitable miscarriage in the gynaecology clinic.If unstable vitals then she should be resuscitated by intravenous fluids,oxygen,blood group and saved.Once she is stable then the detail Hx of the current preganancy should be taken.She should be asked whether she had pelvic USG done and if the foetal heart was visualised or not.Any Hx of UTI and vaginal discharge antedating miscarriage should be elicited.
Hx of previous two miscarriages should be taken.Her previous medical notes should be checked to know the duration of pregnancy,USG report for the foetal viability.It should be checked whether she had evacuation for the POC[products of conception ]or not.Her past medical Hx becomes important in view of recurrent third miscarriage now.Any Hx of infertility treatment/obesity/hirsuitism should be taken to rule out PCOS.In addition hx of heat intolerance,malar rash,polyuria/polydipsia is taken to rule out endocrine/autoimmune disease like Grave\'s disease,SLE,Diabetes mellitus respectively.Any history of abnormal bleeding during minor procedures to rule out thrombophilias.
Physical examination includes BMI for obesity;pulse,B.P,pallor,skin turger to assess for hydration/hypovolumia.Pelvic examination is done to assess uterine size and the cervical os.It should be assessed whether any retained clots or POC are present.Cervical os is open or closed.If uterine size is less than the period of gestation/contracted and empty and the os intending to close then the miscarriage is complete and does not require check curretage.

b]Various investigations done in the emergency clinic are the following:-
Blood group is crossmatched for 2 units .FBC with clotting and thrombophilia screen should be sent for anaemia,platelet count.Thrombophilia screen is done for both congenital and acquired thrombophilias like anti phosphlipid antibodies and lupus anticoagulant[LA].
Karyotyping for the expelled gestational sac and foetal products are done.In recurrent miscarriages foetal karyotype anomalies are less common than in sporadic miscarriage.Karyotyping of the patient and the partner should be done.There is 3-5% incidence of chromosomal anomalies,balanced translocation being the most common in recurrent miscarriages.
Pelvic Ultrasonography should be done to check for the retained POC/clots ;in addition to rule out uterine anomalies and PCOS.TFTs are not done in routine,only if the Hx is suggestive of them.TORCH is not indicated also.
Opportunistic investigations like rubella and HIV are be done.

c]Patient should be informed in sympathetic manner that it is not her fault in this miscarriage.She should be given the contact numbers for the support groups for the emotional councelling.She should be told that she stands good chance for the live birth in the next pregnancy with the supporting care upto 75%.She should report again in 6weeks for the repeat titre of thrombophilia screen,as two samples may be required for the diagnosis.If thrombophilias are positive then the patient is informed that she should report early in the next pregnancy so that low dose aspirin and I/V Heparin can be started early.This treatment can improve the live birth rate upto 70% from 10% in acquired thrombophilias.
If balanced Translocation is positive in maternal/paternal karyotype,then patient is asked to see clinical geneticist for the prenatal diagnosis,pre implantation Genetic Diagnosis[PGD]and the familial chromosomal studies in the future pregnancy.
Pre pregnancy supplementation of folic acid 5mg/day is prescribed 12 weeks before the intended conception and upto 12 weeks of pregnancy.
Patient should be informed that there is practically no treatment for the miscarriages associated PCOS and the uterine anomalies.
Posted by Shachi M.
(a)Justify your initial clinical assessment [5 marks]

This is a gynaecology emergency situation and the aim of initial assessment is to find out the extent of resuscitation needed by the patient. A general examination should be done to assess if the patient is alert conscious and oriented to time, space and person. If she is unconscious a quick assessment should be done to check patency of aiway , if she is breathing and if she has got a pulse.
In a conscious patient, after assessing her general condition, pulse, blood pressure and oxygen saturation should be checked, as hypotension and tachycardia are signs of haemodyanamic compromise.
If available, a haemcue should be done to check the level of haemoglobin, so that blood transfusion can be initiated if needed.
A quick assessment of the amount of blood loss and if the bleeding is ongoing or settling is also important

(b) Which investigations will you undertake in the emergency gynaecology clinic?
A full blood count , group and save, cross match (2 units blood), urea and electrolytes, clotting screen, beta hCG should be performed in the emergency clinic.
If the bleeding settles and the patient is stable, a pelvic ultrasound should be performed .

(c) Which information will you give her before discharge? [10 marks]
This patient has had a complete misarriage.
She should be informed that she has lost the baby, but we do not know why this happened.
Women who have had 3 or more consequtive miscarriages, are said to have recurrent miscarriages.
The incidence of miscarriage is about 10-15% and that of recurrent miscarriage is 2-3%.The patient should be sent home with information(verbal and written) about miscarriage and recurrent miscarriages
Counselling should be offered and leaflets and phone numbers of miscarriage association should be given.
She should be advised that her vaginal bleeding should gradually settle and then completely stop. If the bleeding gets worse, this could be a sign of infection and she should contact gynaecology emergency straight away (Phone numbers of the clinic should be given).
If she wishes to try for pregnancy in future, she can do so when she feels emotionally ready for it.
She should be offered referral to gynaecology clinic for investigation of recurrent miscarriage.
These investigations may or may not give us the cause for the recurrent miscarriage. If the cause is found, in some cases we might be able to offer treatment (eg:prophylactic low molecular weight heparin for thrombophilias).
In someone with 1st trimester miscarriage, the most common known cause is abnormal embryo, which could be due to chromosomal abnormality. Such women should be offered karyotyping of both partners after proper counselling. Karyotyping of products of conception in future miscarriages is a helpful investigation. She sholud be offered testing for anticardiolipin antibodies and lupus anticoagulant and thrombophilia screening to test for inherited and acquired thromophilias. If no reason is found, she can be reassured that she has a 75% chance of successful pregnancy in the future.
Posted by R M.
a) It is gynecological emergency associated with significant morbidity and mortality unless promptly managed. Rapid resuscitation and treatment is necessary. I’ll assess the need for basic life support by checking the patency of her airway, breathing and circulation (by checking pulse and BP). I’ll assess her blood loss. IV access will be obtained using two large bore venflons and blood will be collected for grouping and cross-matching, FBC, clotting screen and serum b hCG. I’ll call for help (if she is in impending shock) from anesthetic registrar, senior mid-wife, consultant and porters to send blood. I’ll commence resuscitation using intravenous crystalloids / colloids and oxygen by mask. Haematology/blood bank will be alerted regarding the need for blood.O negative blood will be given if there is massive blood loss. I’ll perform an abdomino-pelvic examination to assess size of uterus, dilatation of cervix and any tender adnexal mass (to exclude an extra uterine pregnancy). If she is bleeding heavily and clinical pictures suggestive of an incomplete miscarriage, I’ll start IV syntocinon and will prepare her for an emergency ERPC. I’ll inform the anesthetic registrar regarding this. Patient will be closely monitored by checking her pulse, BP, temperature and oxygen saturation. Patient and her relatives will be informed of the clinical situation, necessary interventions and treatment; consent will be taken. I’ll inform my Consultant before shifting the patient to theatre.

b) Urine pregnancy test will be done to reconfirm pregnancy (after ascertaining LMP from patient). I’ll send blood for FBC (to assess Hb) and clotting screen (to exclude coagulopathy). Blood grouping and cross matching will be done as blood may be needed to resuscitate the patient and anti-D needs to be given if found Rh-negative. Serum b hCG to confirm pregnancy (high levels may be suggestive of a molar pregnancy). Swabs will be taken for culture of chlamydia and bacterial vaginosis(to guide antibiotic treatment and contact tracing). Pelvic examination will be done to assess size of uterus and dilatation of cervix which allows categorization of miscarriage (threatened/missed/incomplete…).I’ll do transvaginal USG to see any evidence of intrauterine gestational sac/retained products of conception. Products of conception will be send for histopathology examination and karyotyping (if the local protocol permits).

c) Miscarriage is a distressing situation for the woman and her partner – so at the time of discharge I’ll make arrangements for psychological counseling and emotional support. I’ll explain to her what has happened and the interventions done (like ERPC if any).

The couple might be distressed from three consecutive miscarriages. I’ll tell them there are a number of things which may play part in recurrent miscarriage.Recurrent miscarriage affect 1% of women which is thrice the risk that is expected to happen by chance alone – so some of those affected by recurrent miscarriage may have an underlying cause while majority don’t.

I’ll tell her risk of miscarriage is increased by lifestyle factors like smoking and alcoholism; health problems like poorly controlled diabetes, autoimmune disorders (diseases affecting immune system) like antiphospholipid antibody syndrome(APS), thrombophilias (condition where blood is more likely to clot) if she has any.

I’ll tell them certain blood tests and pelvic USG can detect some of the underlying causes. A test called Karyotyping will be done to detect genetic abnormalities in the couple (genetic counseling needed if positive) and conceptus (if positive, better future pregnancy outcome). If tests for APS (lupus anticoagulant and anticardiolipin antibody) is positive ,there is evidence of better pregnancy outcome on treatment with low dose aspirin and LMWT heparin. If USG shows uterine anomalies, can be corrected with hysteroscopic surgery. Ther is no proven treatment to improve pregnancy outcome in case of polycystic ovaries in an ovulating woman who conceives naturally, though evidence of PCO is found on USG in upto 40% of women with recurrent miscarriage.

Inspite of careful investigations it is not often possible to find a reason for recurrent miscarriage. However there is some evidence that upto 75% couple with unexplained recurrent miscarriage have successful future pregnancy without pharmacological intervention if offered supportive care alone in the setting of a dedicated early pregnancy unit. I’ll also tell her if she conceives next time it is not possible to predict the outcome. I’ll provide her with written information . Discharge summary will be given stating the investigations and procedures done and whether anti-D given or not. Follow up will be arranged.

I’ll give her support address (like Miscarriage Association)
Posted by Ephia Y.
A 20 year old nulliparous woman with 2 previous first trimester miscarriages attends the emergency gynaecology clinic at 12 weeks gestation with severe abdominal pain and heavy vaginal bleeding. She passes several clots and the gestation sac while waiting in the clinic. (a) Justify your initial clinical assessment [5 marks]. (b) Which investigations will you undertake in the emergency gynaecology clinic? [5 marks] (c) Which information will you give her before discharge? [10 marks]

Initial assessment includes checking airway, breathing and circulation as she is bleeding heavily. I will check that she is conscious. Her oxygen saturation, pulse and blood pressure are noted.Venous access is secured with large bore cannula. If her Oxygen saturation is low, oxygen inhalation is started.
A history is taken with regards to her last menstrual period, onset of bleeding and pain. Any previous ultrasound such as a dating scan is noted for documentation of an intrauterine or viable pregnancy. History of previous miscarriages, the gestations at which they occured and any cause detected are checked. A medical history is taken, regarding any autoimmune disease, thyroid disorders, polycystic ovary syndrome thrombophilia, renal disease. Past surgical history taken.
Examination includes abdominal palpation to note uterine size, tenderness, mass, peritonism. A speculum examination is performed to note the cervix and whether open or closed. If any product seen, it is removed. An internal and bimanual examination is performed to note cervical excitation or any adnexal mass to elicit possibilty of ectopic pregnancy though findings of a sac suggests intrauterine pregnancy.

Investigations undertaken are a full blood count for haemoglobin, haematocrit, platelets and white cell count. Blood for group and save. Her Rhesus statues is noted. Cross matching of blood if assessment suggests she requires blood transfusion. Blood for coagulation profile. During speculum examination, high vaginal and endocervical swabs are taken to rule out infections. A pelvic ultrasound may be performed to note if the miscarriage is complete.hCG is sent if there is suspicion of molar pregnancy.The product of conception can be sent for histopathology or cytogenetics with the patients consent.

Before her discharge, she will be councelled regarding her miscarriage. As this was her third pregnancy, she is offered an appointment in the recurrent miscarriage clinic where the couple can be investigated to try and find a cause for the miscarriage. Investigations include karyotype, blood tests for thrombophilia, autoimmune disorders, ultrasound for any pelvic abnormalities. If a cause is found, then treatment can be discussed but she is informed a cause is not always found and recurrent miscarriage remains unexplained in 20% of cases.

If any genetic causes are found, then the couple could be referred to a geneticist.

She is offered support and counselling and bereavement services. Information on support groups like SANDS is provided.

If she conceives then she contacts her GP or the early pregnancy unit for an early scan and follow up in the recurrent miscarriage clinic.

She is also reassured that her chance of conceiving a normal pregnancy are high.


Posted by Asma kamal K.
(a)Recurrent miscarriage is very distressing emotionally, this women needs sympathetic and empathic approach. In view of her pain and heavy bleeding prior to passage of gestational sac , I will ask her about any feeling of weakness ,dizziness, fainting and is she still feels severe pain and bleeding heavily for which she will need urgent resuscitation. I will enquire about all three miscarriages in detail. I will ask about the exact gestational age, ultrasound evidence of embryo or a fetus as anembryonic pregnancy loss usually seen with chromosomal abnormalities. I will ask about utlrasonographic establishment of fetal cardiac activity as pregnancy loss after fetal cardiac activity more commonly seen with antiphospholipid syndrome . I will ask her about her menstrual history, medical history, family history,particularly about PCOS,SLE, DVT ,thrombophilia and diabeties(if uncontrolled).
In her examination I will take her pulse and blood pressure(Hemodynamic stability),BMI and Look for feature for PCOS (Hirsuitism,acne acanthosis nigricans) . With the consent of the woman I will do perspeculum examination to assess the blood loss and to examine the cervical Os for any product of conception as there presence will indicate incomplete miscarriage and there absence and closed Os most probably will indicate a complete miscarriage.
(b) I will send patient blood for FBC, blood grouping and Rh factor, Urea and electrolyte, clotting profile, anti cardiolipin anti bodies, diluted russel viper venom test, karyotype. I will send the expelled gestational sac (if available) for histopathology and karyotyping. I will offer her pelvic ultrasound to rule out retained products of conception, poly cystic ovaries and uterine abnormalities.
(c) I will explain the situation to her, ideally in presence of her partner, I will reassure that the miscarriage has not occurred because of any action or omission on her part. If she turns out to be Rh negative and did not need manual evacuation of uterus then I will explain to her that she does not need Anti D prophylaxis even if the partner is Rh positive(NICE guidlines) because the risk of alloimmunisation is neglegable at this gestation. Anemia if detected on FBC due to her previous history or recent blood loss may need transfusion or oral hematenic support. I will counsel her that in majority of cases no obvious cause could be detected and these woman usually have successful pregnancies next time. She will have to book early in an early pregnancy clinic in the next pregnancy for the recognition of fetal viability and supportive care. As she had her third consecutive miscarriage relevant test had been sent. She will be given follow up appointment to disscuss these investigations and any treatment recommended. The couple may need bereavement counseling. I will give her written information about recurrent miscarriage and give her contact of local and national support group(SAND)
Posted by J P.
a.The history suggests the possibility of miscarriage which is an obstetric emergency and causes significant mortality and psychological morbidity to mother .I will examine the patient including the vitals temperature,pulse rate and blood pressure for any hypovolemic shock .Degree of pallor will also be assessed to find the amount of blood loss and the need for blood transfusion.Gentle abdominal examination to see the uterine size and tenderness if any.I will perform bimanual pelvic examination to assess uterine size,whether os is open or not, the amount of bleeding.Any adnexal tenderness will also be looked into to rule out the rare chance of heterotropic pregnancy.If the patient is not in state of shock and able to communicate I will ask detailed history regarding previous miscarriages, any investigation done. History suggestive of viral illness predisposing this miscarriage will also be enquired. Personal and family history of venous thromboses will be enquired for antiphospholipid syndrome and thrombophilias which may be a cause for recurrent miscarriage.Case records if available will be seen.
b.Intravenous access will be maintained by two 14 gauge needles.Blood will be sent for full blood count , clotting profile,group and save to assess the need for Anti-D prophylaxis.I will also request for Ultrasound in case of suspected incomplete miscarriage for the need for surgical evacuation.Fetal products expelled if available will be sent for karyotyping after appropriate information to the patient and attenders.

c.I will explain this condition as recurrent miscarriage .Since this occurs more than by chance alone any underlying cause will be treated.Karyotyping of both partners is recommended since in 3-5% of recurrent miscarriages chromosomal anomalies will be seen.Results of fetal karyotyping will be awaited.Assessing the antibody titre for the patient for anti phospholipids syndrome and in particular if any family or personal history of thromboses thrombophilia screening becomes necessary.If found positive heparin prophylaxis may be essential. Ultrasound may be used to detect any uterine anomalies but this causing first trimester miscarriages is rare.
I will also tell her that in the absence of symptoms routine tests like GTT,thyroid function test ,TORCH viral screening are of limited value.Empirical treatment with progesterone and corpus luteal support with hcg has no proved evidence.I will reassure her that the success rate of fure pregnancy is high even in absence of treatment.Adequate emotional and psychological support will bee ensured.Support groups addresses will be given. Next appointment will be given for 4 weeks later.
Posted by Drxyz A.

DRXYZ

a) As patient had heavily bleeding so may be in shock. I will stabilize the patient first. Secure 2 IV lines. I shall check pulse, respiration and blood pressure. If tachycardia and hypotension than I shall ask for plasma expanders like hemacel. I shall ask for blood group and crossmatch 2 units of blood.

I will examine the patient quickly. I will do abdominal examination to rule out any abdominal mass. I will do vaginal examination to see the status of cerival os. If there is any vaginal clot I will remove it. If the cervix is closed and minimal bleeding, I will observe the patient. I shall order for USG to see and products of conception.

After stabilizing the patient I will take brief history. I will ask about her pain after expulsion of the sac. If still having pain I shall give her analgesics and keep her NPO until ultrasound report comes. I will ask about any USG in this pregnancy for viability of the fetus to rule out the missed abortion. As this is her 3rd abortion, I shall try to give her sympathy.


b) I will ask for complete blood count to look for Hb, platelet count and wbc count. Blood group if Rh negative I will ask for husband\'s blood group and ask for anti-D antibody test. I shall request for coagulation profile i.e. PT, APTT, serum Fibrinogin levels. USG for any retained product of conception. I shall take the consent of the patient and her partner to send the product of conception for cytogenetic analysis.


c) I will inform the patient regarding investigations for recurrent abortions like karyotyping for patient and partner and consultation with clinical geneticist after reporting as 3-5% of the patients having balanced traslocations i.e Robertsonian and reciprocal. I will request for inherited thrombophilic screening i.e anti-thrombin III defeciency, Protein C and S deficiency, Factor V Leiden deficiency, Prothrombin G mutation, because these can be the cause of recurrent abortion. I will investigate for anit-phospholipid syndrome by sending the blood for aPl and La.

I will explain the patient that if any investigation found to abnormal I will try to treat the condition so she could have a live, healthy baby in her next

pregnancy. I will also tell her that there are cases in which the cause cannot be found but still these patient can have live, healthy baby.

I will inform the patient about her blood loss and need of good diet and iron supplements to replenish the body iron stores.

I will explain the patient the need of aspirin and heparin in the next pregnancy.

I will refer her to psychotherapist and give written information about her condition and also provide her with the the names and contact details of the support groups available in the community.

I will explain the need of follow up for these investigations in gynaecology clinic. I will advise her to consider contraception until the couple is investigated.
Posted by Atashi S.
( a)Woman with these symtoms have a life threatening condition . For initial clinical assesment Iwill note her vital signs -pulse, Blood presure,degree of anemea ,temparature and level of conciousness.At the same time Iwill quick review her history regarding LMP and accuracy of gestational age .Abdominal examination is to be done to detect abdominal tenderness and to find out the height of uterus . Gentle per speculum examination is to be done to note the state of internal os and to detect any visible product of conception hanging through the cervix .
(b) In emergency gynocological clinic at first I will send a sample of blood for full blood count , blood grouping and Rh typing ,clotting screen and urea & electrolyte. I will also request for cross matching of at least one unit of blood . A pelvic USG is to be done to detect any retained product of conception . Product of conception should be send for histopathological examination and for karyotyping .
(c) As this patient is liable to be emotionally upset psychological support is to be given to her . She should be reassured that likelyhood of successfull pregency after recurrent pregency loss is high with supportive care in early pregency assesment unit . She should be investigated before going to be pregnant to find out the cause of miscarriage, as there may be a underlying pathology. She and her husband will go for Karyotyping testing . If there is any abnormality they will go to clinical gentistist. Pelvic USG is to be done to see ovarian morphology to exclude polycystic ovarian syndrome and uterine abnormality.Thrombophillia screen is to be done to rule out acquired or inherited thrombophillia including protein-C and protein-S difficiency, antithrombin -III difficiency and factor V laden mutation.Antiphospholipid antibody syndrome should be screened by doing two test six weeks apart.Third test is to be done if there is discordant result.
If symptom suggestive of Diabetes Mellitus and thyroid disease then diabetic screen and thyroid function test is to be done.I will explain her in majority of the cases no abnormality is found and likelyhood of a subsequent successful pregnancy is high.I will provide her written information on recurrent miscarriage.Further appointment should be done to discuss the result of investigation when available.Contact details of local or national support group should be provided to her.
Posted by N K.
a) Justify your initial clinical assessment [5 marks].
From the diagnosis it is clear that she is miscarrying and if unattended she may exsanguinate. Therefore, first of all her vitals such as BP, pulse rate, temperature and oxygen saturation needs to be assessed including pallor, whilst trying to assess the bleeding by a vaginal examination. Firstly she will need a speculum examination to check for retained products at os, which will need to be removing to control her bleeding. If no products at the os, a digital vaginal examination needs to be carried out to check whether the os is opened or closed. If opened and bleeding, she may require evacuation of retained products. An abdominal examination will be helpful in determining the size of the uterus and tenderness if any. Once stabilized, will enquire about the duration and amount of bleeding at home to estimate the blood loss. I will also ask about her medical, obstetric and family history to ascertain the cause of these recurrent miscarriages. I will debrief the patient and family members.

(b) Which investigations will you undertake in the emergency Gynaecology clinic? [5 marks]
A full blood count should be done to check her Hb status, platelets and elevated WCC incase of any infections and, a group and save is necessary to check her Rhesus status as she may require Anti D and also blood transfusion. A clotting profile is also indicated if she has bled a lot to look for DIC. Ultrasound scan is not very beneficial as she is bleeding.
Removed products needs to be sent for a histological examination to rule out molar pregnancy and to confirm products of conception. A dry specimen needs to be sent for cyto-genetic analysis to check for genetic causes of recurrent miscarriage. Patient consent is necessary for it. Vaginal swabs can be taken and send for to exclude infections.

(c) Which information will you give her before discharge? [10 marks]
She needs to be fully counselled regarding miscarriage and recurrent miscarriage. A sensitive and empathic approach is necessary. I will explain to her that miscarriage is an early pregnancy loss and recurrent miscarriage is when it happens 3 or more time in a row. About I in 100 have recurrent miscarriages. Most couple with recurrent miscarriage has successful birth in future. However a proportion may have some underlying causes for it. I will offer her a clinic appointment where she and her partner need to give blood for investigation and she will also need a pelvic scan to exclude structural anomalies. Despite investigations we may not always be able to find a cause and predict what happens if she falls pregnant again. Available treatments for the known causes can not always be guaranteed to work all the time for everyone. I will also advise her to inform nearest early pregnancy assessment unit if she falls pregnant again.
Will also advise her not to use tampons until she stops bleeding as this may cause infections. It will take 4-6 weeks for her periods, but she can conceive during this time. She will have to use contraception if she wants to avoid pregnancy. She and her partner can start trying for another pregnancy as soon as they feel emotionally and physically prepared.
I will also tell her that it is important to report in case of excessive bleeding, fever, and abnormal vaginal discharge. She can return to work possibly in a week’s time. However, it is an emotionally disturbing event, may take longer to recover.
I will provide her with written information and contact details for support groups such as miscarriage association.
Posted by Farkhanda A.
A
Initial assessment will be made by history and examination. The history already gives the clue of spontaneous miscarriage in first trimester as it happened in her case previously. Thus it is a case of recurrent miscarriage.
She expelled gestational sac in the clinic, I will ask about the pain that is it settling? Ideally it should. I will ask about any aggravating factors which may be aggressive to start her pain or any history of sexual intercourse which may be an aggravating factors. I will also enquire about any surgery on the cervix such as cold knife excision.
In examination, I will check her blood pressure which may be low due to heavy bleeding. Her pulse may be tachycardic. I will do abdominal examination to check any mass such as fibroid which may have caused this miscarriage. In speculum examination (S/E ), I will check for the bleeding to settle down and any products of conception in the cervical os. Usually placenta comes out with gestational sac.
Bimanual examination may not be very informative except giving idea about the size of the uterus and any adenexal swelling.
B
In emergency gynae clinic, while accessing intra venous (IV) route and setting IV fluid , I will take blood for full blood count , for group and save. I will take high vaginal swab and endocervical swabs during S/E to exclude any infection like bacterial vaginosis or Chlamydia trachomatis. The foetus and all other products of conceptions should be sent for histopathology and chromosomal abnormality. For detail investigations to rule out any cause of recurrent miscarriage, she needs discussion and counselling.
C
Before discharge, she needs full discussion and explanation about recurrent miscarriages. She should be told that in first trimester 3 or more consecutive spontaneous miscarriages is a case of recurrent miscarriage. Its incidence is 1%. . She needs some specific investigations to find out the cause of recurrent miscarriages. However , in 75% of cases, only reassurance is needed for successful pregnancy outcome.
I will tell her that in 5% of couples with this problem have chromosomal abnormality such as balanced translocation like reciprocal and Robertsonian. Anatomical abnormality in genital tract, such as bicornuate uterus can be a cause. Thrombophlia screen for congenital factors (Protein S, protein C , factor 5 leiden deficiency, homocystinaemia , antithrombin 111 deficiency and activated protein C resistant deficiency. There are acquired factors such as systemic lupus erythematosis.
Arrange Ultrsound scan to exclude any anatomical cause. Advised her That all investigations which are necessary should be done before next subsequent pregnancy so suitable action can be taken to prevent further loss.
In case of chromosomal abnormality, arrange a meeting with geneticist. Give her written information leaflets.
Give her contact numbers of support groups.

Posted by SHAGUFTA T.
A) Recurrent miscarriage has increased morbidity. As this lady with Recurrent miscarriage (Consecutive loss of 3rd fetus) will be emotionally upset & under stress, I will deal with her empathetically. I will first assess her haemodynamic condition by P, BP, Temperature, respiration, if unstable—I will start rescusitative measures, call for help, Airway, breathing & circulation by 2 large bore cannula, send blood for investigation. After stabilization of her condition, I will take detailed history regarding this pregnancy—duration & severity of pain and bleeding. I will ask if there is any predisposing factor like stress or trauma causing bleeding. I will ask her LMP, regularity of previous cycles. Whether she attended Early Pregnancy Assessment unit (EPAU) in this pregnancy, any dating scan was done, fetal viability documented or not. H/O any vaginal swabs taken, any infection or preexisting disease detected. Her Rubella status checked? Then I will take H/O previous miscarriages (See notes if available) regarding gestational age at time of miscarriage, USG confirmed viability. If she & her partner were investigated for cause of miscarriage. Her past medical/surgical history, any Hx suggestive of PCOS, Thyroid dysfunction, uncontrolled DM. Social & Psychological history taken.
On Examination—her general condition reassessed, BMI checked, Abdominal examination to look for tenderness, vaginal examination to look for amount of bleeding, uterine size, condition of os (open/close), adnexal tenderness, signs of infection, HVS will be sent.
B) Investigations: As she is heavily bleeding, FBC( to check Hb, Hematocrit, need for transfusion, WBC to exclude infection), Blood Gp, Rh status (if negative may need Anti D), C/Match & coagulation profile will be done. I will also send for baseline RFT, U&E, LFT, Pelvic USS (to see retained POCs & to exclude PCOS) if time & her condition permits. If POCs (products of conception )available, will be send for HPE.
C) Before discharge, after stabilization & management of her present condition, I will counsel her that she’s not at fault for occurrence of this situation. I will give her information regarding Recurrent miscarriage investigations & will counsel her & her partner to do them to exclude the causes (if not done already). I will advise her to do USS pelvis to look for PCOS & exclude uterine anomalies. I will tell them to do Karyotyping for both parents, Exclude APS by anticardiolipin & lupus antibodies. Thrombophilia screen, immunological tests not indicated in all cases. Screening for Diabetes, thyroid dysfunction, Torch infections on individual basis if suggested by symptoms. I will inform her regarding followup visit with senior gynecologist to discuss the results of tests & future plans. I will explain her that in Unexplained recurrent miscarriage, there is excellent prognosis in future pregnancy. Berievement counseling with special person arranged, contact details of support groups like well mum, CRUSE, SANDS given. I will advise her to book early in next pregnancy with EPAU (Early Pregnancy Assessment Unit) & to have early dating & viability scan. Appropriate family & social support to be provided. Information leaflet given.
Posted by Iffat ara M.
A):
As this is an emergency so I would review her thoroughly and assess her airway breathing and circulation. I will check her conscious level. If haemodynamically stable I would like to take brief history regarding her LMP, did she conceive spontaneously or by treatment. I would ask about any medical disease especially diabetes, thyroid disease, hypertension etc. Then I would examine thoroughly, look for pallor and will do abdominal examination gently to look for any tenderness and size of uterus, is it palpable, then I will proceed for pelvic examination under aseptic conditions and I will asses the severity of bleeding, any blood clots in vagina and I will check the condition of cervix and uterine size. If cervix is closed and minimum bleeding & uterus seems normal size, it means it is a complete miscarriage.
B):
Regarding investigation I would request for FBC, blood grouping and RH typing, coagulation profile, products of conceptions would be sent for karyotyping. Serum beta.HCG level quantitatively, pelvic ultrasonography (if unable to asses clinically) to rule out retained products of conception.
C):
As miscarriage is associated with significant psychological sequelae, so appropriate support and counseling will be offered to women after miscarriage. Patient will be informed about the causes of recurrent early pregnancy loss. I would explain her that 3-5% of early miscarriages are due to chromosomal anomalies especially balanced reciprocal or robortsonian translocation. So karyotyping of couple will be advised. If abnormal karyotyping result,so they will be reffered to clinical geneticist for genetic counseling,so by preimplantation genetic diagnosis/prenatal diagnosis can improve the pregnancy out come.i will tell her about 75% miscarriages are unexplained.She should be advised to take prepregnancy folicacid .Screening for inherited thrombophilia especially for protein C, S and factor V leiden mutation. Transvigianal ultrasound would be requested for ovarian assessment to rule out polycytic ovaries and any other uterine anomaly. Screening for anti phospholipids syndrome would be requested on two occasions with 6 weeks interval .She will be informed if lupus anticagulanti/anticardiolipn antibodies are positive she may need low dose aspirin/low dose aspirin+ low molecular weight heparin in the future pregnancy as they will improve the live birth rate by 40% & 70% respectively. Clear follow up plan should be documented on the discharge summery. She will be provided with the written information and detailed addresses of the support groups.
Posted by H P.
a) I will ask for immediate help from senior nurse in the clinic, senior registrar, anaesthetic and porters as she has heavy bleeding. I will check her temperature, pulse, blood pressure and oxygen saturation. High grade fever may suggest an infective cause. Hypothermia may be present in septicemia. Hypovolaemia due to blood loss will lead to tachycardia, hypotension and low oxygen saturation. I will clinically assess the amount of bleeding by checking her pads, clothes, degree of pallor, haemodynamic status and consciousness. If she is unconscious or haemodynamically unstable she will be urgently resuscitated. If she is conscious, I will take history regarding duration and severity of symptoms. I would ask her whether she had any early ultrasound during this pregnancy, any interventions or known medical conditions like diabetes or thyroid dysfunction. After verbal consent, I would do her examination. On per abdomen, I would check for any mass (fibroid uterus) or tenderness. On per speculum examination, I would look for presence of active bleeding, clots and whether the os is open. If the os is open and products are seen or active bleeding is present, it would suggest incomplete miscarriage. I would do vaginal examination for uterine size which may be more in case of retained products, molar or multiple pregnancy of fibroid uterus. I would start her on oxytocin infusion till ultrasound is arranged. Foul smelling discharge and tenderness on vaginal examination may suggest an infective etiology. I will check her previous clinical notes if available.

(b) After inserting two wide-bore canula, I will send blood for urgent complete blood count, blood group and save and coagulation profile. Hemoglobin and hematocrit status will give idea of the amount of blood loss. Leucocytosis will suggest infective cause. In case of haemodynamic instability with bleeding I will ask for 4-6 units of packed RBCs. Her rhesus status will help to decide whether she may need anti-D immunoglobulin. I will send her baseline electrolytes, renal and liver function tests which would be helpful if she needs to go to the theatre for evacuation of retained products. I will take triple swabs for Chlamydia and bacterial vaginosis during speculum examination. I will arrange for an urgent portable ultrasound of the pelvis for confirming complete miscarriage or the need for ERPC. I will send the products and gestation sac for histopathological examination and also karyotype as she has no living child and this is her third recurrent miscarriage.

(c) The couple may be suffering from significant psychological trauma and will need empathetic counseling and support. I will debrief her and her partner regarding the events (ERPC if any), investigation sent and the available results. I would inform her that results of karyotype of fetus are awaited. I will inform her that first trimester miscarriages are common and occur in one out of five pregnancies. Most miscarriages have unknown etiology and in about 70% of cases, a healthy successful outcome can be expected without any intervention. However, as she has no living children and three recurrent miscarriages, it would be helpful to investigate her further. Her wishes and concerns would be taken into consideration before any testing. She could be screened for thrombophilia as it is known to be associated in 15% cases. Acquired thrombophilia like antiphospholipid antibody syndrome or SLE requires checking for antibodies twice at 6 week interval for confirmation. The diagnosis of thrombophilia will lead to early interventions during her next pregnancy in the form of low dose aspirin and heparin, increased fetal surveillance. Success rates are 70% versus 10% without treatment. In 3% cases, there may be chromosomal abnormalities in partners and I will offer them karyotype. In case of any abnormalities or balanced translocations, she would be referred to genetist. Uterine structural abnormalities like fibroid, bicornuate or septate uterus or condition like PCOS can be ruled out by pelvic ultrasound before her next visit. If she wishes, I will offer her contraception. Screening for DM and thyroid function will be offered if she has suggestive symptoms. I will give her follow up appointment at clinic in 6-8 weeks to discuss the results and plan of management. If she is not rubella immune I will offer her rubella vaccination before discharge. I will give information leaflets and address of support groups.
I will tell her that in case of excessive bleeding/ pain or fever she should report immediately to ward or EPAU and contact number given. I will give her a detailed discharge summary regarding the investigation and follow up and inform her GP. If she is booked for antenatal clinic, I will cancel her appointments. I will ask her to contact her GP/EPAC early in her next pregnancy.
I will offer her preconceptional folic acid. In case of preexisting medical conditions like DM/ thyroid dysfunction, I will advise her to delay pregnancy till it is well controlled
Posted by Vaishali Sriniv J.
a) I will assess the general condition of the patient and note the vital parameters pulse , BP, temperature as it is obstetric emergency I inform consultant gynaecologist, consultant anaesthetist and senior midwife. Patient should be started on I/V fluids using wide bore I/V cannula. Blood should be sent for grouping and cross matching. I will ask patient about her LMP and previous menstrual history. I will go through her records if available and note if any pelvic ultrasound was done and its findings. History about her previous miscarriages is to be asked .Clinical assessment should be done including per abdominal examination to note tenderness, rigidity and evidence of pyrexia. Per speculam examination is to be done to see whether os is open or not and evidence of any products of conception in the cervical canal. The amount of vaginal bleeding should be accessed.
b) I will send her blood forcomplete blood count, for grouping and cross matching and coagulation profile. Urgent pelvic ultrasound examination is to be arranged to note any retained products of conception in the uterine cavity. and whether os is open or closed.. If patient is bleeding heavily she should be posted for immediate evacuation under anesthesia. In doubt products of conception should be sent for HPE.
c) Patient and her partner should be seen together before discharge and all the events should be explained to them. If patient is Rh negative then she should be given anti D prophylaxix. They should be told that in majority of the cases the cause for recurrent miscarriages is unexplained. The couple is to be reassured that in 60 to 70% of the cases next pregnancy will be successful. They should be given psychological support and all their queries should be answered. They should be told that they need to come for follow-up visit after one month. They need to undergo further tests to find etiology of recurrent miscarriages before planning next prengnancy.. Both of them should undergo blood test for Karyotype, antiphosholipid antibodies. She is to undergo pelvic ultrasound to note any anatomical defect.Patient should continue taking folic acid 5 mg everyday. If next pregnancy also gets miscarried then the products of misconception should be sent for histopathologic diagnosis. Patient should be told that she should register early iif she misses her period.
Posted by S W.
a. History is taken including her previous and whether she experience vaginal bleeding or she got blighted ovum or missed miscarriage and what management she got at that time and if their were any complication happened. Past gynaecological history is also taken , if the patient has PCOS, this can cause her recurrent miscarriage also if the ovulation is induced and pregnancy was not spontaneous. Medical disease , other endocrine / metabolic disease should be reviewed also so as to reach the cause of her situation. We inquire also about family history of genetic diseases and history of consanguinity. Rapid general examination is done including stigma of systemic disease like SLE or thyroid disease. Pallor can reflect blood loss or patient anaemia. Abdominal examination is done to find if there is any rigidity or tenderness , also looking for abdominal distention to rule out ectopic gestation. Speculum examination is done to find if there is still gestation product protruding through the cervix also to assess the amount of bleeding. Uterine size can be checked by bi-manual examination and we check dilatation of internal OS by digital examination.

b. We send for FBC, blood group and Rh status and cross matches. WBS, CRP and urine analysis can reveal infection. Ultrasound examination is done to ensure that there is no retained products of conceptions. The product of conception is reserved to be offered a cytogenic analysis later on .

c. We offer her psychological support and debriefing. The patient informed that she will need further investigation to reach the diagnosis, however, in some cases the cause of repeated miscarriage remain unknown, yet she still have a chance of getting successful pregnancy in the future. Follow up appointment is arranged for her. If the cause of her recurrent miscarriage is reached, treatment can be offered like Antiphospholipid syndrome, we tell her that she will be kept on combined therapy of low dose aspirin and heparin which increase her chance of having a better rate of future live birth. If a chromosomal abbreviation is discovered, we can offer her IVF and PIGD to select a healthy and good quality embryo.
In addition we offer her to take contraception till she regain her physical and psychological well being , we advice her to join support group and provide details and information leaflets. Folic acid is prescribed and we inform her that a letter will be send to her GP about her details to follow up her. We tell her that she should report early to pregnancy clinic if she get pregnant next time.
Posted by SK K.
a)Three or more consecutive miscarriages are called as recurrent pregnancy looses. Implication wise it means great mental and physical concern to the patients and economic burden to any national services by way of the various investigations and treatment that need to be done.

As a part of assessment I would ask this lady the severity of symptoms, onset of the pain and vaginal bleeding, dizziness, giddiness. so as to undertake any immediate resuscitation .Any previous USS showing fetal viability, cardiac activity seen earlier? So as to know if it was blighted ovum or fetal demise.
I would enquire about any living children, past pregnancy losses, the gestation at which the losses occurred whether 1 st or 2 nd trimester, if she has undergone previous investigations. Whether there is any past medical or surgical history as chronic illness like sle , diabetes are also associated with increased miscarriage and if she is on any medicines. The above history will aid in ordering the relevant investigation and management.
It is necessary to confirm her hemodyanamic stability by physical examination and note her pulse, blood pressure, pallor as they would indicate amount of blood loss and if immediate resuscitation is required, general examination, cardiovascular & respiratory system review to rule out systemic illness. Per abdominal examination to feel the uterine size . With her permission gentle per speculum will be done to note the amount of bleeding, any products of conception(if seen could be collected) and to note if cervical os is open. Her history and clinical assessment will indicate if she could be cared as outpatient or inpatient. Since bleeding & pain are severe in this case. I would recommend inpatient care for her

b)I would secure IV cannule as she has profuse bleeding and send FBC, clotting screening, U & E, group as emergency investigations. I will also do USS, preferably TVS but if bleeding very profuse then TAS so as note any retained products of conception. If products available then they would be sent for karyotyping and histopathology.

c)If ultrasound and clinical assessment reveal that it is a complete abortion and the bleeding gets settled then she would be managed expectantly. She will be informed of the finding and reassured that at present there is no need of intervention as spontaneous resolution is likely. Surgical evacuation will be undertaken only in case the USS revealed significant amount of retained products(uterine cavity contents > 15mm) or if her severe bleeding continues .
Also if she is Rh negative and partner Rh positive, she would be informed that anti – D is indicated as she has sever abdominal pain, heavy bleeding and is 12 weeks gestation as also if she underwent surgical intervention
Also she will be explained that the miscarriage has not occurred due to any act of omission from her side hence she should not feel guilty. There is 70% chance of successful pregnancy outcome even after three consecutive miscarriages.
Miscarriages less than 12-14 weeks are more likely due to chromosomal & genetic cause and will require karyotyping of both partners as well as of any available products of conception .During interpregnancy interval she will have to be screened for thrombophilia and antiphospholipid syndromes.
Previous miscarriage if 14 weeks onwards are mostly due to cervical weakness or uterine anomalies she should be investigated with HSG when not pregnant and during pregnancy offered cervical length monitoring and prophylactic cerclages.
She should be persuaded to quit smoking, alcohol abuse, illicit drugs as all this will add to improve outcome
Couple could try for conception whenever the female feels fit.
Rubella vaccination should be checked and offered. Folic acid supplement would be recommended periconceptionally whenever she plans pregnancy.
Before discharge she would be given notes of her present pregnancy details which she could show her GP. Given next appointment for follow up and carrying out relevant investigation. She will be put into contact with support group(SANDS) if she desires .
Most important 24 hrs helpline will be provided .so as to contact if symptoms of pain & bleeding recurs.

Posted by S G.
(a) Justify your initial clinical assessment [5 marks].
Her symptoms are suggestive of miscarriage. Tachycardia, hypotension and tachyponea suggest hemodynamic compromise and so pulse, blood pressure and respiratory rate should be measured. Pyrexia indicates infection and so temperature should be measured. Per abdomen examination for presence of mass and per speculum examination for assessment of bleeding and the status of internal os should be done. Open os with presence of products indicate incomplete miscarriage. Products should be removed to minimize bleeding. Closed os with minimal bleeding is suggestive of complete miscarriage.
(b) Which investigations will you undertake in the emergency gynaecology clinic? [5 marks]
Full blood count for anaemia and infection, rhesus antibody status for the need of anti D immunoglobulin should be sent. Blood group should be saved as she may require blood transfusion. Products of conception should be sent for histology and cytogenetic analysis. Vaginal swab for bacteriology and culture should be sent for infection. Pelvic ultrasound scan for retained products should be arranged.
(c) Which information will you give her before discharge? [10 marks]
I will tell her that she has had a miscarriage in a sensitive and empathetic way. Miscarriage occurs in 10-20% in clinical pregnancy. This is her third miscarriage and hence I will offer her investigations for recurrent miscarriage. I will arrange an appointment at recurrent miscarriage clinic in 6-8 weeks time. She should be informed that bleeding per vaginum can persist for 2-3 weeks but if it becomes heavier or if she develops signs of infection then she should contact early pregnancy unit(EPU) or emergency gynecology services. I will give her the contact numbers of these services. GP and community midwife should be informed. I will tell her about sensitive disposal of products of conception and will give her information leaflet about recurrent miscarriage. I will offer her contraceptive advice if she wishes. I will tell her about the website and support group like SANDS.