• Threatened miscarriage (acute, minimal bleeding, no pain)
• Inevitable miscarriage
• Incomplete miscarriage (heavy bleeding, cramping)
• Missed miscarriage
• Ectopic pregnancy
• Ovarian pathology – cyst rupture, torsion
• Appendicitis

• History
  • Ask about the following:
    • Severity of pain
    • Amount and duration of bleeding
    • Risk factors for ectopic pregnancy – previous ectopic, pelvic inflammatory disease, endometriosis

• Examination
  • Vitals
  • General cardiovascular + respiratory examination
  • Abdominal palpation – lookingfor signs of unilateral peritonism ± shoulder tip pain secondary to diaphragmatic irritation
  • Clinical inspection of vulva and vagina – quantify bleeding, and check for any products of conception (POC)
  • Speculum examination – quantify bleeding, check cervical os status (open or closed) and the presence of POC near the os, or in the vagina
  • Bimanual examination – estimate the size of uterus, and localize area of tenderness

*If uncertain with performing a speculum examination, it would be advisable to ask a more senior medical officer to supervise.

• Investigations
  • FBC
  • Progesterone – a helpful marker when history and clinical examination yield an uncertain diagnosis. Two examples:
    • Low β-hCG, progesterone < 10 and empty uterus on ultrasound, indicates complete miscarriage. The patient can be discharged and followed up in a few days in the Early Pregnancy clinic.
    • β-hCG 800-1000, progesterone 20-60, indicates that an ectopic is more likely
  • Group & hold ± cross-match
    • Rhesus blood group must be collected in any scenario of PV bleeding
    • 20-30% of women are Rhesus-negative and require anti-D injections to prevent sensitization upon exposure to Rhesus-positive fetal cells in the maternal circulation.
  • If POC are obtained from the speculum examination, place in formalin and send to pathology. Rare risk of a partial or complete molar pregnancy.

Ultrasound is a good initial screening tool when combined with a β-hCG level and clinical suspicion for an ectopic pregnancy.

• Transvaginal ultrasound is more sensitive for picking up a gestational sac, which should be visible if β-hCG> 1000.
• Transabdominal ultrasound can detect an 8-week embryo and fetal heartbeat.

• Complete miscarriage
• Early pregnancy of uncertain viability
• Ectopic pregnancy, yet to be determined

• Complete miscarriage
  • Discharge and follow up β-hCGlevels in Early Pregnancy Clinic
• Early pregnancy of uncertain viability (stable), the options are:
  • If β-hCG< 1000,discharge and follow up in Early Pregnancy Clinic
  • Give Mifepristone for 48 hrs before commencing oral/buccal Misoprostol
  • Wait and see, with serial β-hCGlevels
• Early pregnancy of uncertain viability (unstable)
  • If β-hCG< 1000 and symptomatic with risk factors, contact O&G team for emergency dilatation & curettage
• If Rhesus-negative, give anti-D IMI 250U (< 12 weeks gestation) or 625U (> 12 weeks gestation)
• Counselling available in Early Pregnancy Clinic, liaise with midwives and social workers

• Always consider ectopic pregnancy!
• In any amount of PV bleeding in pregnancy, check the Rhesus-group.
• If uncertain about discharging a patient, escalate care.

• NSW Health Policy Directive. Maternity – Management of Early Pregnancy Complications. May, 2012.