Miscarriage & Recurrent Pregnancy Loss — Viva

Q1: Definition & classification (2 min)

"Define miscarriage and classify the clinical types." ^[1]

^[1]

• Miscarriage = spontaneous loss before viability (UK: until 24 weeks).
• Pooled risk 15.3 percent of recognised pregnancies; ~23 million losses per year worldwide.
• 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 miscarriage (RCOG) = 3 or more consecutive pregnancies (~1 percent of couples). Guidelines do not agree on a single definition. APS is the key treatable cause.^[1][2]

Q2: Diagnosis (2 min)

"A woman at 9 weeks presents with bleeding. How do you confirm viability?" ^[1]

^[1]

• Transvaginal ultrasound (TVS) is the diagnostic gold standard — assesses viability, gestational sac, fetal pole and heartbeat.
• NICE NG126 TVS process (to avoid false positives):
  • If CRL is 7.0 mm or more with no heartbeat: second opinion and/or rescan at least 7 days later.
  • If MSD is 25.0 mm or more with no fetal pole: same rule.
• Serial quantitative beta-hCG in PUL: >63 percent rise in 48 hours suggests a developing IUP (ectopic not excluded); >50 percent fall means the pregnancy is unlikely to continue. Do not use progesterone as an adjunct.
• 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]

^[1]

Three options — patient choice drives selection; counsel on success and risks: ^[1]

^[1]

• (1) Expectant — NICE first-line for 7 to 14 days. MIST: infection ~3 percent, same as surgery, but more unplanned admissions and unplanned curettage.

• (2) Medical, missed miscarriage — mifepristone 200 mg oral then 48 hours later misoprostol 800 micrograms (vaginal, oral or sublingual) (NICE 1.11.1 / MifeMiso). Do not offer mifepristone for incomplete miscarriage (use misoprostol 600 micrograms).

• (3) Surgical — suction evacuation. Preferred if heavy bleeding, sepsis, or the woman declines expectant/medical care.^[3]

• Anti-D: do not offer up to 11+6 weeks (NICE 2026). Offer at least 250 IU at 12+0 to 12+6 if medical or surgical management.

• 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]

^[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: aspirin plus heparin (RCOG: vs aspirin alone, miscarriage rate reduced by 54 percent).
• 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]

^[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]

References5ShowHide

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