Questionnaire/history:

Abdominal or pelvic pain?

Amenorrhoea or missed period?

Vaginal bleeding with or without clots?

 Breast tenderness?

Gastrointestinal symptoms

Dizziness?

Fainting or syncope?

Shoulder tip pain?

Urinary symptoms?

Passage of tissue?

Rectal pressure or pain on defecation?

Risk factors:

Previous ectopic pregnancy (EP)?

(Note: risk of recurrent ectopic pregnancy estimated at 18.5%)

Damage to Fallopian tubes - tubal surgery?

Pelvic inflammatory disease?

Fertility treatment?

Smoking?

Multiple sexual partners?

Past medical history?

Current medication?

Known drug allergies?

Investigations:

Pregnancy test (PT)?

Examination:

Pelvic tenderness?

Abdominal tenderness?

Rebound tenderness?

Adnexal tenderness?

Cervical motion tenderness?

Peritoneal signs?

- Abdominal pain?

- Abdominal tenderness?

- Abdominal guarding?

- Abdominal rigidity?

- Exacerbated by moving the peritoneum?

--- By forced cough?

--- Flexing one’s hip?

--- Electing Blumberg’s sign?

Abdominal distension?

Enlarged uterus

Pallor?

Tachycardia?

Hypotension (BP < 100/60)?

Orthostatic hypotension?

Shock or collapse?

Management:

Possible ectopic pregnancy/intrauterine pregnancy (IUP)

Haemodynamically unstable or concern about the degree of pain or bleeding?

-> Refer directly to A&E

Positive PT + pain and abdominal tenderness, pelvic tenderness or cervical excitation?

-> Refer immediately to the early pregnancy unit or OOH gynae unit

Bleeding or other features of early pregnancy complication + pain and gestation uncertain or > 6 weeks?

-> Refer to the early pregnancy unit using clinical judgement to decide on the urgency

Bleeding and gestation < 6/40 with no pain & no risk factors for ectopic?

-> Use expectant management and advise:

--- Return if bleeding continues or pain develops

--- Repeat a urine pregnancy test after 7-10 days & return if it is positive

--- A negative pregnancy test means that the pregnancy has miscarried

Worsening symptoms or signs which could be ectopic pregnancy?

Refer to EPU or OOH gynae using clinical judgement to decide if it should be immediate or within 24hr

Threatened miscarriage (with confirmed IUP and fetal heartbeat)

Vaginal bleeding and no previous history of miscarriage?

If bleeding gets worse or persists beyond 14 days, further assessment

If bleeding stops, start or continue routine antenatal care

If a woman has vaginal bleeding and has had a previous miscarriage?

Refer to Early Pregnancy Assessment Unit (EPU)

Offer vaginal micronised progesterone 400 mg twice daily to women with an intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and have previously had a miscarriage

If a fetal heartbeat is confirmed, continue progesterone until 16 completed weeks of pregnancy

(Note: While the PRISM RCT demonstrated potential benefit in women with early bleeding and a history of miscarriage, data also shows that this treatment is not effective in women with bleeding and no previous miscarriage, nor as a prophylactic in women with recurrent miscarriage and no bleeding)

Follow-up after confirmed miscarriage

Ensure that arrangements for routine antenatal care are cancelled if they have been started

Discuss any questions she has about her miscarriage e.g.

- When to resume sexual intercourse? To avoid until miscarriage symptoms have completely settled

- Trying for another baby? As soon as they feel psychologically and physically ready, and offer pre-conception advice

Grief, anxiety, and depression are common following a miscarriage, commonly at its worst for up to 6 weeks

Reference(s):

CKS 2021

NICE NG 126

Information for patient/carers:

Royal College of Obstetricians and Gynaecologists: Early miscarriage: information for you (pdf)

Miscarriage Association's