MISCARRIAGE
By : Duaa Qahtan Dawood
supervised by: Dr. Azzal Sadiq Dawood
CASE SCENARIOS
1 ) A 24-years old G1P0, 8weeks pregnant lady presented with abdominal cramping and heavy
vaginal bleeding with clots, Examination reveals a soft abdomen with mild lower abdominal
tenderness, vagina is filled with blood and clots. The cervical os is opened and tissue
protruding. The uterus is enlarged 6 weeks.
The most likely diagnosis is:
A) Ectopic pregnancy
B) Threatened abortion
C) Incomplete abortion
D) Complete abortion
E) Placenta previa
The correct answer is:
C) Incomplete abortion
explanation:
• Key findings in the case:
• Heavy vaginal bleeding with clots
• Cervical os is open
• Tissue is protruding from cervix
• Uterus is smaller than dates (pregnant 8 weeks, uterus only 6 weeks size)
2) A 32-years old woman is admitted to the hospital 10 days after a miscarriage in the first trimester.
She complains of abdominal pain, increased vaginal bleeding, and offensive vaginal discharge. An
ultrasound scan reveals evidence of retained products of conception.
What is the most appropriate management?
A) Evacuation of retained products of conception (ERPC)
B ) Intravenous antibiotics
C) Intravenous antibiotics followed by (ERPC)
D ) Oral antibiotics and repeated ultrasound scan in 2 days.
E ) Repeated ultrasound scan in 2 weeks
The correct answer is:
C) Intravenous antibiotics followed by ERPC
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explanation:
• The patient presents with:
• History of miscarriage (10 days ago)
• Abdominal pain + offensive vaginal discharge + heavy bleeding → suggests infection (septic
miscarriage)
• Ultrasound shows retained products• In presence of retained products + infection, we must first
stabilize and give IV antibiotics to reduce risk of spreading infection/sepsis.
• After infection is controlled, do ERPC (surgical evacuation) to remove the retained tissue.
3) A 29-years old G1P1 woman presents to the clinic for a prenatal check-up at 10 weeks'
gestation with concerns of brown vaginal discharge about 1 week ago. She has noticed that
she is no longer nauseated and lost her breast tenderness. On physical examination the cervix
is closed and the uterus is impalpable, Ultrasound reveals a normal appearing 6 weeks fetus,
but no fetal heartbeats.
Which of the following is the most likely diagnosis?
A) Incomplete abortion
B) Complete abortion
C) Missed abortion
D) Threatened abortion
E) Inevitable abortion
The correct answer is:
C) Missed abortion
⸻
explanation:
• Brown discharge (not heavy bleeding).
• Pregnancy symptoms (nausea, breast tenderness) have disappeared.
• Cervical os is closed.
• Ultrasound shows fetus without cardiac activity (fetal death).
4) Miss Y is a 22-year-old who presents at 9 weeks’ gestation with
abdominal pain and vaginal bleeding. She had an ultrasound Span at
7 weeks' gestation, which confirmed an intrauterine pregnancy. Her
observations on admission are blood pressure 135/80 mmHg, pulse
84/minute and temperature 37.6°C.
A What is your differential diagnosis?
A) ectopic pregnancy
B) threatened miscarriage
C) complete miscarriage
D) incomplete miscarriage
E)missed miscarriage
The correct answer is :
B) threatened miscarriage
Explanation:
With a known intrauterine pregnancy, the typical features of threatened miscarriage are vaginal
bleeding with or without abdominal pain. Importantly, the patient is haemodynamically stable.
An ectopic pregnancy has been excluded by her previous ultrasound.
5) A 14-week pregnant woman had an abortion and was told that it is a complete abortion.
This is true regarding complete abortion:
a) Uterus is usually bigger than the gestational date
b) Cervical OS is opened with tissue inside the cervix
c) Need to have evacuation of the uterus
d) After complete abortion, there is minimal or no pain and minimal or no bleeding
e) Follow-up with β-HCG for one year
The correct answer is:
d) After complete abortion, there is minimal or no pain and minimal or no bleeding
⸻
explanation:
• Complete abortion = all products of conception are expelled.
• After that:
• Uterus contracts → size becomes smaller than expected for gestational age.
• Cervical os closes.
• Bleeding and pain resolve (only minimal spotting may persist).
• No further surgical evacuation needed if ultrasound confirms empty uterus.
• β-hCG follow-up for 1 year is for gestational trophoblastic disease (e.g., molar pregnancy), not
for a normal complete abortion.
6) A 40-year-old G3P2 presents with 10weeks amenorrhea, B-HCG: 5000miu/ml, her internal
cervical os is closed. US shows a 2.5cm intrauterine gestational sac with no fetal heart rate. Your
diagnosis is:
A) Missed abortion.
B) Complete abortion.
C) Threatened abortion.
D) Cervical ectopic pregnancy.
E) Complete vesicular mole.
The correct answer is:
a) Missed abortion
⸻
explanation:
• Key findings in this case:
• 10 weeks amenorrhea.
• β-hCG is 5000 mIU/ml → too low for 10 weeks pregnancy (normally should be much higher).
• Ultrasound shows gestational sac but with no fetal heart rate (fetal heart rate can be detect by
transvaginal ultrasound by 5.5 – 6 weeks of gestation )
• Cervical os is closed.
• No mention of heavy bleeding or passage of tissue.
7) A 20-year-old woman at 12 weeks gestation has a 2-day history of vaginal bleeding and lower
abdominal pain. Ultrasound shows a 25 mm fetal pole with absent fetal heart rate. Pelvic
examination reveals her cervix to be 4 cm dilated with bulging membranes.
What is the diagnosis?
A) Threatened miscarriage
B) Cervical incompetence
C) Inevitable miscarriage
D) Pregnancy of uncertain viability
E) Incomplete miscarriage
The correct answer is:
C) inevitable miscarriage
The explanation:
Inevitable miscarriage is defined as bleeding without passage of tissue but with an open cervix.
Management can be expectant, medical, or surgical, with surgical evacuation being the treatment
of choice if bleeding is excessive or vital signs are unstable.
8) A 24-year-old woman (gravida 2, para 0, abortus 1) comes to the emergency department with
vaginal bleeding and abdominal cramps. Her LMP was 10 weeks ago. She denies any recent
attempts at abortion. Her vitals show BP 110/70 mm Hg, pulse 120, and temperature 101.8°F.
Examination reveals a tender 8- to 10-week sized uterus, blood in the vaginal vault, and a foul-
smelling discharge from the cervix, which is dilated to 2 cm.
What is the most likely diagnosis?
A) hydatidiform mole
B) twisted ovarian cyst
C) pelvic inflammatory disease (PID)
D) choriocarcinoma
E) septic abortion
The correct answer is:
E) septic abortion
The explanation:
Septic abortion is likely given the history of vaginal bleeding, uterine tenderness, cervical
dilation, fever, and foul-smelling discharge. Immediate intervention with antibiotics and
uterine evacuation is necessary to prevent systemic infection.
9) A 26-year-old P2 has a 20weeks GA missed abortion. She is given a chance for spontaneous
contractions for weeks. No contractions occurred, only brownish vaginal discharge.
The best management is:
A) Wait for another 5 weeks.
B) Abdominal hysterotomy.
C) Dilatation and curettage.
D) Repeated oxytocin infusion over few days.
E) Oral/ vaginal prostaglandins.
Answer: E) Oral/vaginal prostaglandins
Explanation
• At 20 weeks, dilatation & curettage is not suitable (too large pregnancy).
• Oxytocin infusion is less effective when uterus has been quiescent for weeks.
• Hysterotomy is not first-line unless there is another complication (e.g., obstructed labor, failed
induction).
• Waiting further is unsafe → risk of coagulopathy.
• Prostaglandins (oral/vaginal misoprostol or dinoprostone) are best to induce uterine
contractions and expel the fetus.
10) For the previous question a 26-year-old P2 has a 20weeks GA missed abortion. She is
given a chance for spontaneous contractions for weeks. No contractions occurred, only
brownish vaginal discharge.
The following laboratory parameter has the priority for monitoring:
A) Hemoglobin and hematocrit levels.
B) Fibrinogen level.
C) Blood urea nitrogen (BUN) level.
D) Serum creatinine level.
E) Quantitative B-HCG level.
Answer: B)Fibrinogen level
Explanation
• Retained dead fetus for >4 weeks → risk of DIC (disseminated intravascular coagulation)
due to release of thromboplastin.
• Fibrinogen is the earliest and most sensitive indicator (drops before other coagulation
parameters).
• Hemoglobin/hematocrit are important but do not detect coagulopathy.
• Renal function (BUN/creatinine) not the main concern here.
• β-hCG monitoring is for molar pregnancy, not for missed abortion.
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