Incomplete Miscarriage

Incomplete miscarriage is partial expulsion of the products of conception, with some tissue retained in the uterus and the cervical os open. It results from fetal demise, commonly from chromosomal abnormality, or from unsafe abortion. It matters because retained tissue causes continuing haemorrhage and sepsis, which are important causes of maternal death.

• Common before 13 weeks.
• Risk factors: advanced maternal age, previous miscarriage, uterine anomaly, infection, unsafe abortion.
• Retained tissue can be removed safely in primary care facilities.

Patients have vaginal bleeding, often heavy with clots, and colicky lower abdominal pain after passing some tissue. The os is open, tissue may be felt or seen at the os, and the uterus is smaller than dates and soft.

• Pulse and blood pressure may show hypovolaemia.
• Products may be visible in the vagina or cervical canal.
• Bleeding continues until the uterus is emptied.
• Differential diagnosis: inevitable miscarriage, complete miscarriage, ectopic pregnancy, molar pregnancy, cervical lesion with bleeding.
• Complications: haemorrhage, shock, sepsis, anaemia, cervical injury, uterine perforation during evacuation, Asherman syndrome.

The diagnosis is clinical: bleeding, open os and passed tissue in early pregnancy, confirmed by ultrasound where available.

• Urine pregnancy test, haemoglobin, blood group and Rhesus status, cross-match if bleeding is heavy.
• Transvaginal ultrasound: heterogeneous tissue in the cavity, endometrial thickness above 15 mm.
• Check pulse, blood pressure and temperature; examine with a speculum for tissue at the os.
• Send tissue for histology.

The principle is to empty the uterus promptly, restore volume and prevent sepsis.

• Supportive: insert two large-bore IV cannulae if bleeding is heavy; give Ringer's lactate 1 litre over 30 minutes and repeat guided by pulse and blood pressure; transfuse if haemoglobin is below 7 g/dL or there is shock; remove tissue from the os with ring forceps to reduce bleeding.
• Pharmacological: misoprostol 600 micrograms oral as a single dose, or 400 micrograms sublingual as a single dose, for uterus below 13 weeks size and haemodynamically stable; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); ibuprofen 400 mg oral 8-hourly with food for 3 days; if infection is suspected, give ampicillin 2 g IV 6-hourly plus gentamicin 5 mg/kg IV once daily plus metronidazole 500 mg IV 8-hourly before evacuation; start contraception when the patient wishes.
• Procedures: manual vacuum aspiration under paracervical block (lignocaine 1 percent, 20 mL in total, maximum 3 mg/kg, not above 200 mg) for uterine size up to 12 weeks; for larger uteri use ovum forceps and sharp curettage under anaesthesia with oxytocin 10 IU IM after evacuation.
• Special groups: Rhesus negative women give anti-D immunoglobulin 250 IU IM within 72 hours.
• Red flags: shock, heavy ongoing bleeding, fever above 38 degrees Celsius, abdominal rigidity suggesting perforation, offensive discharge.
• Follow-up: review in 1 to 2 weeks; confirm bleeding has settled; counsel on contraception; check haemoglobin at 4 weeks and treat anaemia with ferrous sulphate 200 mg oral 8-hourly for 3 months.