ULTRASOUND However, this study does also state that there was a


41% rate of viability in embryos which measured less than 3mm and had no cardiac activity. Cardiac activity is present in the early embryo prior to our ability to image it7


, because of this it is the earliest proof


of a viable pregnancy. The study by Jauniaux et al3 states that this should be present in any embryo over 2mm, however, in around 5-10% of embryos the fetal heartbeat cannot be demonstrated. Another initial investigation will be to see how


many weeks the pregnancy should be. This is done by looking at the last menstrual period date (LMP) and the patient’s typical cycle length7


when using ultrasound to determine if the pregnancy is viable and developing as it should14 McParland15


. This will be crucial . The study by


agrees with this statement and provides


a description of what ought to be visualised using ultrasound for each week of gestation (Figure 1). Conversely, Bottomley and Bourne13


state that


although these landmarks may not be present it cannot be assumed there is a failed or failing pregnancy, as there may be inaccuracy in menstrual dates, and not all pregnancies exhibit uniform growth patterns. As observed by the author, each patient would have another investigation during their ultrasound scan into the amniotic sac size. This is usually visualised by five weeks LMP or three weeks post-conception7


. Many


studies agree that if the gestational sac has a mean diameter greater than 20mm and there is no evidence of an embryo or yolk sac it is highly suggestive of pregnancy loss16,13 by Abdallah et al2


. However, a more recent study states that as there is significant


variation in the cut-off values for mean gestational sac diameters, some of the current definitions used to diagnose miscarriages are potentially unsafe and may lead to inadvertent termination of wanted pregnancies.


TYPES OF MISCARRIAGES There are many types of miscarriage, the most common of which include complete, incomplete, missed and embryonic miscarriage17


.


A complete miscarriage refers to the expulsion of all of the products of conception; this would be confirmed by having an ultrasound scan18 However, the study by Condous et al19


. states that if


an intrauterine pregnancy has not previously been visualised during an ultrasound scan, a diagnosis of miscarriage should not be made on the basis of an empty uterus. The outcome of this is that all women who have not had an intrauterine pregnancy previously visualised, have to be managed as a pregnancy of unknown location3


. Incomplete miscarriage refers to irregular


heterogeneous echoes in the endometrial cavity on the ultrasound scan, which demonstrate remaining products of conception that have not been expelled from the body20,3


. It is important to diagnose these


women as they are at higher risk of bleeding and infections; it is normally diagnosed by measuring the endometrial thickness on an ultrasound scan21 However, the study by Ustunyurt et al22


states that


there is no consensus among literature regarding the cut-off level of endometrial thickness for a diagnosis of an incomplete miscarriage or retained products of conception.


Missed miscarriage, however, is where there


is a failed pregnancy of up to 12 weeks, the CRL measures greater than 6mm with no cardiac activity and at the repeat scan there is no change7


. This is frequently treated either by expectant, medical or 20 .


surgical management. Missed miscarriage has been shown to cause a higher rate of unplanned surgical interventions than the other types of miscarriage, this is higher if the patient has opted for medical management23,24


.


. However, the type of management


is entirely dependent upon the ultrasound estimation of gestational age and size of pregnancy, as well as the patient’s preference7


The diagnosis of miscarriages also frequently includes TV scans; this was introduced into common practice due to its ability to detect intrauterine gestation and viability at an earlier gestational age than abdominal ultrasound13


. However, as TV scans are very


invasive, some patients may refuse to have it which can lead to inconclusive scans and the need for repeat appointments3


.


Figure 3 shows the criteria for diagnosing miscarriages using TV scans.


PATIENT PATHWAYS The pathway in which the patient would be referred will depend entirely on the type of miscarriage, gestational age and then the patient’s personal preference. Figure 4 shows the NICE patient pathway for patients who have had a miscarriage. For example, as observed by the author, patients


who have had a miscarriage were offered expectant, medical and surgical management. Expectant management is only offered to patients if it is not contraindicated; for example, if the patient is at increased risk of haemorrhage or there is evidence of infection then alternative options should be explored such as medical or surgical management as shown in the flow diagram25


in cases of patients who are going through expectant management, there is a high rate of success and retained products of conception (RPC) will normally have passed within three days23,26 by Sajan et al27


agrees with these findings they also


do state that there was a higher rate of unplanned admissions and emergency evacuations among the patients who had opted for expectant management. Due to this, the study by Casikar et al26


suggests


the use of colour Doppler to predict the success of expectant management. Medical management has increasingly been used as an alternative to surgical management for many years, following its success when used for therapeutic abortion7


prefer this as it can be done at home and it avoids the need for anaesthetic6,7


. Various studies state that many patients . However, there is a higher


success rate for surgical management compared to medical management and as a result, the patient satisfaction was found to be higher for surgical management7,28 Condous7


. Additionally noted by Bourne and , is that many patients undergoing medical


management found the time until completion very unpleasant due to side effects which can also lead to emergency admission and surgical management. Surgical management, as observed by the


author, was offered if the patient presented with contraindications for either the expectant or medical management. Alternatively, it was also given as a third option for patients to choose if they wish. Many studies state that surgical management has the highest success rate and as a result, the highest patient satisfaction28,6


. However, as stated by Vazquez, Hickey and Neilson29 , with advancements


in technology, surgical management has gone from the ‘gold standard’ of managing miscarriages to


JUNE 2017 . Although the study


. Various studies agree that


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32