DEPARTMENT OF OBSTETRIC &

GYNAECOLOGY
KULLIYYAH OF MEDICINE
INTERNATIONAL ISLAMIC UNIVERSITY
MALAYSIA

CASE WRITE UP
YEAR 5 BLOCK 5 (2017/2018)

TITLE:
MISSED MISCARRIAGE

Name : Faris Mohd Nasir

Matric Number : 1314597

Supervisor : Asst. Prof. Dr. Raja Arif Shah Bin Raja Ismail

Date of submission : 8th June 2018

PATIENT’S PROFILE

Name : Tjin Siu Fung

Age : 34-year-old

Ethnic : Chinese

Occupation : Housewife

Address : Taman Selamat, Kuantan

Status : Gravida 3 Para 2

LMP : 26th March 2018

Date of admission : 18th May 2018

Date of clerking : 21st May 2018

Date of Discharge : 23th May 2018

CHIEF COMPLAINT:
Madam Tjin Siu Feng, a 34-year-old gravida 3 para 2, currently at 7 weeks period of
amenorrhea, admitted to HTAA for further management of bleeding per-vaginal 2 weeks ago.

HISTORY OF PRESENTINF ILLNESS:

This is an unplanned pregnancy. She suspected she was pregnant when she missed her
period for 1 month. She did self-urine pregnancy test and it was positive. 2 days later, she
started to have bleeding per-vaginally. It was fresh blood, around 1 table spoon and it stained
her inner wear. She did not notice passing out any product of conception (POC).
Otherwise, no complain of having abdominal pain, no fever or shortness of breath and
no anemic symptoms such as palpitation, light-headedness, easily fatigue or syncopal attack.
Patient went to seek medical attention at HTAA on the same day. Ultrasound scan was done
but the gestational sac could not be seen. She was told to come back after 1 week to redo the
scan. Rescan was done revealing no viable fetus. She was then admitted for further
management of her current problem.
PAST OBSTETRIC HISTORY
She has 2 children aged 9 and 8-year-old. Both were delivered via spontaneous
vaginal delivery with a birth weight of 3.1 and 3.3 kg respectively. The antenatal and
postnatal history was uneventful. She was on oral contraceptive pill when she started this
pregnancy and stopped immediately after the urine pregnancy test was positive.

PAST GYNAECOLOGICAL HISTORY

She attained menarche at the age of 17-year-old. Her cycle is irregular around 28 days
up to 2 months per cycle and flow of 4-5 days. Heavy flow on second and third day, requiring
3 maxi pads, fully soaked each of them. She denied having any menorrhagia, dysmenorrhea,
dyspareunia, intermenstrual bleeding or postcoital bleeding. Pap smear was never done.

PAST MEDICAL, SURGICAL AND DRUG HISTORY:

She had no known drug or food allergy. Both her past medical and surgical history
was uneventful. She denied taking any traditional medicine or supplement.

FAMILY HISTORY

She is the third out of three siblings. Her father died at the age of 71 years old due to
old age and her mother is 45-year-old and has underlying hypertension on treatment.
Otherwise, no other significant family history.

SOCIAL HISTORY

She is a housewife, living in a single-story terrace house in Taman Selamat with well-
equipped basic amenities. She is living there with her husband and 2 children. Her husband is
a lorry driver with monthly income of around RM3000. Her husband is a smoker. She denied
smoking, consuming alcohol or abusing drugs. She will be taken care by her husband after
discharge. Currently, her children are being taken care by her sister at her sister’s home.
PHYSICAL EXAMINATION
The examination was done on day 3 of admission. On general examination, she was lying
comfortably in a 45° propped up position. She was not in pain or respiratory distress. She is a
medium built woman and has a branula on the dorsum of her left hand with no active infusion.
She was not pale and he oral hydration status was fair. There was no bipedal edema.

Vital Signs
Blood Pressure: 112/53 mmHg (normotensive)
Pulse Rate: 86 beats per minute; regular rhythm and good volume.
Respiratory rate: 20 breaths per minute
Temperature: 37°C (afebrile)

ABDOMINAL EXAMINATION
The abdomen is flat. It moves symmetrically with respiration no surgical scar. Hernia
orifices were intact. The abdomen was soft and non-tender. The uterus was not palpable. No
organomegaly. Kidneys were not ballotable. No ascites. There were no palpable mass and
normal bowel sound was present.

RESPIRATORY EXAMINATION
She was not tachypneic with respiratory rate of 20 breaths per minute. The chest was
normal in shape and both sides moved symmetrically with respiration. There were no surgical
scars, dilated veins or abnormal pulsations seen on her chest. On palpation, the trachea was
centrally located, and the chest expansion was normal and equal on both sides. Vocal fremitus
and resonance were normal and equal on both sides. On percussion, the lungs were resonant.
On auscultation, vesicular breaths sound with normal air entry were heard. There were no
bilateral basal crepitations or abnormal sound noted.

Examinations of other systems were unremarkable.

INVESTIGATIONS

1. Full Blood Count

Reason : This test is done to assess the if the patient is anaemic due to massive blood
loss. It is also important to monitor the platetlet level for DIVC signs.

Hemoglobin : 9.6 g/dl (Low)

MCH : 22.3 pg (Low)
MCV : 72.2 Fl (Low)
MCHC : 30.9 d/dL (Low)
TWBC : 8.5 x 109/L (Normal)
Platelet : 342 x 109/L (Normal)

Result and Interpretation: The hemoglobin level is low as well as her MCV and
MCHC which means that she is having hypochromic microcytic anemia. Her TWBC
and platelets are normal.

2. Beta-hCG
Reason: to confirm pregnancy and distinguis it from any dysfunctional uterine
bleeding or bleeding from other etiology.
Result and Interpretation: not done

3. Blood type and screen

Reason: to check rhesus compatibility and preparing for any need of transfusion later.
Result and Interpretation: not done

4. Coagulation profile
Reason: Disseminated intravascular coagulation is one of the possible complication
of bleeding.
Result and Interpretation: normal value for PT, APTT and INR.

5. Urine Fine Examination Microscopy Examination (UFEME)

Reason: to rule out urinary tract infection, because pregnant women are prone to UTI
Result and Interpretation: not done
6. Trans-Vaginal Ultrasonography
Reason: to check for the viability of the POC
Result and Interpretation: done at EPAU HTAA on the day of admission showing
non-viable gestational sac.

MANAGEMENTS AND PROGRESS

 The patient was admitted after the ultrasound finding shows non-viable pregnancy.
 After securing airway, breathing and circulation, she was given IV normal saline
transfusion.
 She was placed on strict pad chart and to inform if there was any PV bleed or passing
out POC.
 On the 2nd day of admission, in view of no passing out product of conception, she
was given vaginal Misoprostol 800mg.
 On 3rd day of admission, she started to have PV bleed but still no POC.
 Vaginal Misoprostol was repeated on 3rd day of admission.
 She had pass out POC on the 4th day of admission and was discharged a day later.

DISCUSSION
Miscarriage occurs in almost 10 – 20% of pregnancies or 1:5 pregnancies which most
commonly occur in the first trimester. Miscarriage is defined as failure of a pregnancy or
death of a fetus followed by a significant amount of vaginal bleeding associated with
abdominal pain and with or without expulsion of product of conception (POC), before the
24th week POG.
Multiple risk factors have been identified that can lead to miscarriage. The risk factors
can be divided into maternal and fetal factors. Maternal factors include increased maternal
age, maternal endocrine abnormalities, anatomical abnormalities of the female genital tract,
infections, autoimmune, trauma and even psychological disorders. Fetal factor is mainly
chromosal abnormalities of the fetus which may lead to non-viable fetus.
There are 5 types of miscarriage. ‘Complete miscarriage’ is diagnosed after the
expulsion of POC resulting in minimal fresh caginal bleeding and disappearance of other
symptoms like the abdominal pain. The uterus will be smaller than expected gestation and the
cervical os will be closed. Ultrasound of the uterus will show an empty uterine cavity or an
endometrial thickness of less than 15mm. ‘Incomplete miscarriage’ should be suspected when
vaginal bleed remains significant in amount after an expulsion of POC. Abdominal pain may
persist and examination of the pelvis will show a dilated cervical os. Ultrasound may show
presence of POC in the uterine cavity.
‘Missed miscarriage’ is diagnosed by dark altered vaginal bleeding with dissapearing
symptoms of pregnancy. There may be no abdominal pain. Assessment will usually show a
similar uterus and closed cervical os. Ultrasound findings suggesting of non-viable fetus
includes an empty gestational sac of >20mm. ‘Inevitable miscarriage’ is sometimes seen
where the POC is at the cervical os and the patient has excessive vaginal bleeding and the
patient experiences lower abdominal pain. The cervical os is open. This is a non-viable
pregnancy. ‘Threatened miscarriage’ is a viable pregnancy where the patient has slight
vaginal bleeding with mild abdominal cramps. The bleeding should not be associated with
clots. Pelvic examination reveals a closed cervical os and the uterus corresponds to
gestational age. Ultrasonography is useful in confirming pregnancy, viability and
reassurance.
Evaluation could be performed in Early Pregnancy Unit (EPAU) once there is
suspicion of miscarriage. Upon patient’s arrival, we must first determine the type of
miscarriage before we counsel the couple about further managements. Sometimes, patients
may be presented with hypovolemia which may require resuscitation. Diagnosis can easily be
mafe by proper history taking, physical examination which includes pelvic examination and a
transabdominal and transvaginal ultrasound.
The aim of management is to help the couple to be able to make a choice from
treatment options in case the couple needs some time to accept the diagnosis. Treatment
options include expectand, medical or surgical depending on stability of the patient,
suitability of treatment and desire of the couple.
Expectant management is only suitable for patients who are stable and accessible to a
medical facilities. The approach of ‘wait and see’ is to allow spontaneous expulsion of POC
without any immediate intervention. The patient must be informed of the possible
complications such as failure of expulsion, infection or excessive bleeding in which
immediate surgical intervention may be required. If expulsion does not occur after 2 weeks,
she should be monitored for any bleeding tendencies (coagulation profile) and repeat
ultrasound should be performed. This is the type of management applied in this patient.
Medical management is used in patients with missed miscarriage mainly to assist the
expulsion of POC and it can even be carried out in outpatient settings. Among drugs that can
be used include Misoprostol and Mifepristone. Most guidelines recommend the usage of
Misoprostol 800 mcg (200 mcg per tablet) intravaginally for patients who have no
contraindication. The contraindications include previous uterine surgery, bleeding disorders,
immunocompromised and liver disease. Expulsion of POC usually occur within 24 hours
after insertion. If not, another insertion or surgical intervention can be offered.
Surgical evacuation of retained POC (ERPOC) can be done as a day care or inpatient
setting depending on the condition of the patient and urgency of the treatment. Most elective
procedures can be performed as a day care surgery and under regional anesthesia. Vacuum
aspirator or suction should be used to minimise risk of uterine perforation. It has also been
suggested that cervical ripening with prostaglandin is to be done prior to procedure to reduce
dilatation force, haemorrhage and uterine or cervical trauma. Antibiotic prophylaxis should
be given to reduce risk of infection. Patient in day-care settings can even be discharged 6
hours after surgery provided that patient is well and a follow-up appointment should be given
for further care and histopathological examination report.