Miscarriage — structured SAQ (15 marks)

(a) Confirming the diagnosis (3 marks)

One mark each, maximum three. ^[2][3]

• Apply the transvaginal threshold explicitly. A crown-rump length of 7.0 mm or more with no visible heartbeat meets the criterion for a non-viable pregnancy, so 11 mm qualifies.^[2][3]
• Do not act on one image. Obtain a second opinion on viability from a second sonographer or clinician, and/or repeat the scan a minimum of 7 days after the first, before the diagnosis is made and acted upon.^[2][3][22]
• Confirm the pregnancy is intrauterine and single, and exclude other diagnoses — look for a molar appearance, a coexistent second sac, and any adnexal mass or free fluid. Send tissue for histology after any evacuation, because pre-evacuation ultrasound misses many moles.^[8]
• Marks are also awarded for: not using last menstrual period dating to decide whether a heartbeat should be visible; documenting both measurements; and stating that serum hCG has no role once an intrauterine pregnancy is seen. ^[22]

(b) The three management options (6 marks)

Two marks per pathway: one for the pathway with its counselling point, one for the specific detail. ^[1][4]

Expectant management.

• Offer as first line for 7 to 14 days in a stable woman with no infection, no coagulopathy and no previous traumatic pregnancy experience.^[22]
• Provide a home urine pregnancy test at 3 weeks, written safety-netting, analgesia advice and a return for reassessment if bleeding has not started or is persisting.^[22]

Medical management (missed miscarriage regimen).

• Mifepristone 200 mg orally, then 24 to 48 hours later misoprostol 600 micrograms sublingual or buccal, or 800 micrograms vaginal, buccal or sublingual. Repeat misoprostol 400 micrograms if bleeding has not started 24 to 48 hours after the first dose.^[1][21]
• Counsel on pain, heavy bleeding, diarrhoea and vomiting; provide analgesia and antiemetics; give a contact number if bleeding has not started within 48 hours; home urine pregnancy test at 3 weeks.^[1][21][22]

Surgical management.

• Suction aspiration, either manual vacuum aspiration under local anaesthetic as an outpatient or suction aspiration under general anaesthetic in theatre. Avoid dilatation and sharp curettage because of intrauterine adhesions.^[4][21]
• Antibiotic prophylaxis — a single dose of doxycycline with or without metronidazole, ideally about 2 hours pre-procedure, per local resistance patterns. Consent for perforation, cervical trauma, haemorrhage, infection, retained tissue and adhesions.^[9][21]

Full marks require drug, dose, route and timing for the medical option and the named procedure for the surgical option. "Offer medical or surgical management" without specifics scores 1 of 6. ^[1][21]

(c) Anti-D immunoglobulin (2 marks)

• Do not give anti-D at 9+2 weeks. RANZCOG C-Gyn 38 (2025) states that for non-sensitised rhesus D negative women with threatened miscarriage or miscarriage before 10 weeks, routine rhesus D testing followed by anti-D is no longer recommended because the evidence does not show it prevents sensitisation. NICE NG126 draws the equivalent line at up to and including 11+6 weeks.^[21][22]
• Know the dose if it were indicated: 250 IU up to 12 weeks and 625 IU beyond 12 weeks in ANZ practice, or at least 250 IU under NICE for a woman at 12+0 to 12+6 weeks having medical or surgical management. Document the decision not to give it.^[21][22]

(d) Septic miscarriage — febrile and shocked (4 marks)

One mark per element, maximum four. ^[4]

• Recognise and declare sepsis. Full observations including temperature, pulse, blood pressure, respiratory rate, oxygen saturation and conscious state; venous lactate; call for senior obstetric and anaesthetic help early.^[4]
• Resuscitate and culture, then treat promptly. Two large-bore cannulae; blood cultures, high vaginal and urine specimens, full blood count, coagulation, group and crossmatch; prompt broad-spectrum intravenous antibiotics covering Gram negatives, anaerobes and streptococci per local sepsis protocol; intravenous fluids, oxygen, catheter and hourly urine output.^[4]
• Evacuate the uterus once resuscitated. The retained infected tissue is the source; suction aspiration should follow resuscitation rather than wait for the fever to settle. Send tissue for histology and microbiology.^[4][8]
• Escalate and plan. High-dependency or intensive care if organ dysfunction persists; involve infectious diseases or microbiology if she is not improving; debrief and arrange follow-up including a discussion of future pregnancy.^[4]