Surgical management of miscarriage and abortion — structured SAQ (15 marks)

(a) Immediate priorities and investigations (3 marks)

One mark each, to a maximum of three. ^[1]

• Resuscitate first: airway, breathing, circulation; two large-bore cannulae; intravenous fluids; oxygen if hypoxic; quantify ongoing blood loss. The open os with passed tissue and heavy bleeding is an incomplete miscarriage needing stabilisation before theatre.
• Investigations: full blood count, group and save (or crossmatch if bleeding is heavy), a coagulation screen, and a quantitative human chorionic gonadotrophin; a transvaginal ultrasound to confirm the diagnosis and exclude ectopic.
• Escalate and consent early: inform the consultant and theatre, allocate roles; the temperature of 37.9 degrees with tachycardia raises the possibility of septic miscarriage — screen for sepsis (lactate, cultures) and prepare for source control.^[1][2]

(b) Management options and factors favouring surgery (4 marks)

One mark for the framework of options; up to three marks for factors favouring surgery in this woman. ^[1][3]

• Three options for first-trimester miscarriage: expectant, medical (misoprostol alone or mifepristone plus misoprostol), and surgical (manual or electric vacuum aspiration). Expectant management is the least effective; medical management is broadly as effective as surgery; mifepristone plus misoprostol is more effective than misoprostol alone.^[3][4]
• Factors favouring surgery in this woman: heavy ongoing bleeding with haemodynamic compromise, the open os with retained products (incomplete miscarriage), and possible evolving sepsis — all are indications for surgical evacuation rather than expectant or medical management.^[1]
• Patient choice after counselling would be a further indication in a stable woman, but here the clinical picture drives the decision.^[1]

(c) Preoperative preparation, antibiotics and anti-D (4 marks)

One mark per point, maximum four. ^[2][5]

• Antibiotic prophylaxis: the AIMS trial studied a single preoperative dose of oral doxycycline 400 mg and metronidazole 400 mg. It reduced pelvic infection by the original strict criteria (1.5 per cent vs 2.6 per cent) but not by the pragmatic broad primary outcome (4.1 per cent vs 5.3 per cent). Many units give prophylaxis, particularly where postoperative infection carries greater morbidity.^[2]
• Anti-D: check her blood group; if she is RhD-negative, offer anti-D immunoglobulin within 72 hours of the evacuation to prevent Rhesus alloimmunisation.^[5]
• Consent including the risks of bleeding, infection, uterine perforation, cervical injury, Asherman syndrome, anaesthetic risk, and the small chance of repeat evacuation; explain that tissue is sent for histology.
• Theatre preparation: group and save or crossmatch, anaesthetic review, and ensure suction (manual or electric) and appropriately sized cannulae; cervical priming with misoprostol if the cervix is difficult or for a difficult evacuation.^[3]

(d) Post-evacuation fever and tenderness — management (4 marks)

One mark per point, maximum four. ^[2]

• Recognise post-evacuation sepsis (likely endometritis ± retained products): examine for uterine tenderness, purulent discharge and pelvic peritonism; take blood cultures, a full blood count, C-reactive protein and lactate; start the sepsis six within the hour.
• Broad-spectrum intravenous antibiotics covering anaerobes and gram-negative organisms, in line with local guidance.
• Assess for retained products by ultrasound; if retained tissue is present or the sepsis fails to resolve, arrange repeat evacuation after resuscitation.^[1]
• Escalate to senior obstetric and anaesthetic support and, if shocked, critical care; document, debrief, and submit an incident report. Send the original and any repeat tissue for histology.^[1]