Surgical management of miscarriage — structured oral station (12 minutes)

Opening prompt — "Tell me your diagnosis and your next step."

Model response — say it in this order: [4]

• "Her mean sac diameter is 18 mm with no embryo. That is below the validated cut-off of 25 mm for diagnosing miscarriage of an empty sac, so I cannot call this non-viable yet."
• "I would repeat the transvaginal ultrasound after seven to fourteen days and apply the repeat-scan criteria — a sac whose mean diameter has not doubled after 14 days, or a sac of 12 mm or more showing no embryo with a heartbeat after seven days or more, would confirm miscarriage."
• "Meanwhile I would exclude an ectopic, check her blood group and haemoglobin, and safety-net her for heavy bleeding or pain."[4]

Examiner is listening for: the exact cut-off, the repeat-scan interval, and that you do not rush to surgery.

Probe 1 — "The repeat scan confirms a missed miscarriage. She asks what her options are."

• "There are three options — expectant, medical, and surgical — and I would counsel her on each."
• "Expectant management is the least effective and carries the highest rate of later intervention. Medical management with mifepristone plus misoprostol is broadly as effective as surgery and, for missed miscarriage, mifepristone 200 mg followed two days later by misoprostol 800 micrograms was more effective than misoprostol alone in the MifeMiso trial."[3]
• "Surgical management is suction evacuation — manual or electric — and sharp curettage as a sole method is no longer recommended. The network meta-analysis ranked manual vacuum aspiration highest for satisfaction and lowest for infection."[3]

Probe 2 — "She chooses surgical management. How do you prepare her?"

• "I consent her for the risks — bleeding, infection, uterine perforation, cervical injury, Asherman syndrome, anaesthetic risk, and the small chance of repeat evacuation — and I explain that all tissue goes to histology to exclude a molar pregnancy."[1]
• "I give prophylactic antibiotics based on the AIMS trial: a single preoperative dose of oral doxycycline 400 mg and metronidazole 400 mg. It reduced pelvic infection by strict criteria, though the pragmatic broad primary outcome was neutral."[2]
• "If she is RhD-negative, I give anti-D within 72 hours to prevent Rhesus alloimmunisation."[5]

Probe 3 — "Two days after the evacuation she phones with fever and abdominal pain. What do you do?"

• "I ask her to come in immediately. I am worried about post-evacuation endometritis or retained products."
• "On arrival I assess for sepsis, examine for uterine tenderness and purulent discharge, take blood cultures, a full blood count, C-reactive protein and lactate, and start the sepsis six with broad-spectrum intravenous antibiotics."[2]
• "I arrange an ultrasound for retained products; if tissue is retained or the sepsis does not resolve, I repeat the evacuation after resuscitation, with senior support."[1]

Probe 4 — "She is upset and blames herself for the miscarriage. How do you respond?"

This is a scored domain — demonstrate it out loud: [1]

• Sit at her eye level, use her name, and address the misconception directly and kindly: miscarriage is common and almost never caused by anything she did.
• Acknowledge grief, offer written information and a follow-up appointment, and signpost support organisations.
• Avoid medicalised or dismissive language; do not conduct the conversation with your back turned.

Probe 5 — "What follow-up will you arrange?"

• If the histology is normal and she recovers, review only if symptoms persist; counsel that a single early miscarriage does not usually require investigation.[1]
• If molar pregnancy is identified, refer to the gestational trophoblastic disease service for serial human chorionic gonadotrophin surveillance and reliable contraception.[1]
• Document a clear discharge and safety-net plan, arrange anti-D and contraception, and offer a debrief.