Bleeding 3 Miscarriage

Hello, here comes another exciting game. Challenge accepted?? ....Click on the picture to start. [[<img src="/Bleeding3/meme1.jpg" >->Story]]

<img src="/Bleeding3/dolly.jpg"/> Mrs. Dolly, a 35-year-old G3 P1+1 at 13 weeks POA, presents to the Early Pregnancy Clinic complaining of brownish vaginal discharge for the past 3 days. She denies any lower abdominal pain. She has a 6-year-old son who was delivered vaginally and is currently healthy. A year ago, she had a complete miscarriage at 8 weeks of gestation. Which of the following is/are possible differential diagnoses? [[1. Twisted ovarian cyst]] [[2. Miscarriage]] [[3. Ectopic pregnancy]] [[4. Molar pregnancy]]

No, dear. That is not the correct choice. It is certainly crucial to enquire about menstrual history including last menstrual period, her previous menstrual cycles, contraceptions etc. However, read the question carefully again. It asked, "The following are further relevant points in the history that you should elicit from Mrs. Dolly EXCEPT"? Never mind. Try again :-) (track: 'no dear', 'play') (track: 'no dear', 'volume', 0.5)

No, dear. That is not the correct choice. It is certainly crucial to obtain a detailed history of the vaginal bleeding such as amount, duration, colour, presence of blood clots, symptoms of anaemia. However, read the question carefully again. It asked, "The following are further relevant points in the history that you should elicit from Mrs. Dolly EXCEPT"? Never mind. Try again :-) (track: 'no dear', 'play') (track: 'no dear', 'volume', 0.5)

No, dear. That is not the correct choice. It is certainly crucial to enquire about social history such as smoking, alcohol, substance abuse. However, read the question carefully again. It asked, "The following are further relevant points in the history that you should elicit from Mrs. Dolly EXCEPT"? Never mind. Try again :-) (track: 'no dear', 'play') (track: 'no dear', 'volume', 0.5)

Yes! You are very observant. You read the question carefully which asked, "The following are further relevant points in the history that you should elicit from Mrs. Dolly, EXCEPT:" Paternal history is not relevant here. In addition to the histories mentioned, you need to consider the following as aetiological factors for early pregnancy problems: • Trisomies (Down's syndrome), Triploidies and tetraploidies , Monosomy X0 (Turner's syndrome) • Translocation (hereditary) • Diabetes, hypothyroidism, luteal phase deficiency, polycystic ovarian syndrome • Uterine septa (bicornuate uterus) • Endometrial adhesions (post-curettage or Asherman's syndrome) • Salmonella typhi, malaria, cytomegalovirus, Brucella, toxoplasmosis infection • Mycoplasma hominis, Chlamydia trachomatis, Ureaplasma urealyticum infection • Tobacco, anaesthetic gases, arsenic, benzene, solvents, ethylene oxide • Antiphospholipid syndrome and other thrombophilias Click [[here|exam]] for the next step. (track: 'yess', 'play') (track: 'yess', 'volume', 0.5)

Mrs. Dolly, a 35-year-old G3 P1+1 at 13 weeks POA, presents to the Early Pregnancy Clinic complaining of brownish vaginal discharge for the past 3 days. She denies any lower abdominal pain. She has a 6-year-old son who was delivered vaginally and is currently healthy. A year ago, she had a complete miscarriage at 8 weeks of gestation. She used the oral contraceptive pill for 6 months after her miscarriage. She is keen to have another child. She is a business executive and smokes 2 cigarettes per day. She drinks alcohol during weekend parties with her business partners. Upon further history taking, Mrs. Dolly mentions that starting from yesterday, her per vaginal bleeding increased in amount with passage of clots and some tissue. While in hospital, she develops lower abdominal pain which is cramping in nature, but no shoulder tip pain. What physical examination/examinations would you like to perform? Choose the BEST answer. [[1. Speculum examination]] [[2. Bimanual examination]] [[3. General examination]] [[4. Abdominal examination]] [[5. All of the above]]

The following are further relevant points in the history that you should elicit from Mrs. Dolly, EXCEPT: [[1. Menstrual history including last menstrual period, her previous menstrual cycles, contraceptions etc]] [[2. Detailed history of vaginal bleeding such as amount, passage of product of conception, grape like vesicles, duration of bleeding, colour, presence of blood clots, and symptoms of anaemia]] [[3. Maternal social history such as smoking, alcohol, and substance abuse]] [[4. Paternal history of diabetes, hypertension, and epilepsy]]

Oopss, sorry. That's not true. Mrs Dolly is expriencing early pregnancy bleeding. Twisted ovarian cyst will present with lower abdominal pain, which she does not have. That's OK. Try again. <img src="/Bleeding3/torsion.jpg"/> Image source: https://www.youtube.com/watch?v=P2psN9o7hUQ (track: 'smirk', 'play') (track: 'smirk', 'volume', 0.5)

You are good! In any early pregnancy bleeding, you should consider the following: • Ectopic pregnancy • Miscarriage • Molar pregnancy • Bleeding from local causes such as cervical polyps, premalignant or malignant lesions of cervix, vaginal erosions. Click [[here|history]] to continue. (track: 'Bingo', 'play') (track: 'Bingo', 'volume', 0.5)

Ohhhh. That is NOT the best choice. Yes, you need to do speculum examination. But the question is, "Choose the BEST answer". You have now learnt to read the question properly. It can happen in your year-end exams as well as professional exams. READ THE QUESTIONS CAREFULLY. Now, try again. <img src="/Bleeding3/speculum.jpg"/> (track: 'oh', 'play') (track: 'oh', 'volume', 0.5)

Ohhhh. That is NOT the best choice. Yes, you need to do bimanual examination. But the question is, "Choose the BEST answer." You have now learnt to read the question properly. It can happen in your year-end exams as well as professional exams. READ THE QUESTIONS CAREFULLY. Now, try again. <img src="/Bleeding3/bimanual.png"/> Image source: © Lippincott. Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking 12thed. (track: 'oh', 'play') (track: 'oh', 'volume', 0.5)

Ohhhh. That is NOT the best choice. Yes, you need to do general examination. But the question is, "Choose the BEST answer." You have now learnt to read the question properly. It can happen in your year-end exams as well as professional exams. READ THE QUESTIONS CAREFULLY. Now, try again. <img src="/Bleeding3/consult.jpg"/> (track: 'oh', 'play') (track: 'oh', 'volume', 0.5)

Ohhhh. That is NOT the best choice. Yes, you need to do abdominal examination. But question asked, "Choose the BEST answer. You have now learnt to read the question properly. It can happen in your year-end exams as well as professional exams. READ THE QUESTIONS CAREFULLY. Now, try again. <img src="/Bleeding3/abdoexam.jpg"/> (track: 'oh', 'play') (track: 'oh', 'volume', 0.5)

Excellent! You are very attentive and careful. Yes, ALL the answers are correct. You need to perform the following: 1. General examination to check BMI, conscious level, pallor, temperature, blood pressure, and pulse rate. 2. Abdominal examination to check any tenderness, size of uterus, and free fluid. 3. Speculum exaimination and bimanual examination to check cervical os open or closed, amount and colour of bleeding, any passage of product of conception, grape like vesicles, cervical excitation test, size of uterus, and any adnexa mass. Because you have done so well, you have been promoted and must face further challenges. Click [[here|inv]] to reveal Mrs. Dolly's examination findings. (track: 'short success', 'play') (track: 'short success', 'volume', 0.5)

On examination, Mrs Dolly's vital signs are stable and her abdomen is soft. Her uterus is not palpable. A pelvic examination is done and the findings will be revealed later. What investigations would you like to do to help you make a diagnosis? [[1. Full blood count, coagulation profile, and renal funtion test]] [[2. Full blood count, Blood grouping and Rhesus, and ultrasound pelvis]] [[3. Ultrasound pelvis, full blood count, and karyotyping ]]

No, dear. Coagulation profile is not neccessary here. Remember not to order irrelevant tests as it is a waste of resources and may do more harm than good. Try again. (track: 'no', 'play') (track: 'no', 'volume', 0.5)

That is correct. You need to obtain the following: 1. Full blood count to check haemoglobin level, total WBC and platelet count. 2. Blood grouping in case she needs a blood transfusion, and rhesus status in case she needs Rhesus D prophylaxis 3. Ultrsound pelvis to differentiate between miscarriage, molar pregnancy and ectopic pregnancy. Click [[here|pathways]] to go to the next section. (track: 'one cheer', 'play') (track: 'one cheer', 'volume', 0.5)

No, dear. Karyotyping of parents will only be considered in cases of recurrent miscarriages (loss of three or more consecutive pregnancies). Try again. (track: 'no', 'play') (track: 'no', 'volume', 0.5)

From here onwards, you will need to make decisions based on different scenarios. Here are five scenarios covering five different clinical conditions that Mrs Dolly could have. Let's start with Scenario 1. Enjoy! <div class="row1"> <div class="column1"> Scenario 1: [[<img src="/Bleeding3/Hall1s.jpg" alt="Scenario 1" style="width:100%">->1]] </div> <div class="column1"> Scenario 2: [[<img src="/Bleeding3/Hall2s.jpg" alt="Scenario 2" style="width:100%">->2]] </div> <div class="column1"> Scenario 3: [[<img src="/Bleeding3/Hall3s.jpg" alt="Scenario 3" style="width:100%">->3]] </div> </div> <div class="row2"> <div class="column2">Scenario 4: [[<img src="/Bleeding3/Hall4s.jpg" alt="Scenario 4" style="width:66%">->4]] </div> <div class="column2">Scenario 5: [[<img src="/Bleeding3/Hall5s.jpg" alt="Scenario 5" style="width:66%">->5]] </div> </div> (track: 'music box', 'play') (track: 'music box', 'volume', 0.5)

Scenario 1 On examination, Mrs Dolly's vital signs are stable. Her temperature is 36.5°C, her BP is 110/70 mmHg, and her pulse rate is 90/minute. Her abdomen is soft and her uterus is not palpable. Pelvic examination reveals a bulky uterus with closed cervical os and minimal blood seen on the examining finger. Cervial excitation is negative, and no adnexa mass is felt. Her Haemoglobin is 11.2 g/dL and Blood group is O positive. Below is her pelvic ultrasound picture. Fetal heart activity is seen. <img src="/Bleeding3/USS1.jpg" /> Image source: Turner, Steve, Perinatal Programming of Childhood Asthma: Early Fetal Size, Growth Trajectory during Infancy, and Childhood Asthma Outcomes, Journal of Immunology Research, 2012, 962923, 9 pages, 2012. https://doi.org/10.1155/2012/962923 What is your diagnosis? [[1. Complete miscarriage]] [[2. Incomplete miscarriage]] [[3. Threatened miscarriage]] [[4. Septic miscarriage]] [[5. Missed miscarriage]]

Uhhh...Incorrect Try again. (track: 'yell', 'play') (track: 'yell', 'volume', 0.2)

Hey that's true. Clinical features of a threatened miscarriage: 1. Clinical presentation - Bleeding ± - Abdominal pain - Closed cervix 2. Ultrasound findings - Intrauterine gestation sac - Fetal pole - Fetal heart activity Now go to the [[next|question1]] question. (track: 'clapping', 'play') (track: 'clapping', 'volume', 0.2)

Uhhh...Incorrect Try again. (track: 'yell', 'play') (track: 'yell', 'volume', 0.2)

Scenario 2 On examination, Mrs Dolly's temperature is 36.5°C, her BP is 94/56 mmHg, and her pulse rate is 116/minute. Her abdomen is soft, and the uterus is not palpable. Pelvic examination reveals a bulky uterus with open cervical os. Active vaginal bleeding is noted and products of conception are seen at cervical os. Cervial excitation is negative, and no adnexa mass is felt. Her haemoglobin is 7.3 g/dL. Blood group is O negative. Below is an image of her pelvic ultrasound. No intrauterine sac is seen but products of conception are seen near the os. <img src="/Bleeding3/REtPOC.png" /> Image source: https://obimages.net/free-chapter-normal-abnormal-first-trimester-exam/ What is your diagnosis? [[1. Complete miscarriage]] [[2. Incomplete miscarriage]] [[3. Threatened miscarriage]] [[4. Septic miscarriage]] [[5. Missed miscarriage]]

Incorrect. Try again (track: 'Game over', 'play') (track: 'Game over', 'volume', 0.2)

Great job! Mrs Dolly is having an incomplete miscarriage. The following are features of an incomplete miscarriage: 1. Bleeding ± pain 2. Open cervix 3. Persistence of conception products inside the uterine cavity on transvaginal scan. Now go to the [[next|question2]] question. (track: 'Success', 'play') (track: 'Success', 'volume', 0.2)

Incorrect. Try again (track: 'Game over', 'play') (track: 'Game over', 'volume', 0.2)

Oh no. That is not a wise choice. The fetus is still viable and cervical os is still closed. Try again. (track: 'Baby Giggle 1', 'play') (track: 'Baby Giggle 1', 'volume', 0.2)

Excellent! Reassure Mrs Dolly and let her go home with a plan to return to clinic in 2 weeks for reassessment. Remind her to come back immediately if the bleeding increases or her lower abdominal pain gets more severe. Now, it's time for the next scenario. Go back to the [[scenarios|pathways]] and choose Scenario 2.

Oh no. That is not a wise choice. The fetus is still viable and cervical os is still closed. Try again. (track: 'Baby Giggle 1', 'play') (track: 'Baby Giggle 1', 'volume', 0.2)

That is right. For incomplete miscarriage, you can proceed with either surgical evacuation of retained products of conception (ERPOC) or medical evacuation (with prostaglandin or RU486). Click [[here| here]] to proceed. <img src="/Bleeding3/DC.jpg"/> Image source: https://www.obgynecologistnyc.com/procedures/dilation-and-curettage-dc/ (track: 'yess', 'play') (track: 'yess', 'volume', 0.2)

That is tragic. Mrs Dolly is experiencing active bleeding with an open cervical os and is passing products of conception. She is hypotensive and tachycardic. Since you let her go home without any intervention, she succumbed to massive bleeding. But...don't feel guilty. Fortunately, in this game, you get a second chance. Go back and try again. <img src="/Bleeding3/malpractice.jpg"/> (track: 'sad', 'play') (track: 'sad', 'volume', 0.2)

That is right. For incomplete miscarriage, you can proceed with either medical evacuation (with prostaglandin or RU486) or surgical evacuation of retained products of conception (ERPOC) Click [[here| here]] to proceed. <img src="/Bleeding3/cervagem.jpg"/> Image source: http://www.draisyahafiz.com/2014/03/ (track: 'yess', 'play') (track: 'yess', 'volume', 0.2)

You successfully performed surgical/medical evacuation on Mrs Dolly. As she is Rhesus negative, should she be given anti-D immunoglobulin? [[1. Yes]] [[2. No]]

Yes, you need to give her Anti D immunoglobulin (Ig) prophylaxis because her blood group is O negative, to prevent rhesus isoimmunization. Anti-D Ig is given following a spontaneous miscarriage if the pregnancy is >12 weeks or there was heavy bleeding or pain or if the patient underwent medical/surgical management. In pregnancies < 12 weeks gestation, anti‐D Ig prophylaxis is only indicated following ectopic pregnancy, molar pregnancy, therapeutic termination of pregnancy, and in cases of uterine bleeding where this is repeated, heavy, or associated with abdominal pain. The minimum dose should be 250 IU. A test for fetomaternal haemorrhage (FMH) is not required. For potentially sensitising events between 12 and 20 weeks gestation, a minimum dose of 250 IU should be administered within 72 h of the event. A test for FMH is not required. <img src="/Bleeding3/rhesus.jpg"/> Image source: https://www.biologynotes.site/rh-factor-and-how-it-works/ Well done, you've completed this scenario. Now, go back to the [[scenarios|pathways]] and choose Scenario 3. (track: 'Bingo', 'play') (track: 'Bingo', 'volume', 0.2)

That is wrong, you need to give her Anti-D Ig to prevent rhesus isoimmunization. Anti-D Ig is given following a spontaneous miscarriage if the pregnancy is >12 weeks or there was heavy bleeding or pain or if the patient underwent medical/surgical management. Try again. (track: 'uh oh', 'play') (track: 'uh oh', 'volume', 2.0)

Scenario 3 On examination, Mrs Dolly's temperature is 36.5°C, her BP is 120/70 mmHg, and her pulse rate is 82/minute. Her abdomen is soft and her uterus is not palpable. Pelvic examination reveals a bulky uterus with closed cervical os. Minimal old blood is noted. Cervical excitation is negative and no adnexa mass is felt. Her Haemoglobin is 11 g/dL and her blood group is O positive. Below is an image of her pelvic ultrasound. No intrauterine sac is seen, and no products of conception are seen. Endometrial thickness is 12 mm. <img src="/Bleeding3/UScomplete.jpg" /> Image source: https://www.medison.ru/ultrasound/gal475.htm What is your diagnosis? [[1. Complete miscarriage]] [[2. Incomplete miscarriage]] [[3. Threatened miscarriage]] [[4. Septic miscarriage]] [[5. Missed miscarriage]]

Yesss. That is right. Mrs Dolly is having a complete miscarriage. The following are features of a complete miscarriage: 1. Bleeding and pain stopped 2. Closed cervix 3. Empty uterus 4. Endometrial thickness <15 mm Now proceed to the next [[part|question3]] (track: 'lightapplause', 'play') (track: 'lightapplause', 'volume', 0.2)

Nope. Try again. (track: 'wake up', 'play') (track: 'wake up', 'volume', 0.4)

Hello, no. Try again. (track: 'Smirk 1', 'play') (track: 'Smirk 1', 'volume', 0.4)

Correct. She is now well enough to go home. Call her back in 2 weeks to review again. Remind her to come back if she develops a fever, feels unwell, or develops foul smelling discharge with lower abdominal pain. Now that you've completed this scenario, go back to the [[scenarios|pathways]] and choose Scenario 4. (track: 'cheer', 'play') (track: 'cheer', 'volume', 0.1)

No, no. Try again. (track: 'Smirk 1', 'play') (track: 'Smirk 1', 'volume', 0.4)

Scenario 4 On examination, Mrs Dolly's temperature is 36.5°C, her BP is 120/70 mmHg, and her pulse rate is 82/minute. Her abdomen is soft and her uterus is not palpable. Pelvic examination reveals a bulky uterus with closed cervical os. No blood is seen. Cervial excitation is negative, and no adnexa mass is felt. Her Haemoglobin is 11 g/dL. Her Blood group is O positive. Below is an image of her pelvic ultrasound. An intrauterine sac measuring 30 mm is seen, no fetal pole is noted. <img src="/Bleeding3/USovum.jpg" /> Image source: https://somewhitespace.blog/2020/11/22/dream-and-disappointment-and-dream-again/ What is the most likely diagnosis? [[1. Complete miscarriage]] [[2. Incomplete miscarriage]] [[3. Threatened miscarriage]] [[4. Septic miscarriage]] [[5. Missed miscarriage]]

Nope. Try again. (track: 'bye bye', 'play') (track: 'bye bye', 'volume', 0.2)

Hooray.....That's right! Mrs Dolly is having a missed miscarriage. Here are the features of a missed miscarriage: 1. ± Bleeding ± pain ± loss of pregnancy symptoms 2. Closed cervix 3. Fetal pole >7 mm with no fetal heart activity 4. Mean gestation sac diameter >25 mm with no fetal pole or yolk sac Go to the next [[part|question4]] (track: 'short success', 'play') (track: 'short success', 'volume', 0.8)

Right. All three management options are correct. You can manage her either surgically, medically, or expectantly. Now it's time for the final scenario. Go back to the [[scenarios|pathways]] and choose Scenario 5 (track: 'clapping', 'play') (track: 'clapping', 'volume', 0.2)

Right. All three options are correct. You can manage her either surgically, medically, or expectantly. Now it's time for the final scenario. Go back to the [[scenarios|pathways]] and choose Scenario 5 (track: 'clapping', 'play') (track: 'clapping', 'volume', 0.2)

Scenario 5 On examination, Mrs Dolly's temperature is 39°C, her BP is 96/65 mmHg, and her pulse rate is 114/minute. Her abdomen is tense and tender, and her uterus is not palpable. Pelvic examination reveals a bulky uterus with open cervical os, and foul-smelling products of conception are seen. Cervical excitation is negative, and no adnexa mass is felt. Her Haemoglobin is 8.2 g/dL. Her total WBC is 23 x109/L (normal range 4 - 11 x109/L). Her blood group is O positive. Below is an image of her pelvic ultrasound. No intrauterine sac is seen, and the presence of irregular products of conception is noted. <img src="/Bleeding3/USS5.jpg" /> Image source: https://quizlet.com/570467653/chapter-43-pathology-of-the-uterus-flash-cards/ What is the most likely diagnosis? [[1. Complete miscarriage]] [[2. Incomplete miscarriage]] [[3. Threatened miscarriage]] [[4. Septic miscarriage]] [[5. Missed miscarriage]]

No, no. Try again. (track: 'error', 'play') (track: 'error', 'volume', 0.2)

Yessss! Mrs Dolly is having a septic miscarriage which is very serious. Now, choose the best management sequence IN THE CORRECT ORDER. [[1. Resuscitation (airway, breathing, circulation), insert 2 large bore IV lines, remove products of conception in operation theatre, obtain blood cultures, commence IV broad spectrum antiobiotics.]] [[2. Resuscitation (airway, breathing, circulation), insert 2 large bore IV lines, commence IV broad spectrum antibiotics, remove products of conception in operation theatre, obtain blood cultures.]] [[3. Resuscitation (airway, breathing, circulation), insert 2 large bore IV lines, obtain blood cultures, commence IV broad spectrum antibiotics, remove products of conception in operation theatre.]] (track: 'yess', 'play') (track: 'yess', 'volume', 0.2)

No, no. Try again. (track: 'error', 'play') (track: 'error', 'volume', 0.2)

Huhhhh With your sequence of management, Mrs Dolly collpased with septicaemic shock on the way to theatre and died. Sorry, think again. <img src="/Bleeding3/cry.jpg"/> (track: 'attack', 'play') (track: 'attack', 'volume', 0.2)

Ohh noo. Because you started antibiotics BEFORE obtaining blood cultures, the cultures have come back negative with no bacterial growth detected. Now Mrs Dolly isn't improving with the antibiotics you gave her and you are unable to identify the most effective antibiotics for her infection as you cannot test for sensivities on negative cultures. Obtaining blood cultures during antibiotic therapy is associated with a significant loss of pathogen detection. Therefore, it is strongly recommended that blood cultures are obtained before antibiotic administration in patients with sepsis. Try again. <img src="/Bleeding3/BCpack.jpg"/> Image source: https://abronexports.com/Bottle_blood_culture_special_cap_aluminium_butyle_cap_Pack_kit_abron_ab-79-b30_kit.htm (track: 'attack', 'play') (track: 'attack', 'volume', 0.2)

Right! The correct systematic management for Mrs Dolly for septic miscarriage is as follows: 1. Resuscitation (airway, breathing, circulation) 2. Insert 2 large bore IV lines 3. Obtain Blood cultures 4. Commence IV broad spectrum antibiotics 5. Mainstay of treatment is the removal of products of conception in the operation theatre. Obtaining blood cultures during antibiotic therapy is associated with a significant loss of pathogen detection. Therefore, it is strongly recommended that blood cultures are obtained before antibiotic administration in patients with sepsis. Click [[here|final]] to finish. <img src="/Bleeding3/BCpack2.jpg"/> Image source: https://www.iskushealth.com/product/procedure-kits/ (track: 'firstbeat', 'play') (track: 'firstbeat', 'volume', 0.2)

<h3>Well done, and a Big Congratulations to you!</h3> You have successfully completed a long and complicated journey with lots of twists and turns. It's time for a big celebration with your friends. Bon appetit ;-) Access the reading list [[here|reading list]]. <img src="/Bleeding3/buffet.jpg"/> Artwork for this website were generated by the author using AI tools (Ideogram 2.0 and DALL-E) (track: 'happykids', 'play') (track: 'happykids', 'volume', 0.2)

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Recommended reading: 1. <a href="/Bleeding3/Miscarriage Gynaecology by 10 Teachers 18th Ed.pdf" target="_blank">Miscarriage, Gynaecology by Ten Teachers 18th ed.</a> 2. <a href="/Bleeding3/Miscarriage Oxford Handbook of Obstretics & Gyneacology 3rd Ed.pdf" target="_blank">Bleeding in Early Pregnancy and Miscarriage, Oxford Handbook of Obstetrics & Gynaecology, 3rd ed.</a> 3. <a href="/Bleeding3/Ectopic pregnancy and miscarriage diagnosis and treatment (NICE 2019).pdf" target="_blank">Ectopic and miscarriage: diagnosis and initial management (NICE guidelines 2019)</a> 4. <a href="/Bleeding3/Anti-D guidelines (BCSH 2014).pdf" target="_blank">BCSH guideline for the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn (2014)</a> (link: "Restart Game")[(reload:)]

How would you manage Mrs Dolly for her threatened miscarriage? [[1. Surgical evacuation by dilatation and currettage]] [[2. Reassurance and see her back in 2 weeks]] [[3. Medical evacuation by prostaglandin]]

Mrs Dolly's vital signs are currently stable. The bleeding has stopped and her abdominal pain has ceased. How would you manage her complete miscarriage? [[1. Surgical evacuation by dilatation and currettage]] [[2. Observation, let her go home and see her back in 2 weeks]] [[3. Medical evacuation by prostaglandin]]

Mrs Dolly's vital signs are currently stable. The bleeding has stopped and the abdominal pain has ceased. How would you manage Mrs Dolly for a missed miscarriage? [[1. Surgical evacuation by dilatation and currettage]] [[2. Expectant management, let her go home and see her back in 2 weeks]] [[3. Medical evacuation by prostaglandin]]

Mrs Dolly is promptly resuscitated and two pints of O negative blood are transfused. How do you further manage Mrs Dolly for her incomplete miscarriage? [[1. Surgical evacuation of retained products of conception (ERPOC)]] [[2. Reassurance, let her go home and see her back in 2 weeks]] [[3. Medical evacuation by prostaglandin]]