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Threatened miscarriage with recurrent bleeding — MRCEM SBA MCQ

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HardObstetric and gynaecological emergenciesThreatened miscarriage with recurrent bleedingMRCEM SBA

A 34-year-old woman at 12+4 weeks’ gestation attends the emergency department after her third episode of vaginal bleeding in five days. She has passed several small clots today but has no severe pain. Her pulse is 88/min, blood pressure 118/72 mmHg and haemoglobin 121 g/L. Speculum examination shows a closed cervix. Specialist ultrasonography confirms a single intrauterine pregnancy with a fetal heartbeat. She had one previous miscarriage, is RhD negative and has no known red-cell antibodies. The gynaecology team has assessed her, arranged follow-up and provided advice about returning if bleeding increases. Which treatment plan is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Offer vaginal micronised progesterone 400 mg twice daily; consider anti-D immunoglobulin 250 IU after discussion.

The fetal heartbeat, intrauterine location and closed cervix establish a threatened rather than a confirmed miscarriage. Because she is bleeding and has had a previous miscarriage, NICE recommends vaginal micronised progesterone 400 mg twice daily; with a confirmed heartbeat, treatment continues until 16 completed weeks. Her RhD-negative status, gestation of 12+4 weeks and recurrent bleeding also bring her within NICE’s June 2026 recommendation to *consider* 250 IU anti-D immunoglobulin, discussing its blood-plasma origin with her. ([nice.org.uk](https://www.nice.org.uk/guidance/ng126/chapter/management-of-miscarriage)) A reflects the former approach to anti-D in threatened miscarriage but misses the current gestational-age and bleeding exception. B delays indicated progesterone despite the definitive scan; awaiting confirmation would be reasonable if pregnancy location or viability had not yet been established. C adds a Kleihauer test, which NICE advises against for quantifying fetomaternal haemorrhage in this setting. D confuses recurrent bleeding with confirmed miscarriage: the pregnancy remains viable and she is haemodynamically stable. Urgent surgical management would instead be considered for a confirmed miscarriage with clinically significant ongoing haemorrhage. ([nice.org.uk](https://www.nice.org.uk/guidance/ng126/chapter/management-of-miscarriage))

Reference: NICE NG126: Management of miscarriage (17 June 2026) — https://www.nice.org.uk/guidance/ng126/chapter/management-of-miscarriage NICE NG126: Resource impact statement (June 2026 update) — https://www.nice.org.uk/guidance/ng126/resources/resource-impact-statement-pdf-8779033659589 NICE NG126 update: Anti-D immunoglobulin prophylaxis, recommendations 1.7.3–1.7.5 (2026) — https://www.nice.org.uk/guidance/GID-NG10444/documents/450