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A - MSRA Gynaecology [8] > [13] Miscarriage > Flashcards

[13] Miscarriage Flashcards

1
Q

What is a miscarriage?

A

When there is loss of pregnancy before 24 weeks gestation

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2
Q

What % of recognised pregnancies end in miscarriage?

A

12-24%

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3
Q

Why is the rate of miscarriage probably higher than we know?

A

They may occur before pregnancy is realised

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4
Q

What number of hospital admissions occur due to miscarriage annually?

A

42,000

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5
Q

What % of miscarriages occur in the first trimester?

A

85%

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6
Q

How does the risk of miscarriage change with gestational age?

A

Falls rapidly

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7
Q

What are the risk factors for miscarriage?

A
  • Maternal age >30
  • Cigarette smoke
  • Excess alcohol
  • Low pre-pregnancy BMI
  • Paternal age >45 years
  • Fertility problems and taking longer to conceive
  • Illicit drug use
  • Uterine surgery or abnormalities
  • Uncontrolled DM
  • Stress, anxiety or traumatic events
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8
Q

Why does risk of miscarriage increase with maternal age?

A

Due to risk of chromosomal abnormalities increasing

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9
Q

What are some protective factors against miscarriage?

A
  • Previous live birth
  • Nausea
  • Healthy diet
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10
Q

Is a cause for miscarriage always identified?

A

No in many cases it isn’t

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11
Q

How does the prognosis of future pregnancies in miscarriage with an unidentifiable cause compare to a miscarriage with a known cause?

A

It is generally better

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12
Q

What are some identifiable causes of miscarriage?

A
  • Chromosomal abnormalities
  • Endocrine factors
  • Maternal illness and infection
  • Maternal lifestyle and drug history
  • Abnormalities of the uterus
  • Cervical incompetence
  • Autoimmune factors
  • Thrombophilic defects
  • Alloimmune factors
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13
Q

What is the most common type of chromosomal abnormality?

A

Autosomal trisomies

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14
Q

What % of miscarriages due to chromosomal abnormalities are caused by autosomal trisomies?

A

50%

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15
Q

What endocrine factors can lead to miscarriage?

A
  • Failure of corpus luteum
  • PCOS
  • Poorly controlled diabetes
  • Untreated thyroid disease
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16
Q

Why can corpus luteum failure lead to miscarriage?

A

Progesterone production is predominantly dependant on the corpus luteum in the first 8 weeks

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17
Q

What maternal illnesses can lead to miscarriage?

A
  • Severe febrile illness
  • Syphilis
  • Listeria
  • Mycoplasma
  • Bacterial vaginosis
  • Other systems illness e.g. cardiac, renal or hepatic disease
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18
Q

What maternal lifestyle factors can lead to miscarriage?

A
  • Smoking
  • Alcohol use
  • Caffeine
  • Cocaine
  • Cannabis
  • Stress
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19
Q

What drug history can lead to miscarriage?

A
  • Anti-depressant sue

- Peri-conceptual NSAID use

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20
Q

What uterine abnormalities can lead to miscarriage?

A
  • Congenital abnormalities

- Asherman’s syndrome

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21
Q

What congenital abnormalities of the uterus can lead to miscarriage?

A
  • Bicornuate uterus

- Subseptate uterus

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22
Q

Congenital uterine abnormalities are present in what % of women with recurrent miscarriage?

A

15-30%

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23
Q

What is Asherman’s syndrome?

A

Where damage to the endometrium and inner uterine walls cause the surfaces to become adherent, partially obliterating uterine cavity

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24
Q

When can cervical incompetence lead to?

A

2nd trimester miscarriage or early preterm delivery

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25
Q

How does a miscarriage due to cervical incompetence present?

A

Usually painless, rapid and bloodless

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26
Q

How can cervical incompetency be diagnosed?

A
  • Passage of a Heger 8 dilator without difficulty in a non-pregnant woman
  • USS
  • Pre-menstrual hysterogram
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27
Q

What is the most common cause for cervical incompetency?

A

Physical damage by mechanical dilation of the cervix or during childbirth

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28
Q

What autoimmune factor can commonly cause miscarriage?

A
  • Antiphospholipid antibodies
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29
Q

What % of women with recurrent miscarriage have antiphospholipid antibodies present?

A

15%

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30
Q

What is the live birth rate in women with untreated antiphospholipid syndrome?

A

As low as 10%

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31
Q

What is thought to cause pregnancy loss in antiphospholipid syndrome?

A

Thrombosis of uteroplacental vasculature and impaired trophoblast function

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32
Q

What other risks in pregnancy are associated with antiphospholipid syndrome?

A
  • IUGR
  • Pre-eclampsia
  • Venous thrombosis
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33
Q

What is the commonest presentation of miscarriage?

A

Vaginal bleeding with pain worse than a period

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34
Q

What should be looked for on examination in suspected miscarriage?

A
  • Signs of haemodynamic instability
  • Abdominal distension with localised tenderness
  • Assess diameter of os and look for products of conception on speculum
  • Assess uterine tenderness and adnexal mass on bimanual
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35
Q

What are some signs of haemodynamic instability?

A
  • Pallor
  • Tachycardia
  • Tachypnoea
  • Hypotension
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36
Q

What are the types of miscarriage?

A
  • Threatened miscarriage
  • Inevitable miscarriage
  • Missed miscarriage
  • Incomplete miscarriage
  • Complete miscarriage
  • Recurrent miscarriage
  • Septic miscarriage
37
Q

What are the features of a threatened miscarriage?

A
  • USS shows viable pregnancy
  • Mild bleeding
  • Usually little to no pain
  • Os is closed
38
Q

What percentage of women with a threatened miscarriage will go on to have a complete miscarriage?

A

50%

39
Q

What is an inevitable miscarriage?

A
  • Heavy bleeding with clots and pain
  • Os is open
  • Pregnancy will not continue
40
Q

What is a missed miscarriage?

A
  • Fetus is dead but retained
  • History of threatened miscarriage and persistent, dark-brown discharge
  • Decreased or absent early pregnancy symptoms
41
Q

What is an incomplete miscarriage?

A

Products of conception are partially expelled

42
Q

What is a complete miscarriage?

A

Confirmed uterine pregnancy in history followed by bleeding and clots with subsequent USS showing no pregnancy tissue in uterus

43
Q

What is recurrent miscarriage?

A

3 or more consecutive miscarriages

44
Q

What is a septic miscarriage?

A

When products of conception get infected

45
Q

What are the features of a septic miscarriage?

A
  • Fever
  • Rigors
  • Uterine tenderness
  • Bleeding/discharge
  • Pain
46
Q

What might investigations show in septic miscarriage?

A
  • Leucocytosis and raised CRP

- Features of complete or incomplete miscarriage

47
Q

What are the differentials for a miscarriage?

A
  • Ectopic pregnancy
  • Hydatiform mole
  • Cervical/uterine malignancy
48
Q

When is a patient suspected for a miscarriage?

A
  • Positive urine pregnancy test

- Vaginal bleeding with or without pain

49
Q

What investigations should a patient with a suspected miscarriage receive initially?

A
  • Transvaginal ultrasound scan in an early pregnancy assessment unit
  • Serum beta-HCG
50
Q

What must be looked for on USS in suspected miscarriage?

A
  • Fetal cardiac activity
  • Fetal crown-rump length
  • Mean sac diameter and fetal pole
51
Q

What is the most important finding on USS to exclude miscarriage?

A

Fetal cardiac activity

52
Q

When can fetal cardiac activity normally be observed on transvaginal USS?

A

5.5-6 weeks gestation

53
Q

Why is crown-rump length an important measure in assessing a suspected miscarriage?

A

To estimate gestation

54
Q

When can a conclusive diagnosis of miscarriage not be made?

A

When CR length <7mm and no fetal heart activity detected

55
Q

When should a scan be repeated if a conclusive diagnosis of miscarriage cannot be made due to CR length?

A

7 days later

56
Q

How can an intrauterine pregnancy be confirmed on USS if fetal pole is not visible?

A

Gestational sac and yolk sac

57
Q

What does the management of a suspected miscarriage depend on if using the gestational and yolk sacs to confirm intrauterine pregnancy?

A

Mean sac diameter

58
Q

How is the mean sac diameter obtained?

A

By measuring the sac in three dimensions

59
Q

When can a diagnosis of failed pregnancy be made based on mean sac diameter?

A

If >25mm

60
Q

When must a repeat scan in 10-14 days be made based on mean sac diameter?

A

<25mm

61
Q

When can a transabdominal USS be used to assess miscarriage?

A

If TVUS is not acceptable to the patient or in later gestation

62
Q

Why is transabdominal USS not readily used to assess miscarriage?

A

It is less sensitive and specific

63
Q

What can a serum beta-HCG be useful for in assessing suspected miscarriage?

A

Differentiating from an ectopic pregnancy

64
Q

How can an ectopic pregnancy be differentiated from miscarriage using beta-HCG?

A

Serial measurements:

  • Lowering suggests miscarriage
  • Steady suggests ectopic
65
Q

What other blood tests may be useful in suspected miscarriage?

A
  • FBC
  • Blood group and Rh status
  • CRP
66
Q

What are the three types of management for miscarriage?

A
  • Conservative
  • Medical
  • Surgical
67
Q

What do women require regardless of management if they are Rh -ve and > 12 weeks gestation in miscarriage?

A

Anti-D prophylaxis

68
Q

What do women require if they are having surgical management for miscarriage and are Rh -ve regardless of gestation?

A

Ant-D prophylaxis

69
Q

What is involved in conservative management of miscarriage?

A

Allowing the products of conception to pass naturally

70
Q

What should patients have if choosing conservative management of miscarriage?

A

24 hour access to gynaecological services

71
Q

What are the advantages of conservative management of miscarriage?

A
  • Can remain at home
  • No side effects
  • No anaesthetic or surgical risk
72
Q

What are the disadvantages of conservative management of miscarriage?

A
  • Unpredictable timing
  • Heavy bleeding and pain
  • Chance of being unsuccessful and requiring further intervention
73
Q

What follow up should be given for conservative management of miscarriage?

A

Either:

  • Repeat scan in 2 weeks
  • Pregnancy test in 3 weeks
74
Q

What are the contraindications to conservative management of miscarriage?

A
  • Infection

- High risk of haemorrhage e.g. coagulopathy or haemodynamically unstable

75
Q

What is involved in medical management of miscarriage?

A

Use of vaginal misoprostol to stimulate cervical ripening and myometrial contractions

76
Q

What is misoprostol?

A

A prostaglandin analogue

77
Q

What is usually given 24-48 hours prior to misoprostol?

A

Mifepristone

78
Q

What are the advantages of medical management of miscarriage?

A
  • Can be at home if desires (with 24/7 access to gynae)

- Avoids anaesthetics and surgical risks

79
Q

What are the disadvantages of medical management of miscarriage?

A
  • Can cause vomiting and diarrhoea
  • Heavy bleeding and pain
  • Chance of emergency surgery required
80
Q

What follow up is given in medical management of miscarriage?

A

Pregnancy test 3 weeks later

81
Q

What are the types of surgical management miscarriage?

A
  • Manual vacuum aspiration

- Evacuation of retained products of conception (ERPC)

82
Q

Under what anaesthetic is manual vacuum aspiration performed?

A

Local

83
Q

When can manual vacuum aspiration be performed?

A

If <12 weeks gestation

84
Q

Under what anaesthetic is ERPC performed for miscarriage?

A

General

85
Q

How is an ERPC for miscarriage performed?

A
  • Speculum is passed to visualise cervix

- Cervix is dilated and suction tube passed to remove products of conception

86
Q

What are the clinical indications for surgical management miscarriage?

A
  • Persistent excessive bleeding
  • Haemodynamic instability
  • Evidence of infected retained tissue
  • Suspected gestational trophoblast disease
87
Q

What are the advantages of surgical management miscarriage?

A
  • Planned procedure
  • Can help patient cope
  • Unaware during ERPC
88
Q

What are the disadvantages of surgical management miscarriage?

A
  • Anaesthetic risk
  • Infection
  • Uterine perforation
  • Haemorrhage
  • Asherman’s syndrome
  • Bowel or bladder damage
  • Retained products of conception

A - MSRA Gynaecology [8] (52 decks)

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