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Gaby’s Green Top Guidelines > 2023 17 Recurrent Miscarriage > Flashcards

2023 17 Recurrent Miscarriage Flashcards

1
Q

What is the definition of recurrent miscarriage?

A

3+ first trimester miscarriages

Consider investigation of 2+ if clinical impression of pathological cause

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2
Q

Which thrombophilias should be tested for in RCM?

A

Acquired:
Lupus anticoagulant
Anticardiolipin

Not inherited:
Protein C
Antithrombin deficiency
MTHFR mutation

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3
Q

Which thrombophilias should be tested for in 2nd trimester miscarriage?

A

Factor V Leiden
Prothrombin gene mutation
Protein S deficiency

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4
Q

Which miscarriages should cytogenetic analysis be offered for?

A

3rd & subsequent MC
Any 2nd trimester MC

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5
Q

When should parental peripheral blood karyotyping be offered in miscarriage?

A

Unbalanced structural chromosomal abnormality in fetal tissue
Unsuccessful pregnancy tissue test
No pregnancy tissue available

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6
Q

What testing should be offered for congenital uterine anomalies in RCM?

A

3D ultrasound

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7
Q

Which endocrine tests should be offered in RCM?

A

TFTs
Thyroid peroxidase antibodies

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8
Q

What immunological screening should be offered in RCM?

A

None! Not…
HLA
Cytokine
NK cells

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9
Q

What lifestyle advice should be advised in RCM?

A

BMI 19-25
Smoking cessation
Limit alcohol
Limit caffeine <200mg/day

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10
Q

When & what thromboprophylaxis should be offered in RCM?

A

Antiphospholipid syndrome
Not unexplained RCM

Aspirin & heparin
From +ve pregnancy test to 34/40
Following risk/benefit discussion

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11
Q

When should resection of a uterine septum be offered?

A

Recurrent miscarriage
2nd trimester miscarriage
Ideally in research context

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12
Q

When & what progestogen supplementation should be offered in RCM?

A

Bleeding in early pregnancy
400mg micronised PV BD
Until 16/40

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13
Q

What supportive care should be offered in RCM?

A

Dedicated specialist clinic

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14
Q

What should not be offered in RCM?

A
  1. Inherited thrombophilia screening (other than specifics in 2nd trimester)
  2. Parental karyotyping unless pregnancy tissue problem
  3. Immunological screening
  4. Infection screening
  5. Sperm DNA testing
  6. Thromboprophylaxis unless antiphospholipid syndrome
  7. PGT-A
  8. Thyroxine if euthyroid even if TPO
  9. Progesterone unless bleeding
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15
Q

What is the incidence of sporadic miscarriage?

A

Sporadic:
12-19: 13%
20-24: 11%
25-29: 12%
30-34: 15%
35-39: 25%
40-45: 50%
45+: 90%

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16
Q

What is the incidence of recurrent & 2nd trimester miscarriage?

A

Recurrent: 1%
2nd trimester: 1%

17
Q

What are the miscarriage rates for different numbers of previous miscarriages?

A

0: 11%
1: 17%
2: 28%
3: 40%
4: 47%
5: 64%

18
Q

What are the risk factors for miscarriage?

A
  1. Advancing maternal age
  2. Advancing paternal age (less so)
  3. Number of previous miscarriages
  4. Black ethnicity
  5. Smoking
  6. Alcohol excess
  7. Caffeine excess
  8. BMI <19 or >25
19
Q

What factors haven’t been proven to affect miscarriage rate?

A
  1. Previous live birth
  2. Consanguinity
  3. Environmental chemical exposure
20
Q

What fetal chromosomal anomalies can result in sporadic miscarriage?

A

Trisomy
Polyploidy
Monosomy
Structural anomalies

21
Q

Which congenital uterine structural anomalies increase the risk of miscarriage?

A

Yes: septate & bicornuate
2nd trimester: these & arcuate
No: didelphys, unicornuate

22
Q

How do acquired uterine anomalies impact on miscarriage rate?

A

Myomas: increased 2nd trimester
Polyps: no data
Intrauterine adhesions: not enough data but increase with number of previous D&C

23
Q

Which cervical features predispose to 2nd trimester miscarriage?

A

Previous cervical cone biopsy
Ultrasonographically short cervix

24
Q

What endocrine conditions increase risk of miscarriage?

A
  1. Poorly controlled diabetes
  2. Poorly controlled thyroid disease
  3. Subclinical hypothyroidism, TSH>2.5
  4. Thyroid autoantibodies
  5. PCOS
  6. Prolactin imbalances
  7. (Luteal phase defect: inconclusive)
25
Q

How is antiphospholipid syndrome diagnosed?

A

Lupus anticoagulant or anticardiolipin
2 positive tests
At least 12 weeks apart
At least 6 weeks post-miscarriage
Possibly anti-B2-glycoprotein-1

26
Q

What is the test for lupus anticoagulant antibodies?

A

dRVVT:
Dilute Russell’s Viper Venom Time
With platelet neutralisation procedure

27
Q

What is the test for anticardiolipin antibodies?

A

ELISA

28
Q

What maternal complications can be associated with heparin?

A

Bleeding
Hypersensitivity reactions
Heparin-induced thrombocytopenia

Gaby’s Green Top Guidelines (27 decks)

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