Abortion, TOP and Miscarriage

Question 1

How common are miscarriages?

Answer 1

Occur in 25% pregnancies but women might not be aware

Question 2

What, by definition, is a miscarriage?

Answer 2

A loss of pregnancy of 24 weeks or earlier
Sometimes the classification is as early as 20 weeks
After this it is defined as a stillbirth

Question 3

What is a THREATENED MISCARRIAGE?

Answer 3

PV bleeding, painless with CLOSED CERVICAL OS before 24 weeks with an ongoing pregnancy

Question 4

What is an INEVITABLE MISCARRIAGE?

Answer 4

PV bleeding with OPEN CERVICAL OS and usually some associated pain

Question 5

What is a MISSED MISCARRIAGE?

Answer 5

This is when the gestational sac is present but there is no evidence of fetal pole or yolk sac

Question 6

What are some risk factors for miscarriage?

Answer 6

Increased maternal age 
Smoking 
Consuming alcohol 
Recreational drug use 
High caffeine intake 
Obesity 
Infections and food poisoning 
Health problems (e.g. cardiac, diabetes, hypertension and hyperthyroid)
Medicines e.g. ibuprofen, methotrexate and retinoids 
Unusual shape of uterus 
Cervical incompetence

Question 7

How should a threatened miscarriage be treated?

Answer 7

Expectant management
Tell a woman that if her bleeding gets worse or persists beyond 14 days she should come back - if stops continue with antenatal care
Consider medical management if high haemorrhage risk or if she has had previous traumatic association with pregnancy

Question 8

How can miscarriage be medically managed?

Answer 8

Vaginal misoprostol 800mcg (can give orally if preferred) - this is for incomplete or missed miscarriage
She will then begin bleeding after 24 hours
Consider analgesics and anti-emetics
Advise them to take a pregnancy test after 3 weeks and return if this is positive

Question 9

How can miscarriage be surgically managed?

Answer 9

Manual vacuum aspiration under LA

Surgical management under a GA

Question 10

What is a stillbirth?

Answer 10

Fetal death beyond 24 weeks

Question 11

What causes stillbirth?

Answer 11

Sometimes they are classed as ‘unexplained’
PLACENTAL PROBLEMS - e.g. abruption or praaevia
MATERNAL PROBLEMS - pre-eclampsia, maternal drugs and alcohol, obstetric cholestasis, diabetes, infection, obese, multiple pregnancy, RHESUS STATUS
FETAL PROBLEMS - Cord prolapse, Genetic physical defect

Question 12

What infections can be associated with stillbirth?

Answer 12

Chlamydia, GBS, Haemophilus, E.coli, toxoplasmosis, Rubella, cytomegalovirus

Question 13

How will a stillbirth usually present initially?

Answer 13

RFM
Reduced growth on scans is a risk factor
Absent fetal heart beat on scan - full real time USS MUST BE DONE

Question 14

What needs to happen before a TOP can occur?

Answer 14

Must confirm woman is under 24 weeks of pregnancy

The termination order must be signed by 2 separate physicians

Question 15

When can you terminate a pregnancy?

Answer 15

CDE CLAUSE
C- Continuation of the pregnancy would cause greater harm to the woman’s physical or mental health then the termination (94% done with this)
D - Danger. Greater risk to with continuing pregnancy than termination, could be to mother, unborn baby o existing children
E - Significant risk that if it were born it would be born with significant congenital abnormalities

Question 16

How should an unwanted pregnancy be managed?

Answer 16

Confirm with bHCG tests
Confirm with USS to get an idea of, gestational age, single or multiple, uterine pregnancy (not ectopic) and viability of pregnancy

Question 17

How should you consider counselling a woman before having a TOP?

Answer 17

Has she weighed up implications and risks?
Discuss continuation of pregnancy and adoption?
BE SYMPATHETIC AND NON-DIRECTIONAL
GIVE TIME
Consider contraceptive plan for the future

Question 18

What investigations should be ordered before a termination?

Answer 18

BLOODS: Hb, ABO and Rh (Rh- will need anti-D)
Estimation of gestational age (USS or LMP)
Commonly given prophylactic abs (1g azithromycin)
provide verbal and written information

Question 19

How do we decide which form of termination is require d depending on gestational age?

Answer 19

<9weeks = EARLY MEDICAL ABORTION
9-13weeks = LATE MEDICAL ABORTION
13-24 weeks = MID-TRIMESTER MEDICAL ABORTION

Question 20

When should an early medical abortion be offered and what does it involve?

Answer 20

<9weeks
EVERYONE is offered 200mg MIFEPRISTONE tablet and then MISOPROSTOL 400mcg PO 36/48 hours later
Sometimes you might need an extra dose of 400mcg misoprostol especially if between 7w and 9w

Question 21

When can a late medical abortion be offered and what does it involve?

Answer 21

9-13w
MIFEPRISTON 200mg PO followed by 800mcg MISOPROSTOL - up to 4 more doses of 400mcg can be offered until abortion is completed

Question 22

When can a mid-trimester medical abortion be offered and what does it involve?

Answer 22

13-24w
MIFEPRISTONE 200mg followed by 800mcg VAGINAL MISOPROSTOL
+ an extra mifepristone

Question 23

What are some risks/complications of TOP?

Answer 23

Varying time to complete procedure 
Sometimes they fail 
RPOC 
Haemorrhage 
Pain 
Rupture of uterus 
Psychological problems 
Infection

Question 24

In what forms can an abortion be surgically managed?

Answer 24

Vacuum aspiration up to 14 weeks
Surgical evacuation from 17-15w
Dilation and Evacuation - 15-18w
Surgical evacuation without fetocide - 19-22w
Surgical evacuation with fetocide - 22-24w

Question 25

What needs to be done before surgical management of abortion?

Answer 25

The cervix needs to be primed

Using MISOPRISTOL 400mcg either given vaginally or sub-lingually about 3 hours before operation

Question 26

What are some risks/complications with surgical management of TOP?

Answer 26

Failure, trauma, haemorrhage, sepsis, PID, hysterectomy, death, continuing pregnancy, injury to cervix, psychological trauma

Question 27

What extra procedures might you need to warn a women she might need later while consenting for surgical TOP?

Answer 27

Hysterectomy
Repeat TOP
Blood transfusion
Laparotomy

Question 28

What are some common complications of all TOPs?

Answer 28

RPOC - advise about persistent bleeding
Haemorrhage 1 in 1000 cases 
Failure - 2.3 per 1000. Return for follow up
Perforation 
Infection (prophylactic abx)
Cervical trauma 
Future fertility - no reduction

Question 29

What advice should you always consider giving women after TOP?

Answer 29

CONTRACEPTIVE ADVICE
IUD/IUS can be implanted same day as can depot injections the implant and the pill/patch/ring
Pill doesn’t need to be taken for 5 days after

Question 30

How might an ectopic pregnancy present?

Answer 30

Pain +++ lower abdominal might be lateralised 
Vaginal bleeding 
Amenorrhoea (missed periods)
Vomiting 
Nausea
Collapse 

Woman’s abdomen is likely to be tender on examination and there might be pelvic and/or cervical motion tenderness

Question 31

If you suspect ectopic pregnancy how should you investigate it?

Answer 31

TVUSS is gold standard

Question 32

What are your three treatment options for a woman with ectopic pregnancy?

Answer 32

Expectant management
Medical management
Surgical management

Question 33

When might medical management of ectopic be suitable?

Answer 33

For women with little to no pain
With an adnexal mass <35mm and no fetal heart beat 
Serum hCG <1500U/L
Stable 
No uterine pregnancy

Question 34

What is medical management of an ectopic?

Answer 34

Methotrexate

Question 35

When might a surgical management of ectopic be more suitable?

Answer 35

If there is a heart beat
If it is anywhere other than adnexal
If bHCG is >1500 U/L

Question 36

What is the surgical management of an ectopic?

Answer 36

Salpingostomy or salpingectomy

Question 37

What should also be offered following surgical management of an ectopic?

Answer 37

Anti-D (if woman is Rh-)