Attrition of Pregnancy Flashcards
Definition of miscarraige
Pregnancy loss in the first 20 weeks of gestation
Definition of recurrent miscarriage
3 miscarriages IN A ROW
Definition of inevitable miscarraige
Pain and bleeding in a pregnant woman less than 20w GA with DILATED CERVICAL OS
If leave woman stable there is a small (3-5%) change of progression to term
Definition of incomplete miscarriage
Some of the products of conception have been expelled, whether spontaneous completion of miscarriage will occur is unknown
Definition of complete miscarraige
All products of conception have been expelled
Definition of missed miscarriage
A pregnancy which has failed but has not eliminated products of conception
Definition of septic miscarriage
A miscarriage associated with sepsis, likely to have been associated with a backyard termination attempt gone wrong (very rare these days)
Definition of threatened miscarriage
Pain and bleeding during early pregnancy that does not result in miscarriage
Rate of miscarriage in early pregnancy
Increase with age and rate of recurrent miscarriages
1 in 6 clinical pregnancies will miscarry
Risk increases by 50% for women over the age of 35
1 in 4 women will miscarry at some point in their life
1-2% incidence of recurrent miscarriage (majority of which are unexplained)`
Main cause for early miscarriage
Foetal aneuploidy (60%) Mostly errors in female gamete meiosis, increased risk with maternal age
Presentation of miscarriage
Abdominal/Pubic pain + PV bleeding in a pregnant woman under 20 weeks GA
Investigations to perform if suspect miscarriage
Ultrasound - foetal heart, embryo located in gestational sac
hCG - change from +ve to -ve
Laboratory confirmation that tissue expelled contains chorionic villi
If taking to surgery: Hb, Blood group and antibody screen
Management of miscarriage
Expectant
Surgical evacuation
Medical evacuation
Grief Support
Indications for expectant management of a miscarriage
Threatened miscarriage (PV bleeding + pain, FHR detectable)
Spontaneous incomplete miscarriage
(less likely to be successful at later gestational ages)
Expectant management of a miscarriage
Watch and wait to see if completes
Ensure woman has 24 hour contact details
Follow-up after 2-3 days (?infection, ?completion)
Indications for surgical evacuation of miscarriage
Heavy bleeding or pain and prolonged symptoms
Women with intact gestational sac and no live embryo who have not expelled products within reasonable time (e.g. blighted ovum)
Woman’s choice (may be uncomfortable waiting)
Which surgical evacuation procedure will be performed for miscarriage at what gestational ages
Less than 13 weeks: Vacuum aspiration
Over 13 weeks: dilation and evacuation (D and C)
Exclusion criteria for medical evacuation of miscarriage
Anaemia (less than 100) Haemorrhagic disorder or anticoagulants Ischaemic heart disease Myocardial infarction Severe asthma Living over 1 hour from hospital
Medications given in medical evacuation of miscarriage
Misoprostol 400mcg (2 x 200mcg tablets) Sublingual administration Repeat every 3 hours to a maximum of 4 total doses PRN analgesia Have woman remain in hospital
Side effects of misoprostol
Temperature rise + shivering
Diarrhoea
Nausea and vomiting
Options if incomplete evacuation of miscarriage within 3 hours of final dose of sublingual misoprostol
Dilation and evacuation
OR
12 hour break followed by vaginal misoprostol
(4 tablets initially in posterior fornix, followed by 2 tablets every 3 hours for 3 doses)
Prognosis following 1 single miscarriage
Does not put at increased risk of miscarriage in subsequent pregnancies
Causes of recurrent miscarriages
Uterine/cervical: - congenital anomalies (arcuate/septate) - acquired (polyps/fibroids) - Cervical incompetence Parental karyotype Congenital/acquired thrombophilia (typically second trimester loss) - Antiphospholipid syndrome Endocrine/ovaries - insulin resistance - PCOS - reduced ovarian reserve
