Attrition of Pregnancy

Question 1

Definition of miscarraige

Answer 1

Pregnancy loss in the first 20 weeks of gestation

Question 2

Definition of recurrent miscarriage

Answer 2

3 miscarriages IN A ROW

Question 3

Definition of inevitable miscarraige

Answer 3

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

Question 4

Definition of incomplete miscarriage

Answer 4

Some of the products of conception have been expelled, whether spontaneous completion of miscarriage will occur is unknown

Question 5

Definition of complete miscarraige

Answer 5

All products of conception have been expelled

Question 6

Definition of missed miscarriage

Answer 6

A pregnancy which has failed but has not eliminated products of conception

Question 7

Definition of septic miscarriage

Answer 7

A miscarriage associated with sepsis, likely to have been associated with a backyard termination attempt gone wrong (very rare these days)

Question 8

Definition of threatened miscarriage

Answer 8

Pain and bleeding during early pregnancy that does not result in miscarriage

Question 9

Rate of miscarriage in early pregnancy

Increase with age and rate of recurrent miscarriages

Answer 9

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)`

Question 10

Main cause for early miscarriage

Answer 10

Foetal aneuploidy (60%)
Mostly errors in female gamete meiosis, increased risk with maternal age

Question 11

Presentation of miscarriage

Answer 11

Abdominal/Pubic pain + PV bleeding in a pregnant woman under 20 weeks GA

Question 12

Investigations to perform if suspect miscarriage

Answer 12

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

Question 13

Management of miscarriage

Answer 13

Expectant
Surgical evacuation
Medical evacuation
Grief Support

Question 14

Indications for expectant management of a miscarriage

Answer 14

Threatened miscarriage (PV bleeding + pain, FHR detectable)
Spontaneous incomplete miscarriage
(less likely to be successful at later gestational ages)

Question 15

Expectant management of a miscarriage

Answer 15

Watch and wait to see if completes
Ensure woman has 24 hour contact details
Follow-up after 2-3 days (?infection, ?completion)

Question 16

Indications for surgical evacuation of miscarriage

Answer 16

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)

Question 17

Which surgical evacuation procedure will be performed for miscarriage at what gestational ages

Answer 17

Less than 13 weeks: Vacuum aspiration

Over 13 weeks: dilation and evacuation (D and C)

Question 18

Exclusion criteria for medical evacuation of miscarriage

Answer 18

Anaemia (less than 100)
Haemorrhagic disorder or anticoagulants
Ischaemic heart disease
Myocardial infarction
Severe asthma
Living over 1 hour from hospital

Question 19

Medications given in medical evacuation of miscarriage

Answer 19

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

Question 20

Side effects of misoprostol

Answer 20

Temperature rise + shivering
Diarrhoea
Nausea and vomiting

Question 21

Options if incomplete evacuation of miscarriage within 3 hours of final dose of sublingual misoprostol

Answer 21

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)

Question 22

Prognosis following 1 single miscarriage

Answer 22

Does not put at increased risk of miscarriage in subsequent pregnancies

Question 23

Causes of recurrent miscarriages

Answer 23

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