Clinical: Pregnancy Loss Flashcards
Define miscarriage
- Loss of intra-uterine pregnancy before 24 completed weeks
- Loss of fetus/mbryo <500 g and less than 22 completed gestational weeks
Typical presentation of spontaneous abortion
Vaginal bleeding and uterine cramps or back pain
5 potential ultrasound findings for spontaneous abortion
- Anembryonic pregnancy
- Abortion in progress
- Missed abortion
- Retained products of conception
- Abnormally shaped gestational sac
US for anembryonic pregnancy
Large (>18 mm) gestational sac without embryo
US for abortion in progress
Low-lying gestational sac (thick arrow), decidual reactoi nand hemorrhage (mixed hyper- and hypo-echoic material between arrowheads)
7 causes of sporadic miscarriage
- Chromosomal abnormalities
- Fetal malformations
- Placental abnormalities
- Infection
- Fetal sex
- Mulitple pregnancy
- Maternal health
4 chromosomal abnormalities associated with multiple fetal abnormalities (risk for sporadic miscarriage)
- Trisomies
- Monosomy X (45X0)
- Polyploidy (69XXY, 69XXX)
8 infections that may cause sporadic miscarriage
- Listeria
- Toxoplasmosis
- Malaria
- Rubella
- CMV
- HIV
- B19 parvo (late)
- Syphilis (late)
7 steps of the pathophysiology of sporadic miscarriage
- Fetal demise or abnormal placental invasion
- Reduced trophoblastic invasion
- Blood flow enters the intervillous space and dislodges the conceptus
- Further intrauterine bleeding
- Local prostagladin release
- Pain
- Uterine contraction/expulsion of the conceptus
3 presentations of miscarriage
- Bleeding (threatened miscarriage)
- Complete miscarriage
- Arrested pregnancy
Define complete miscarriage
Cervix opens and conceptus/products expelled
3 conditions associated with incomplete miscarriage
- Massive hemorrhage
- Cervical shock syndrome
- Urgent evacuation of the uterus
3 treatments for sporadic miscarriage
- Expectant management
- Cytotec (misoprostol)
- Suction curettage
2 risks of suction curettage
- Infection
- Uterine damage
Define recurrent miscarriage
Three (or more) consecutive miscarriage
Define primary recurrent miscarriage
No previous llive births
Define secondary recurrent miscarriage
At least one successful pregnancy
6 reproductive problems that recurrent miscarriage is associated with
- Infertility
- Late miscarriage
- Stillbirth/NND
- Ectopic pregnancy
- Fetal abnormality TOP
- Prematurity/IUGR
7 etiologies of recurrent miscarriage
- Genetic
- Anatomical
- Infective
- Endocrine
- Immune
- Thrombophilic
- Unexplained
5 examples of genetic causes of recurrent miscarriage
- Prental chromosomal abnormalities (peripheral blood karyotype of both parents)
- Recurrent fetal aneuploidy (fetal cytogenetic analysis)
- Balanced or reciprocal translocations
- Robertsonian translocation
- Pericentric inversions
2 anatomical causes of recurrent miscarriage
- Uterine anomalies
- Fibroids
8 uterine anomalies
- Arcuate
- Subseptate
- Septate
- Unicollis bicornuate
- Bicolis bicornuate
- Didelphus
- Unicornuate
- Hypoplastic
Treatment for arcuate and didelphys uterine anomalies
None
Treatment for septate and subseptate uterine anomalies
Resect septum
Treatment for bicornuate uterus
Consider metroplasty usually as last resort
Treatment for fibroids causing recurrent miscarriage
Myomectomy (only if no other cause identified)
3 infective causes of recurrent miscarriage
- Syphilis
- Malaria
- Bacterial vaginosis (trichomonas vaginalis)
4 endocrine causes of recurrent miscarriage
- Systemic endocrine disease
- Diabetes (esp NIDDM)
- Thyroid disease
- Luteal phase deficiency
- PCOS (hypersecretion of LH, hyperinsulinemia)
3 immune causes of recurrent miscarriage
- Autoimmune disease
- Antiphospholipid syndrome (PAPS, aPL, APS, APAs)
- Allo-immune factors
3 auto-immune diseases associated with recurrent miscarriage
- SLE
- Antithyroid antibodies (anti-thyroglobulin and anti-thyroid peroxidase)
- Anti-nuclear antibodies
2 antiphospholipid antibodies
LA and aCL
Diagnosis of antiphospholipid syndrome
dRVVT (for LA) and ELISA (for aCL). Need at least two tests at least 6 weeks apart
3 treatments of antiphospholipid syndrome
SC heparin and LDA until 34 weeks
Potential IVIG for thrombocytopenia
7 thrombophilic causes of recurrent miscarriage
- APS (acquired thrombophilic state)
- Hyperhomocysteinemia (dietary or MTHFR mutation)
- Activated protein C resistane (factor V leiden)
- Protein S deficiency
- Protein C deficiency
- AT III deficiency
- Prothrombin G20210A mutation
Effect of hyperhomocystenemia
Impairs endothelial function and promotes thrombosis
Cause of acquired hyperhomocystenemia
Deficiencies of Vit B6, (B9) and B12
Cause of inherited hyperhomocystenemia
MTHFR mutation
NOTE: individuals homozygoud for MTHFR mutation are NOT at increased risk of RM by most recent meta-analysis
Treatment for acquired hyperhomocysteinemia
Folate and B12 supplementatoin
Effect of activated Protein C resistance
Factor V resistant to cleavage by activated Protein C
Cause of inherited activated Protein C resistance
Factor V Leiden mutation (hetero- or homo-)
Test for activated protein C resistance
Test for APCR and FVL
Treatment for activated protein C resistance
LDA and heparin?
Effect of prothrombin G20210A mutation
Increased factor II (prothrombin)
3 thrombophilic causes that are not directly related to recurrent miscarriage, but which should be treated due to risk of thrombosis anyway
- Inherited hyperhomocystenemia
- Protein C deficiency
- Anti-thrombin III deficiency
