Early pregnancy Flashcards
Discuss gestational trophoblastic disease:
-Definition
-Composition
-Incidence
-Risk factors (5)
- Spectrum of tumours of placental tissue that develop from abnormal fertilisation. Premalignant condition
- Made entirely of fetal material including syncitiotrophoblasts and cytotrophoblasts. Produces tHCG
- 1:200-1000 pregnancies
- Risk factors
-Extremes of age >15 yrs RR - 20, >45 RR = 10
-Diet deficient in protein
-Asian ethnicity
-Women with blood group A or whose partners are blood group 0 (RR 10)
-Previous GTD 1:70
How does GTD present during pregnancy (with percentages) (6)
- Vaginal bleeding (90%)
- Suspicious USS findings
- Hyperemesis (15-30%)
- Theca lutein cysts (15-30%) more likely to progress to GTN
- Hyperthyroidism (10%)
- PET (10%)
What is the presentation of GTD on USS and histo
1. Partial mole
2. Complete mole
- Partial mole
USS - focal vesicular areas, abnormal MSD, if fetus may be IUGR or multiple abnormalities
Histo- trophoblastic hyperplasia, hydropic villi +/- fetal tissue - Complete mole
USS - multiple large vesicular structures, enlarged cystic ovaries. No fetus. Snow storm
Histo-No fetal material, Marked villous hyperplasia. Hydropic swollen chorionic villi
Describe the management of molar pregnancy
Baseline: FBC, G&H, LFT, TFT, Cr, CXR
1. Suction evacuation
-Can use priming miso
-Avoid uterotonics
-Anti D if Rh-ve
-Histo to lab for confirmation on dx ( karyotype, p57 staining + in partial mole)
2. Weekly HCG until 3 consecutive normal
-Partial mole - stop once 3 x normal
-Complete mole - monthly for 6 months once 3 x normal
3. Counselling to patient and GP
-1:70 repeat
-No impact on fertility
-Contraception till cleared - COC OK. Avoid IUD until HCG normal. (increased risk perforation + dissemination)
-Early USS and HCG 6 weeks PP in following pregnancies
4. Discuss at MDM and ref to National registry
How should ongoing PVB of GTD be managed (3)
- Needs to suspect GTN or RPOC
- Consider repeat evacuation if
-Molar pregnancy was dx on histo only
-Persistently elevated HCG
-No evidence of mets on CXR
-Risk score 0-4 - Don’t do repeat evacuation if HCG >5000
- If repeat evacuation do with hysteroscopy
Describe miscarriages
-Definition
-Incidence
-Causes (5)
-Types (5)
- Pregnancy which spontaneously ends <20 weeks and <400g
- Incidence
-10-15% of clinically recognised pregnancies
-<5% after 9 weeks gestation
-10% at 30yrs. 50% by age 45 - Causes
-Chromosomal - 50%.
-Increases with age
-Less common cause as gestation increases
-Mostly Trisomies (22%) Monosomy (8%), Triploidy (8%)
-Infection - rarely
-Listeria, campylobacter, rubella, cocksackie, CMV.
-BV in second trimester
-Uterine abnormalities
-Bicornuate, septate, arcuate, DES
-Cx incompetence in 2nd trimester
-Haemoatological
-Antiphospholiid syndrome
-Thrombophillias
-Unexplained 25% - Types
-Threatened - PVB before 20/40
-Inevitable - PVB open Cx no passage of products
-Incomplete - Passage of some products
-Complete - products passed
-Septic - infected POC
Describe expectant management for miscarriage
-When to offer
-Advantages
-Disadvantages
-Success rates
-Offer if <6 weeks as first line
-Offer alternative if has condition where excessive PVB is an issue, Sx of infection, previous Obstetric related trauma
-Can wait up to 2 weeks
-FU at 14/7 if woman wants to continue expectant management
-Do PT in 3/52 to check miscarried
Advantage: non-invasive, avoid anaesthetic
Disadvantage: unpredictable, can take days to weeks, prolonged PVB and pain. Highest risk of unscheduled PVB
Success: By D7 25-50% By D14 50-80%. Most successful if incomplete 75-96%
Repeat UPT in 3 weeks if still Positive for review
Describe medical management for miscarriage
-Regimens
-Advantages
-Disadvantages
-Success rates
- Regimens
If <13 weeks
-Don’t give mife (Recent Meta analysis suggests Mife + miso better cf miso RR1.5)
-PO or PV miso is acceptable. Base on woman’s preference
-Missed miscarriage 800mcg miso can give second dose
-Incomplete miscarriage 600mcg PO
If >13 weeks
-Missed miscarriage - 200mcg PV/SL every 4-6 hrs
-Incomplete miscarriage - 200mcg PV/SL every 6 hrs - Advantages: Non invasive, avoids anaesthetic
- Disadvantage: Heavier longer PVB, May still need surgery -16%
Meta analysis suggests do difference between medical and surgical management - Success:
Overall 84%, Incomplete 93%
Mife + miso most effective form of managing miscarriage - but inconsistent data. More research needed - UPT in 3/52
Describe surgical management for miscarriage
-When to offer
-Advantages
-Disadvantages
-Success rates
-Risks (7)
- First line if haemodynamically unstable, sepsis, Heavy PVB or suspicious for GTD
- Advantages: Predictable time frame, faster resolution, shorter bleeding
Less analgesia requirement cf Miso RR 0.43 (Meta ana)
3: Disadvantages: Anaesthetic required, perforation, Ashermanns, uterine adhesions. - Success - 95-97%
- Risks:
-Overall significant risk 6%
-Bleeding - Tx 3:1000
-Infection 40:1000
-Uterine adhesions 19:1000 - mostly mild. Worse with more procedures.
-Repeat surgery 3-18:1000
-Perforation: 1:1000
-Cx trauma : <1:1000
-PTB RR 1.29
When should anti-D be prescribed post miscarriage
-When
-Dose
-Timing
When:
-Threatened miscarriage >12 weeks
-Spontaneous miscarriage >10 weeks
-Surgical management <10 weeks
-No clear evidence for spont miscarriage <10 weeks
Dose:
-Singleton up to 12 weeks - 250IU
-Multiple or >12 weeks 625 IU
Timing:
-By 72hrs
-Can have benefit up to 10 days
What is the risk of further miscarriages
After 1 miscarriage - 20% risk of repeat
After 2 miscarriages - 30% risk of repeat
After 3 or more miscarriages - 40-50% risk of repeat
Discuss the PRISM trial
-Type
-Aim
-Inclusion
-Intervention
-Primary outcome
-Results
- RCT multicentre and double blinded
- To determine if progesterone in women with threatened miscarriage improves live birth rates
- Women <12 weeks with PVB and known IUP
- 400mg BD PV progesterone vs placebo till 16/40
- Live birth >34 weeks
- Results
-Number included 4150 (~2080 each arm)
-No previous miscarriage - RR 0.99
-1-2 previous miscarriage - RR 1.05 ( CI 1.0-1.12)
-3 or more miscarriages - RR 1.28 ( CI 1.08 - 1.51)
-Any previous miscarriages RR 1.09 (CI 1.03 - 1.15)
-NNT 29 for 1 live birth
Discuss the MIST trial
-Type
-Aim
-Inclusion
-Primary outcome
-Results
- RCT
- To compare expectant, medical and surgical management of first trimester miscarriage in terms of gynaecological infection
- Women with dx missed or incomplete miscarriage <13 weeks
- Outcomes
-Primary outcome - Gynae infection at 2 weeks and 8 weeks
-Secondary outcome - Unplanned admission to hospital, unplanned surgical evacuation - Results:
-No difference with infection rates
-Significantly higher rates of unplanned admission and surgical management with expectant and medical management
Discuss the Zhang trial
-Type (2)
-Aim (1)
-Inclusion criteria (1)
-Primary outcomes (1)
-Results (4)
- Study type
-RCT to 800mcg misoprostol or Surgical ERPOC
-Randomised 3:1 - Aim
-To assess the efficacy, safety and acceptability of medical management - Inclusion criteria
-Women (n = 652) - first trimester pregnancy failure (missed miscarriage, fetal death, incomplete or inevitable miscarriage) - Primary outcome
-Treatment failure = repeat or evacuation by 30 days - Results:
-n = 650 500 to miso 160 to surgical
-84% success with medical management 71% after first dose.
-97% success with surgical management
No difference in haemorrhage, infection, ED visits between groups
-Increased blood loss in miso group (SS)
-Medical management found to be acceptable
What is the criteria for missed miscarriage (3)
Initial scan
-MSD >25mm and no visible yolk sac
-CRL >7mm and no FH seen
-No Sac or fetal growth over a time period no less than 7 days
Discuss ectopic pregnancy
-Definition
-Incidence
-Classification and incidence of each
-Risk factors
- implantation and development of pregnancy at a site other than endometrial cavity
- 1% of pregnancies
- Classification
-Tubal - 95%
-Ampullary - 55%
-Isthmic 25%
-Fimbrial 17%
-Interstitial - 2%
-Other
- CS Scar 6% of ectopic in women with >=1 previous CS
- Cervical 1%
Intramural, ovarian, abdominal - Risk factors
-Tubal damage - PID, Surgery, endometriosis
-Chromosomally abnormal pregnancies
-Progesterone containing contraception
-POP 4-6%, Jadelle - 10-20%
-IUD - Mirena 50%, CuIUD 30%
-DES, ART, Smoking, Douching
-30% no risk factors
-Previous ectopic
What are the USS signs of ectopic pregnancy
-Sensitivity, specificity
-% inconclusive on USS
-Feature - 5
- If ectopic identified Sens - 87-99%, Spec 94-99%
- 10-50% scans inconclusive
- Features:
-Empty extrauterine GS moving separately to ovary - 12-20%
-Complex inhomogenous adnexal mass moving sep from ovary 20-40% (Most common finding)
-Empty uterus
-Pseudo sac in the uterus 20%
-FF in POD
Discuss expectant management of ectopic
1. Criteria
2. Monitoring
3. Prognosis
- Criteria
-Clinically stable and pain free
-HCG <1000 (Can consider <1500)
-Tubal ectopic <35mm with no visible FHB
-Can be followed up - Monitoring
-HCG 2,4,7 then weekly until negative
-If not falling by >15% then clinical review +/- USS - Prognosis
-Up to 90% success if HCG <1000
-Up to 66% success if HCG <1500
-No difference between medical and expectant management in terms of tubal rupture, additional treatment, fertility outcomes, time to be able to conceive again
How should a PUL be managed (6)
If haemodynamically stable can:
-HCG 48hrs apart
-If rise >63% then likely IUP but some ectopics can double appropriately (HCG doesn’t tell location of pregnancy)
-Repeat USS once HCG >1500. If IUP not seen then likely ectopic
-If HCG decreases by >50% likely miscarriage. Suggest PT at 14/7 and if neg has miscarried
-Don’t use progesterone to work out if IUP or viable or ectopic
-Anything in between 50% decline and 63% rise refer to EPAU
Discuss medical management of ectopic pregnancy
-Criteria
-Meds
-Follow-up
-Prognosis
-Side effects (6)
- Criteria
-No significant pain
-Ectopic <35mm
-HCG <5000. Ideally <1500
-No Fetal heart
-No evidence of rupture
-No IUP
-Able to be followed up - Medication = methotrexate - destroys proliferating trophoblasts. Dose50mg/M2
- Follow up
-HCG 1,4,7 Continue weekly till negative
-If drop of <15% between D4-D7 = repeat treatment
- Needs USS before second dose to R/O Rupture and FHR
-Avoid pregnancy 3 month
-Avoid Alcohol and folic acid until HCG <5 - Prognosis
-90% success, 14% need repeat dose, 10% need surgery
-Better success with lower initial HCG <1000 or slow rising HCG before Rx - Side effects of methotrexate
-Bone marrow suppression
-Pulmonary fibrosis or pneumonitis
-Liver cirrhosis
-Renal failure
-GIT sx - flatulence and bloating
Discuss surgical management of ectopic pregnancy
-Methods (2)
-Follow-up
- Methods
-Aim Laparoscopic approach
-Salpingectomy
- If contralateral tube normal, active bleeding, no risk factors for infertility
-No difference in fertility outcomes or repeat ectopic
-Salpingotomy
-If contralateral tube damage and fertility desired
-Up to 1:5 women will need further treatment MTX or surgery
-Higher rates of pregnancy if fertility issues - Follow-up
-Salpingectomy - UTP in 3 weeks
-Salpingotomy - Follow HCG until negative. 20% require further Rx - If RH neg give Anti D (not required for medical or expectant management)
Discuss the prognosis of ectopic pregnancy
-70% of women will go on to have an IUP following ectopic
-Risk of recurrence
- 1 x previous with normal tube 6-12%
- 1 x previous with abnormal tube 25-50%
- 2 x previous 25-40%
-If no infertility issues then outcomes the same for all methods
-If subfertility then MTX or expectant better
Discuss cervical ectopic pregnancy
-Incidence
-USS findings (5)
-Management
- 1% of all ectopic pregnancies
- USS findings
-Barrel shaped cervix
-Empty uterus
-GS below level of internal os
-Absence of sliding sign / miscarriages in the cervix slide (Distinguishes between the two)
-Blood flow around GS with colour doppler - Management
- Medical. First line- MXT - systemic or intra sac. Best if HCG <10,000
- Surgical. Second line- Hysteroscopy + resection, D&C, Hysterectomy. Only in significant bleeding
Discuss caesarian scar ectopic pregnancy
-Incidence
-Types
-USS features (4)
-Management (4)
-FU
- Epidemiology
-1:2500 pregnancies
- 6% of ectopic pregnancies in women who have had a CS
- 3-5% risk of recurrence - Types:
-Endogenic - grows into uterine cavity. Can reach term, increased risk of placenta accreta spectrum)
-Exogenic - grows outwards into serosal surface, increased risk of first trimester rupture and haemorrhage - USS findings (first line for dx)
-Empty uterine cavity
-GS or mass embedded in previous lower segment scar
-Thin (1-3mm) or absent myometrium between GS and bladder
-Prominent vascular pattern on doppler - Management - no RCTs to base advise on
- Expectant - not recommended as first line
-Consider if: aSx, non viable CSP and HCG dropping or viable clearly endogenic in woman declining TOP. - Medical - if woman stable and CSP unruptured
-Systemic MXT - Interventional radiology
-Intragestational sac MXT/Sac aspiration/KCl - Surgical - recommended first line but not much in the literature.
-Dilation & suction curettage
-Laparoscopic / open resection
-Hysteroscopic resection
-Hysterectomy
-Combined lap and hysteroscopic - Follow-up
-Until HCG -ve
-If HCG plateaus consider MXT
-Consider CS scar defect repair
-Recommend CS in next delivery
-Early USS in future pregnancies
Describe interstitial ectopic pregnancy
-Location (2)
-USS features (3)
-Management
-Located at the proximal tubal part of the uterus where it enters the uterus.
-Ectopic able to grow larger as myometrium stronger and distendable
-Different from cornual as these occur in a uterus with a structural abnormality - i.e. rudementary horn.
2. USS features
-GS sac located laterally in the interstitial part of the tube
-Less than 5mm of myometrium in all imaging planes
-Presence of interstitial line sign (80% sens, 98% spec)
3. Management
-Expectant - if asx and HCG dropping or low
-Medical - systemic MXT, USS guided intrasac MTX +/- KCl, lap guided intrasac MXT +/- KCl
-Surgical
-Laparoscopic/open wedge resection of cornual +/- Salpingostomy
-Hysterectomy
-Hysteroscopic resection with USS or lap guidance
Describe ovarian ectopic pregnancy
-USS features (4)
-Management
- USS features:
-No agreed criteria
-Empty uterus
-Echogenic ring with internal anechoic area on ovary
-Unable to separate cystic mass from ovary - negative sliding sign
-CL seen separately - Management:
-Laparoscopic first line as required to make Dx
-Wedge resection
-Enucleation
-Oophorectomy if bleeding ++
Can use systemic MXT if surgical risk is high
Discuss heterotropic pregnancy
-Incidence
-Flags for heterotropic pregnancy
-Management
-FU
- Epidemiology:
-1:4000 (used to think 1:40,000)
-1:1000 in ART pregnancies - Red flags for heterotropic pregnancy
-Rising HCG despite miscarriage
-IUP with persistent pelvic pain
-Post ART - Management
If unstable - surgical management
-Laparoscopic removal of non-IUP
-Avoid manipulation of uterus
If stable
-Wants IUP - KCl to ectopic + sac aspiration or surgical resection of ectopic
-Doesn’t want IUP - Systemic MXT or intra-sac MXT or surgical resection + D&C
-If IUP not viable and stable can consider expectant - Follow-up
-USS FU to check resolution of ectopic
Discuss HCG
-Timing to be positive after ovulation
-Normal rise
-Peak concentration
-False positives (4)
- Timing
-Usually positive in UPT at time of missed period
-Earliest detectable = 6 days post ovulation on serum HCG
-Earliest detectable = 8 days post ovulation on UTP
-UPT positive when serum HCG 25-50 - HCG rise
-Normal rise = doubles every 48hrs.
-Normal low rise = 63% increase every 48hrs
-15% of pregnancies have an abnormal rise
->63% rise in 48hrs has a PPV of 96.5% for IUP - Peak concentration = 100,000 IU/L (most women)
- False positives
-IVF - exogenous HCG
-Chemical pregnancy
-HCG secreting tumour
-HCG secretion from pituitary
What are the earliest signs of IUP on USS
- Decidual reaction - echogenic ring with thickened decidua
- Double decidual sign - 2 concentric echogenic rings
- IUP can only be dx when YS or FP seen
-Pseudo sac can be mistaken for IUP but most likely is early IUP (99.98%) not ectopic (0.02%) if no adnexal mass seen
Discuss CRL
-How to measure
-Expected growth
-Dating with CRL
- Method of measurement
-If <7 weeks do length
-If >7 weeks do sagittal plan - Expected growth = 1mm / day
- GA in days = CRL mm + 42
Discuss dating in early pregnancy
-What to use
-Approximate dates by apparent structures (4)
- How to date
-Use LMP if sure and regular periods
-Use Scan if - unsure LM, irregular periods, >7 day discrepancy between EDD with LMP and scan - Approximate dates by structures
-GS but nothing else - 5/40 (4+3)
-GS + YS but nothing else -5.5/40 (>5)
-GS + YS + FH but can’t measure embryo - 6/40
-Fetal pole -7-8 weeks
What are the possible outcomes of a PUL? (4)
- Failing PUL - 50%
- IUP 30%
- Ectopic 20%
- Persisting PUL 2%
Describe the management of PUL
- Cannot r/o ectopic - give safety netting advice (written)
- Clinical symptoms are more important the HCG levels
- Don’t use serum progesterone to determine location.
- Don’t use HCG measures to determine location
- Take HCG measures 48hrs apart
-If >63% rise = likely IUP but can’t rule out ectopic
-Repat in 48hrs
-USS once HCG >1500 or after 7-14 days
-If level drop >50% - likely failing PUL
-Repeat HCG in 2 weeks then weekly until <5
-If level decreased <50% or rise <63% then specialist review
-Repeat USS in 7-10 days
Describe the management of RPOC
-When to investigate
-Investigations
-When to treat
-Treatment
- Bleeding after 3 weeks from miscarriage, Heavy PVB, fevers pain
- HCG - if neg then dx very unlikely, if + is suggestive
- USS - poorly specific for RPOC - mimics clot
- Treat if sx. Don’t treat asx women
- Treatment:
-Expectant if stable and RPOC <1cm
-Medical miso 400 PO
-Surgical - if septic, unstable, or requested.
-Hysteroscopic approach favoured
Discuss recurrent miscarriage
-Definition
-Incidence
-Causes (7)
- Definition
Loss of three or more consecutive pregnancies before 24 weeks (some societies say 2) - Incidence
-3 consecutive losses - 1%
-2 consecutive losses - 5% - Causes
-Unknown - 50%
-Age
-Chromosomal abnormalities 30-57%
-Parental chromosomal abnormalities - 3-5%
-60% balanced reciprocal translocation
-40% Robertsonian transloaction
-Antiphopholipid syndrome - 10-20%
-Inherited thrombophillia - FV Lieden, Prothrombin gene mutation
-Uterine anomalies
-congenital 6% -septate, arcuate, bicournuate
-Acquired - fibroids - submucosa/intramural, adhesions
-Endocrine factors - hypothyroidism, diabetes, PCOS, TPO antibodies, prolactin imbalances
-Previous miscarriage
-Smoking, caffeine, alcohol
-Extremes of BMI
-Infection
-Sperm DNA fragmentation
What are the investigations for recurrent miscarriage?
- Karyotyping both parents if fetal material shows abnormality
- Early follicular phase FSH and estradiol - assess diminished egg reserve
- THS T4 TPO
- Pelvic USS +/- saline infused sonohysterography
- Antiphospholid screen
-Anticardiolipin antibodies, lupus anticoagulent, anti B2- glycoprotien. 6/52 post miscarriage and 2 positive results 12 weeks apart. - Thrombophillia screen if loss in second trimester - Protein C and S def, factor V leiden, prothrombin gene mutation. 6/52 postnatal and without hormones
- Thrombophillia screen otherwise not recommended
- Test the pregnancy tissue for cytogenetics. If unbalanced translocation test the parents for balanced translocations.
What is the management for recurrent miscarriage
-Depends on cause
1. Parental chromosomal abnormality
- ref to genetics
- Can consider prenatal or preimplantation genetic screening - not routinely suggested
2. Antiphospholipid antibody syndrome
-Aspirin from pre-pregnancy until 34/40
-UFH/LMWH 40mg from positive pregnancy test till at least 34/40
-Can improve birth rate from 10-70%
3. Inherited thrombophillias - no evidence for LMWH but could consider for FVL, prothrombin Gene, protein S def +/- Hx of second trimester loss +/- risk factors doe thrombosis
4. Uterine abnormalities
-Septum hysteroscopic resection - observational data only
-Fibroids and polyps - no data but seems reasonable
5. Unexplained
-Reassurance - life birth rate following 3 miscarriages 70%
-Consider PV progesterone if PVB 400mg micronised PV BD until 16/40 in threatened miscarriage
6. Treat hypothyroidism and hyperprolactinemia.
-If euthyroid and TPO+ don’t treat.
-Can treat moderate Subclinical hypothyroid with TPO + but not mild cases
7. Maintain a weight between 19-25 BMI, stop smoking, limit caffeine and alcohol
Describe the epidemiology of abortion
-Life time risk
-Number of pregnancies ending in termination
-Number of deaths / yr where termination is illegal
- Life time risk = 33%
- Number of pregnancies terminated = 1:4
- Number of maternal deaths 50,000/yr
What are the longer term risks of abortion (5)
- Psychological trauma - studies not causative
- Small increase in subfertility
- Small increase in subsequent miscarriage
- Small increase in PTB with recurrent STOP
- Increase in PID if current infection
No increase in breast cancer, no increase in placenta praevia, no increase in ectopic pregnancy
Describe early TOP
-Definition
-Success rates
-Methods
-Regimen
- TOP before 8+6/40
- 95% success in medical TOP
- Methods
- Medical - mife 200mg then miso 36-48hrs later 800mcg
Sx onset 6-8hrs. 95% Complete within 24hrs - Surgical - MVA or suction curretage
-Not recommended <7/40 - increased failure rate
-recommend surgical priming with miso 2 x 400mcg 30 and 60 mins prior to procedure
Discuss late TOP
-Definition
-Methods
-Complications
-When should feticide be offered
- TOP after 8+6/40
- Methods
Surgical evacuation 14-24 weeks
-medical priming of cervix from 12/16 weeks
-medical and manual priming of cervix 16-24 weeks
Medical IOL >14 weeks
-Should be hospitalised
-Mife 200mg then miso 400mcg Q3H after 24-36hrs
-Offer feticide if risk of live birth 1-5% of births 18-24 weeks - Complications:
Surgical: RPOC, Infx, Cx lacceration, Uterine perforation, Bleeding
Medical: Retained placenta 10-20%, bleeding requiring transfusion 1-2%, RPOC, Live fetus born 1-5%, failed procedure if not delivered in 72hrs
What are the RANZCOG recommendations for use of mife in MTOP (4)
- Mife + miso is best available regimen for MTOP.
- Termination should be conducted in accordance with local legal requirements
- Where TOP is offered emergency services should be available
- For gestations >9 weeks treatment should be in a treatment facility
Discuss threatened miscarriage
-Management
-If PVB in viable IUP offer 400mg micronised progesterone PV BD
-Continue to 16/40 pregnancy
Discuss pregnancy outcomes post ectopic management
-Differences between management options in fertile women (3)
-Differences in management options in sub-fertile women (2)
- Differences in management options in fertile women
-No difference in fertility rates in all management options
-No difference in repeat tubal ectopic in all management options
-No difference in tubal patency rates - Difference in management options in sub-fertile women
-Fertility higher in expectant and medical management
-MXT doesn’t impact ovarian reserve
What are the main causes of second trimester miscarriage (3)
-Infection
-Uterine abnormalities
-Cervical insufficiency
Discuss the SPIN trial
-Aim (1)
-Study design (4)
-Primary outcomes (1)
- Aim
-To assess whether LMWH and LDA + intensive pregnancy surveillance reduces rate of pregnancy loss cf intensive pregnancy surveillance alone in women with 2 or more consecutive pregnancy losses - Study design
-Multicentre RCT
-Included if >= 2 consecutive pregnancy losses before 24/40 and <7/40 in current pregnancy
-Randomised to 75mg LDA + 40mg SC clexane or surveillance only
-FU till 36/60 - Primary outcomes
-Pregnancy loss rate
-Tolerance and safety of LMWH
Discuss the SPIN trial
-Number included (1)
-Outcomes (2)
- Number included
-n= 300 ~ 150 in each arm - Outcomes
-No difference in pregnancy losses between the two groups 22 in intervention arm vs 20% in control (NS)
-No difference in serious adverse events between groups
Discuss the trial investigating aspirin + heparin vs aspirin alone for recurrent miscarriage
-Aim (1)
-Study design (5)
-Primary outcomes (1)
-Secondary outcomes (3)
- Aim
-To determine the impact LMWH +/- aspirin on outcomes for women with recurrent miscarriage - Study design
-RCT. Blinded for aspirin but not heparin
-Three arms: heparin + aspirin, aspirin only, Placebo
-Included women with at least 2 pregnancy losses <20/40
-Women were enrolled at gest <6/40
-Aspirin continued to 36/40. Heparin continued until labour - Primary outcome
-Live birth rate - Secondary outcome
-Miscarriage rate
-Obstetric complications
-Adverse fetal and maternal events
Discuss the trial investigating aspirin + heparin vs aspirin alone for recurrent miscarriage
-Number included in study
-Results
- Number included in the study
n = 360 approx 120 in each arm - Results
-No difference in live birth rates between the three groups
-No difference were seen in secondary outcomes
Discuss the findings of 2021 Meta analysis on management of first trimester loss (5)
- Expectant management least effective to achieve complete evaluation of products
- There was similar effectiveness mife + miso or miso only and surgical management
- No evidence to suport miso + evac combo
- Mife and miso better than miso but lack of good data and more research required
- Satisfaction same across all modalities
