Early Pregnancy - Miscarriage

Question 1

What is a Miscarriage?

Answer 1

A spontaneous termination of a pregnancy.

Question 2

What is an Early Miscarriage?

What is a Late Miscarriage?

Answer 2

Early = Before 12 Weeks.
Late = Between 12-24 Weeks.

Question 3

What is a Missed Miscarriage?

• Foetus State.
• Cervical Os.

Answer 3

Foetus State : Gestational sac contains a dead foetus before 20 weeks without any symptoms of expulsion.
Cervical Os : Closed.

Question 4

What is a Threatened Miscarriage?

• Cervical Os.
• Foetus State.

Answer 4

Cervical Os : Closed.

Foetus State : Still alive.

Question 5

What is an Inevitable Miscarriage?

• Cervical Os.
• Foetus State.
• Clinical Features (3).

Answer 5

Cervical Os : Open.
Foetus State : Intrauterine but will be lost due to open os.
Clinical Features : (i) Heavy Vaginal Bleeding; (ii) Clots; (iii) Pain.

Question 6

What is an Incomplete Miscarriage?

• Foetus State.
• Cervical Os.

Answer 6

Foetus State : Retained products of conception remain in the uterus after miscarriage.
Cervical Os : Open.

Question 7

What is a Complete Miscarriage?

• Foetus State.
• Cervical Os.

Answer 7

Foetus State : A full miscarriage has occurred and no products of conception remain in the uterus.
Cervical Os : Closed.

Question 8

What is an Anembryonic Pregnancy/Blighted Ovum?

Answer 8

Foetus State : Gestational sac is more than 25mm but contains no embryo.

Question 9

What is classed as a Recurrent Miscarriage?

Answer 9

Having 3+ consecutive miscarriages.

Question 10

Differential Diagnoses of Miscarriages (3).

Answer 10

1. Ectopic Pregnancy (Main).
2. Hydatidiform Mole.
3. Cervical/Uterine Malignancy.

Question 11

Epidemiology of Miscarriages (3).

Answer 11

1. 15-20% of early pregnancies miscarry.
2. Recurrent Spontaneous Miscarriages affect 1% of women.
3. Rate of Miscarriage increases with age.

Question 12

Aetiology/Risk Factors of Recurrent Miscarriages (9).

Answer 12

1. Older Age - Idiopathic.
2. Anti-Phospholipid Syndrome.
3. Hereditary Thrombophilias.
4. Uterine Abnormalities.
5. Genetic Factors e.g. Balanced Translocations in Parental Chromosomes.
6. Chronic Histiocytic Intervillositis.
7. Chronic Endocrine Disease.
8. Smoking.
9. Cervical Incompetence.

Question 13

Give 3 Chronic Endocrine Diseases and 1 Chronic Autoimmune Disease that are predisposing factors to Recurrent Miscarriages.

Answer 13

1. Diabetes.
2. Untreated Thyroid Disease.
3. Systemic Lupus Erythematosus (SLE).
4. Polycystic Ovarian Syndrome (PCOS).

Question 14

What is Antiphospholipid Syndrome?

Answer 14

A disorder associated with Antiphospholipid Antibodies where the blood becomes prone to clotting i.e. the patient is in a hyper coagulable state. It is mainly associated with Thrombosis and complications in pregnancy - Recurrent Miscarriage.

Question 15

Aetiology of Antiphospholipid Syndrome (2).

Answer 15

1. Primary.

2. Secondary to Other Autoimmune Conditions e.g. SLE.

Question 16

Management of Pregnant Patients with Antiphospholipid Syndrome.

Answer 16

Low-Dose Aspirin + LMWH Lifelong (LLL).

Question 17

What are the 3 main inherited thrombophilias associated with recurrent miscarriages?

Answer 17

1. Factor V Leiden (commonest).
2. Factor II (Prothrombin) Gene Mutation.
3. Protein S Deficiency.

Question 18

How do inherited thrombophilias associated with recurrent miscarriages?

Answer 18

2nd Trimester Pregnancy Loss - presumably due to thrombosis of the uteroplacental circulation.

Question 19

Give 6 uterine abnormalities that can cause recurrent miscarriage.

Answer 19

1. Uterine Septum (partition through uterus).
2. Unicornuate Uterus (single-horned uterus).
3. Bicornuate Uterus (heart-shaped uterus).
4. Didelphic Uterus (double uterus).
5. Cervical Insufficiency.
6. Fibroids.

Question 20

What is Chronic Histiocytic Intervillositis?

Answer 20

A rare cause of recurrent miscarriage (in 2nd trimester), IUGR and IUD where macrophages (mononuclear cells) accumulate in the intervillous spaces of the placenta to cause inflammation.

Question 21

Investigation of Choice in Miscarriage & Features (2C).

Answer 21

1. Investigation of Choice : Transvaginal Ultrasound Scan.
2. Look for 3 key features that appear sequentially - the most recent feature is most relevant in assessing viability of pregnancy.
   2A. Mean Gestational Sac Diameter.
   2B. Foetal Pole and Crown-Rump Length.
   2C. Foetal Heartbeat.

Question 22

Significance of Foetal Heartbeat.

Answer 22

Once the foetal heartbeat is visible, the pregnancy is considered viable. Expect this once crown-rump length is 7+mm. If there is still no foetal heartbeat, repeat 1 week later before confirming non-viable pregnancy.

Question 23

Significance of Foetal Pole.

Answer 23

Expect this once mean gestational sac diameter is 25+mm. If there is still no foetal pole, repeat 1 week later before confirming an anembryonic pregnancy.

Question 24

Investigations in Recurrent Miscarriages (2).

Answer 24

1. Initiate after 3+ 1st Trimester Miscarriages or 1+ 2nd Trimester Miscarriages.
2. Refer to Specialist in Recurrent Miscarriage to check for any of the causes.

Question 25

General Management of Miscarriages (3).

Answer 25

1. Expectant Management. 2. Medical Management. 3. Surgical Management.

Question 26

Expectant Management of Miscarriages (4).

Answer 26

1. 1st line in women with no risk factors for heavy bleeding or infection. 2. Give 1-2 weeks to allow miscarriage to occur spontaneously. 3. Repeat urine pregnancy test 3 weeks after bleeding and pain settling to confirm completion. 4. If persistent/worsening bleeding, further assessment and medical/surgical management (incomplete miscarriage)

Question 27

NICE Recommendations for Medical/Surgical Management (3).

Answer 27

1. Increased Risk of Haemorrhage (late 1st trimester, coagulopathies, unable to have blood transfusion). 2. Previous Adverse/Traumatic Experience with Pregnancy (e.g. Stillbirth, Miscarriage, APH). 3. Evidence of Infection.

Question 28

Medical Management of Miscarriages (4).

Answer 28

1. A dose of Misoprostol to expedite process of miscarriage either as vaginal suppository or oral dose. 2. If bleeding has not started in 24 hours, advised to contact the doctor. 3. Give with antiemetics and analgesia. 4. Use pregnancy test 3 weeks later to check.

Question 29

Mechanism of Action of Misoprostol.

Answer 29

It is a Prostaglandin Analogue that will bind to Prostaglandin receptors on myometrial cells to soften the cervix and stimulate strong myometrial contractions to expel tissue.

Question 30

Adverse Effects of Misoprostol (2).

Answer 30

1. Heavier Bleeding and Pain. | 2. Vomiting & Diarrhoea.

Question 31

Surgical Management of Miscarriage (4).

Answer 31

1. Manual Vacuum Aspiration (Local Anaesthetic as an Outpatient). 2. Electric Vacuum Aspiration (under General Anaesthetic). 3. Give Misoprostol to soften cervix prior. 4. Anti-Rhesus D Prophylaxis to Rhesus negative women.

Question 32

Manual Vacuum Aspiration (4).

Answer 32

1. Local Anaesthetic applied to cervix. 2. Tube attached to specially designed syringe is inserted through cervix into uterus. 3. Manually aspirate contents of uterus. 4. Use if below 10 weeks of gestation and more appropriate for parous (previously given birth) women.

Question 33

Electric Vacuum Aspiration (3).

Answer 33

1. Traditional Surgical Management of Miscarriage. 2. General Anaesthetic is administered before performing the operation via vagina and cervix without any incisions. 3. Cervix is gradually widened using dilators and products of conception are removed through cervix using electric-powered vacuum.

Question 34

Prognosis of Incomplete Miscarriage.

Answer 34

1. Risk of Infection. 2. Medical (Misoprostol) or Surgical (ERPC - Evacuation of the Retained Products of Conception). 3. Complication of ERPC : Endometritis.