Early pregnancy - Miscarriage and TOP Flashcards
what is a misscarriage?
spontaneous termination of pregnancy
early = before 12 weeks
late = between 12 and 24
what is a missed miscarriage?
fetus is no longer alive but no symptoms have occurred
what is a threatened miscarriage
vaginal bleeding with closed cervix and fetus is alive
what is an inevitable miscarriage?
vaginal bleeding with an open cervix
what is an incomplete miscarriage?
retained products of conception remain in the uterus after miscarriage
what is a complete miscarriage?
full miscarriage has occurred and there are no products of conception left in the uterus
what is an anembryonic pregnancy?
gestation sac is present but contains no embryo
what is the investigation of choice when diagnosing a miscarriage?
transvaginal ultrasound scan
there are 3 features that appear sequentially as a pregnancy develops and as each appears, the feature before becomes less relevant in assessing the viability. what are these features?
mean gestational sac diameter
fetal pole and crown-rump length
fetal heartbeat
when is a fetal heartbeat expected and if it is visible, what does this mean?
when the crown-rump length is 7mm or more
visible = viable
what happens when the crown-rump length is LESS than 7mm WITHOUT a fetal heartbeat?
scan repeated after at least 1 week to ensure a heartbeat develops
what happens when the crown-rump length is 7mm or more without a fetal heartbeat?
scan is repeated after 1 week before confirming a non-viable pregnancy
A fetal pole is expected once the mean gestational sac diameter is 25mm or more. what happens when there is a mean gestational sac diameter of 25mm or more, WITHOUT a fetal pole?
scan repeated after 1 week before confirming an anembryonic pregnancy
how is a miscarriage managed at less than 6 weeks gestation (presenting with bleeding)
managed expectantly - as long as they have no pain or other complications or risk factors
involves awaiting the miscarriage without investigations or treatment
uss unlikely to be helpful this early on
repeat urine pregnancy test preformed after 7-10 days- if negative misscariage conformed
refer if bleeding/pain continues
how is misscarriage managed after more than 6 weeks gestation?
refer to EPAU for women with bleeding and positive pregnancy test
uss to confirm location and viability - must consider and exclude ectopic
3 options - expectant, medical and surgical
describe expectant management for miscarriage in pregnancy more than 6 weeks
offered 1st line to women without risk for heavy bleeding or infection
1-2 weeks given for miscarriage to happen spontaneously
urine pregnancy test performed 3 weeks after bleeding and pain settle to confirm miscarriage is complete
persistent pain and bleeding requires further investigation - repeat uss
what is the medical management of miscarriage after 6 weeks gestation?
misoprostol - prostaglandin analogue (binds to prostaglandin receptors and activates them
soften cervix and stimulate uterine contractions
vaginal suppository or oral dose
side effects are heavier bleeding, pain, vomiting, diarrhoea
what are the 2 options for surgical management of a miscarriage after 6 weeks gestation?
manual vacuum evacuation under local anaesthetic as an outpatient
electric vacuum aspiration under GA
what is given before surgical management to soften the cervix?
misoprostol
describe manual vacuum evacuation
local anaesthetic to cervix
tube attached to a syringe inserted through cervix into uterus
person performing procedure then manually aspirates the contents of the uterus
woman must understand the process and be below 10 weeks
more appropriate in women who have previously given birth
describe electric vacuum aspiration
GA
performed through the vagina and cervix
cervix gradually widened using dilators and products of conception removed through cervix using electric powered vacuum
what needs to be given to rhesus negative women?
anti rhesus D prophylaxis
what is an incomplete miscarriage?
occurs when retained products of conception remain in the uterus after the miscarriage
create an infection risk
what are the 2 options for treating an incomplete miscarriage?
medical management with misoprostol
surgical management - evacuation of retained products of conception
describe evacuation of retained products of conception (ERPC) and its complications
GA
cervix gradually dilated
retained products removed through the cervix using vacuum aspiration and curettage
complication - endometritis
what is classed as recurrent misscarriage?
3 or more consecutive miscarriages
risk of miscarriage increases with age
when are investigations initiated for recurrent miscarriages?
3 or more 1st trimester miscarriages
1 or more 2nd trimester miscarriages
what are some causes of recurrent miscarriage?
- idiopathic - particularly older women
- antiphospholipid syndrome
- hereditary thrombophilias
- uterine abnormalities
- genetic factors
- Chronic histiocytic intervillositis
- chronic diseases such as diabetes, untreated thyroid disease, SLE
what is antiphospholipid syndrome?
disorder associated with antiphosphlipid antibodies where blood becomes prone to clotting
pt is in a hypercoagulable state
main associations - thrombosis and recurrent miscarriage
occurs on it own or secondary to autoimmune condition
risk of miscarriage reduced by low dose aspirin and LMWH
test for antiphospholipid antibodies
name 3 hereditary thrombophilias
Factor V Leiden - most common
Factor II gene mutation
Protein S deficiency
name some uterine abnormalities that can cause recurrent miscarriage
- Uterine septum (a partition through the uterus)
- Unicornuate uterus (single-horned uterus)
- Bicornuate uterus (heart-shaped uterus)
- Didelphic uterus (double uterus)
- Cervical insufficiency
- Fibroids
what is chronic histiocytic intervillositis?
rare cause of recurrent miscarriage - particularly 2nd trimester
can cause IUGR and intrauterine death
Histiocytes and macrophages build up in the placenta, causing inflammation and adverse outcomes. It is diagnosed by placental histology showing infiltrates of mononuclear cells in the intervillous spaces.
what investigations are done to investigate recurrent miscarriage
antiphospholipid antibodies
testing for hereditary thrombophilias
pelvic ultrasound
genetic testing of the products of conception
genetic testing on parents
how is recurrent miscarriage managed?
depends on underlying cause
PRISM trial - benefit to using vaginal progesterone pessary’s during early pregnancy for women with recurrent miscarriages presenting with bleeding
RCOG - insufficient evidence for progesterone supplementation
what is termination of pregnancy (TOP) or abortion?
elective procedure to end a pregnancy
legal requirements for abortion ref zero to finals
n abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of:
- The woman
- Existing children of the family
The threshold for when the risk of continuing the pregnancy outweighs the risk of terminating the pregnancy is a matter of clinical judgement and opinion of the medical practitioners.
An abortion can be performed at any time during the pregnancy if:
- Continuing the pregnancy is likely to risk the life of the woman
- Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
- There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
The legal requirements for an abortion are:
- Two registered medical practitioners must sign to agree abortion is indicated
- It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
how is a medical abortion carried out?
mifepristone - anti progesterone which halts pregnancy and relaxes cervix
misoprostol - prostaglandin analogue 1-2 days later, soften cervix and stimulate uterine contractions. from 10 weeks gestation, additional misoprostol doses every 3 hours are required until expulsion
how is a surgical abortion carried out
LA, LA + sedation or GA
misoprostol, mifepristone or osmotic dilators to soften and dilate the cervix
2 options - cervical dilation and suction of contents of the uterus, cervical dilation and evacuation using forceps
what must rhesus negative women be given having a medical abortion, and those having a surgical abortion?
Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis.
Rhesus negative women having a surgical TOP should have anti-D prophylaxis. The NICE guidelines (2019) say it should be considered in women less than 10 weeks gestation.
what post abortion care should women be advised about and what are some complications?
may experience vaginal bleeding and abdominal cramps intermittently for 2 weeks
urine pregnancy test performed 3 weeks after abortion to confirm its complete
contraception discussed
complications - bleeding, pain, infection, failure of abortion, damage to cervix or uterus or surrounding structures
