Early pregnancy - Miscarriage and TOP

Question 1

what is a misscarriage?

Answer 1

spontaneous termination of pregnancy

early = before 12 weeks

late = between 12 and 24

Question 2

what is a missed miscarriage?

Answer 2

fetus is no longer alive but no symptoms have occurred

Question 3

what is a threatened miscarriage

Answer 3

vaginal bleeding with closed cervix and fetus is alive

Question 4

what is an inevitable miscarriage?

Answer 4

vaginal bleeding with an open cervix

Question 5

what is an incomplete miscarriage?

Answer 5

retained products of conception remain in the uterus after miscarriage

Question 6

what is a complete miscarriage?

Answer 6

full miscarriage has occurred and there are no products of conception left in the uterus

Question 7

what is an anembryonic pregnancy?

Answer 7

gestation sac is present but contains no embryo

Question 8

what is the investigation of choice when diagnosing a miscarriage?

Answer 8

transvaginal ultrasound scan

Question 9

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?

Answer 9

mean gestational sac diameter

fetal pole and crown-rump length

fetal heartbeat

Question 10

when is a fetal heartbeat expected and if it is visible, what does this mean?

Answer 10

when the crown-rump length is 7mm or more

visible = viable

Question 11

what happens when the crown-rump length is LESS than 7mm WITHOUT a fetal heartbeat?

Answer 11

scan repeated after at least 1 week to ensure a heartbeat develops

Question 12

what happens when the crown-rump length is 7mm or more without a fetal heartbeat?

Answer 12

scan is repeated after 1 week before confirming a non-viable pregnancy

Question 13

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?

Answer 13

scan repeated after 1 week before confirming an anembryonic pregnancy

Question 14

how is a miscarriage managed at less than 6 weeks gestation (presenting with bleeding)

Answer 14

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

Question 15

how is misscarriage managed after more than 6 weeks gestation?

Answer 15

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

Question 16

describe expectant management for miscarriage in pregnancy more than 6 weeks

Answer 16

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

Question 17

what is the medical management of miscarriage after 6 weeks gestation?

Answer 17

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

Question 18

what are the 2 options for surgical management of a miscarriage after 6 weeks gestation?

Answer 18

manual vacuum evacuation under local anaesthetic as an outpatient

electric vacuum aspiration under GA

Question 19

what is given before surgical management to soften the cervix?

Answer 19

misoprostol

Question 20

describe manual vacuum evacuation

Answer 20

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

Question 21

describe electric vacuum aspiration

Answer 21

GA

performed through the vagina and cervix

cervix gradually widened using dilators and products of conception removed through cervix using electric powered vacuum

Question 22

what needs to be given to rhesus negative women?

Answer 22

anti rhesus D prophylaxis

Question 23

what is an incomplete miscarriage?

Answer 23

occurs when retained products of conception remain in the uterus after the miscarriage

create an infection risk

Question 24

what are the 2 options for treating an incomplete miscarriage?

Answer 24

medical management with misoprostol

surgical management - evacuation of retained products of conception

Question 25

describe evacuation of retained products of conception (ERPC) and its complications

Answer 25

GA

cervix gradually dilated

retained products removed through the cervix using vacuum aspiration and curettage

complication - endometritis

Question 26

what is classed as recurrent misscarriage?

Answer 26

3 or more consecutive miscarriages

Question 27

risk of miscarriage increases with age

Answer 27

Question 28

when are investigations initiated for recurrent miscarriages?

Answer 28

3 or more 1st trimester miscarriages

1 or more 2nd trimester miscarriages

Question 29

what are some causes of recurrent miscarriage?

Answer 29

• idiopathic - particularly older women
• antiphospholipid syndrome
• hereditary thrombophilias
• uterine abnormalities
• genetic factors
• Chronic histiocytic intervillositis
• chronic diseases such as diabetes, untreated thyroid disease, SLE

Question 30

what is antiphospholipid syndrome?

Answer 30

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

Question 31

name 3 hereditary thrombophilias

Answer 31

Factor V Leiden - most common

Factor II gene mutation

Protein S deficiency

Question 32

name some uterine abnormalities that can cause recurrent miscarriage

Answer 32

• Uterine septum (a partition through the uterus)
• Unicornuate uterus (single-horned uterus)
• Bicornuate uterus (heart-shaped uterus)
• Didelphic uterus (double uterus)
• Cervical insufficiency
• Fibroids

Question 33

what is chronic histiocytic intervillositis?

Answer 33

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.

Question 34

what investigations are done to investigate recurrent miscarriage

Answer 34

antiphospholipid antibodies

testing for hereditary thrombophilias

pelvic ultrasound

genetic testing of the products of conception

genetic testing on parents

Question 35

how is recurrent miscarriage managed?

Answer 35

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

Question 36

what is termination of pregnancy (TOP) or abortion?

Answer 36

elective procedure to end a pregnancy

Question 37

legal requirements for abortion ref zero to finals

Answer 37

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

Question 38

how is a medical abortion carried out?

Answer 38

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

Question 39

how is a surgical abortion carried out

Answer 39

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

Question 40

what must rhesus negative women be given having a medical abortion, and those having a surgical abortion?

Answer 40

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.

Question 41

what post abortion care should women be advised about and what are some complications?

Answer 41

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