Early Pregnancy (Miscarriage; Recurrent Miscarriage)

Question 2

What is the difference between early and late miscarriage?

Answer 2

Early miscarriage
- < 12 weeks’ gestation

Late miscarriage
- 12- 24 weeks’ gestation

Question 3

Describe the different types of miscarriage [6]

Answer 3

Missed miscarriage
– the fetus is no longer alive, but no symptoms have occurred

Threatened miscarriage
– vaginal bleeding with a closed cervix and a fetus that is alive

Inevitable miscarriage
– vaginal bleeding with an open cervix

Incomplete miscarriage
– retained products of conception remain in the uterus after the miscarriage

Complete miscarriage
– a full miscarriage has occurred, and there are no products of conception left in the uterus

Anembryonic pregnancy
– a gestational sac is present but contains no embryo

Question 4

Why does vaginal bleeding occur in a miscarraige? [2]

Answer 4

Haemorrhage in the decidua basalis leading to necrosis and inflammation

Ovum is unable to continue to develop in the uterus
* Initiates uterine contractions
* Cervix begins to dilate causing the loss of fetus and pregnancy tissu

Question 5

Why are complete miscarriages more likely before 12 weeks [1] and 12-24 weeks? [1]

Answer 5

prior to 12 weeks
- a complete miscarriage is more likely as the placenta is unlikely to have been independently developed, thus being expelled together with the fetus

12-24 weeks:
- gestation sac is more likely to rupture and the fetus then expelled while parts of the placenta remain in the uterus

Question 6

Describe the presentation of:
* complete miscarriage [1]
* incomplete miscarriage [1]

Answer 6

complete miscarriage:
- Bleeding stops and further treatment is not needed

incomplete miscarriage:
- Placenta is not fully expelled and bleeding persists
- Surgical management needed

Question 7

Describe the presentation of:
* missed miscarriage [2]
* threatened miscarriage [2]

Answer 7

Missed miscarriage:
- no symptoms have occurred
- the cervix is closed

Threatened miscarriage:
- Vaginal bleeding +/- pain
- Closed cervical os
- Viable pregnancy

Question 8

Describe the presentation of:
* inevitable miscarriage [2]

Answer 8

Inevitable miscarriage:
- vaginal bleeding
- open cervical os
- Progresses to an incomplete or complete miscarriage

Question 9

Describe the clinical features of a miscarriage:

Answer 9

• Vaginal bleeding - brownish light spotting to heavy bright-red blood with clots;
• Lower abdominal cramping pain
• Vaginal fluid discharge/tissue discharge
• Loss of pregnancy symptoms (eg. No more nausea/breast tenderness)
• Lower back pain

Should be suspected in all women with bleeding in early pregnancy

Question 10

What investigations should you perform for a suspected miscarriage?

Answer 10

• Transvaginal US (TV-US): to determine the location and viability of the pregnancy.
• Serumb-hCGtitres - bhCG levels will decrease after a miscarriage as it is produced by the placenta.
• Serum progesterone
• Urine pregnancy test
• FBC
• Rhesus status

Question 11

What happens if you suspect a miscarriage, but can’t locate it on a TVUS? [1]

Answer 11

If unable to determine the status of the fetus, a repeat scan will be done after a minimum of 7 days.

Question 12

What are the two key ddx of an ectopic pregnancy? [2]

Answer 12

Ectopic pregnancy
Molar pregnancy
Ruptured ovarian corpus luteum cyst
Ovarian torsion
Fibroid degeneration

Question 13

How do you differentiate an ectopic pregnancy from a miscarriage?
Similarities: [2]
Differences [4]

Answer 13

Ectopic pregnancy:
* Similarities: vaginal bleeding and lower abdominal pain
* Differences: pain is usually unilateral, more severe, and before bleeding presents. The bleeding in an ectopic pregnancy also tends to be darker and less heavy. There is also cervical excitation in ectopic pregnancy.

Question 14

How do you differentiate an molar pregnancy from a miscarriage?
Similarities: [2]
Differences [4]

Answer 14

Similarities:
* vaginal bleeding
* abdominal pain.

Differences:
- heavy and prolonged bleeding with clots
- ± brown watery vaginal discharge.
- The uterus is large for its gestational dates.
- There are exaggerated symptoms of pregnancy such as extreme morning sickness.

Question 15

There are three key features that the sonographer looks for in an early pregnancy. What are they? [3]

Answer 15

There are three key features that the sonographer looks for in an early pregnancy:
* Mean gestational sac diameter
* Fetal pole and crown-rump length
* Fetal heartbeat

Question 16

There are three key features that the sonographer looks for in an early pregnancy. These appear sequentially as the pregnancy develops. As each appears, the previous feature becomes less relevant in assessing the viability of the pregnancy. These features are:

Answer 16

• Mean gestational sac diameter
• Fetal pole and crown-rump length
• Fetal heartbeat

Question 17

Describe the clinical significance of the following with regards to their relationship with each other:
* Mean gestational sac diameter
* Fetal pole and crown-rump length
* Fetal heartbeat

Answer 17

When a fetal heartbeat is visible, the pregnancy is considered viable.

A fetal heartbeat is expected once the crown-rump length is 7mm+

Question 18

When would you repeat a scan with regards to the following on TVUS: [3]
Mean gestational sac diameter
Fetal pole and crown-rump length
Fetal heartbeat

Answer 18

• When the crown-rump length is less than 7mm, without a fetal heartbeat, the scan is repeated after at least one week to ensure a heartbeat develops.
• When there is a crown-rump length of 7mm or more, without a fetal heartbeat, the scan is repeated after one week before confirming a non-viable pregnancy.
• A fetal pole is expected once the mean gestational sac diameter is 25mm or more. When there is a mean gestational sac diameter of 25mm or more, without a fetal pole, the scan is repeated after one week before confirming an anembryonic pregnancy.

Question 19

Describe the managment of a miscarriage if its a < 6 weeks gestation [3]

Answer 19

Less Than 6 Weeks Gestation:
- Women with a pregnancy less than 6 weeks’ gestation presenting with bleeding can be managed expectantly provided they have no pain and no other complications or risk factors (e.g. previous ectopic)
- involves awaiting the miscarriage without investigations or treatment
- A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed

NB: An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen.

Question 20

In which scenerios are miscarriages medically or surgically managed? [3]

Answer 20

increased risk of haemorrhage
* she is in the late first trimester
* if she has coagulopathies or is unable to have a blood transfusion

previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)

evidence of infection

Question 21

Describe the management of a missed miscarriage [2]

Answer 21

1. oral mifepristone
2. 48 hours later: misoprostol (unless the gestational sac has already been passed)
3. if bleeding has not started within 48 hours after misoprostol treatment, they should contact their healthcare professional

Question 22

Describe the medical management of incomplete miscarriage [2]

Answer 22

a single dose of misoprostol (vaginal, oral or sublingual)
women should be offered antiemetics and pain relief

Question 23

Describe the medical management of a threatened miscarriage [4]

Answer 23

• If patient stable: observe symptoms
• In women with a previous miscarriage, use of vaginal
  micronized progesterone (400mg twice daily) NICE
  2021
• Advise to return if symptoms worsen or do not settle after 14 days
• Analgesia, written information, contact details and safety netting advice should be given

Question 24

Describe the surgical managment that can be offered for miscarriages [2]

Answer 24

Manual vacuum aspiration under local anaesthetic as an outpatient:
- A tube attached to a specially designed syringe is inserted through the cervix into the uterus.
- manually uses the syringe to aspirate contents of the uterus

Electric vacuum aspiration under general anaesthetic:
- performed through the vagina and cervix without any incisions
- The cervix is gradually widened using dilators, and the products of conception are removed through the cervix using an electric-powered vacuum.

Question 25

Which drug is given prior to surgical treatment of miscarriage? [1] Why? [1]

Answer 25

Prostaglandins (misoprostol) are given before surgical management to soften the cervix.

Question 26

When is manual vacuum aspiration not indicated? [1]

Answer 26

After 10 weeks gestation

Question 27

When do you / dont you give women anti-D IG for rh-ve women? [2]

Answer 27

Give anti-D immunoglobulin to rhesus-negative women who have had surgical intervention for their miscarriage

Do not give anti-D immunoglobulin to women who have only had medical management, a threatened, or complete miscarriage

Question 28

What is the definition of recurrent miscarriage? [1]

Answer 28

Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions. It occurs in around 1% of women

Question 29

Name 5 causes of recurrent miscarriages [5]

Answer 29

• antiphospholipid syndrome
• endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
• uterine abnormality: e.g. uterine septum
• parental chromosomal abnormalities
• smoking

Question 30

TOM TIP: If you remember one cause of recurrent miscarriages, remember []

Consider this in patients presenting in exams with recurrent miscarriages. There may be a past history of [1] deep vein thrombosis.

Test for []
Treatment is with [2]

Answer 30

TOM TIP: If you remember one cause of recurrent miscarriages, remember antiphospholipid syndrome

Consider this in patients presenting in exams with recurrent miscarriages.

There may be a past history of deep vein thrombosis.

Test for antiphospholipid antibodies, and treatment is with aspirin and LMWH.

Question 31

Which inheritied thrombophilias should you remember that could cause recurrent miscarriages? [3]

Answer 31

Factor V Leiden (most common)
Factor II (prothrombin) gene mutation
Protein S deficiency

Question 32

Describe the different uterine miscarriages that could cause recurrent miscarriages [6]

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

Describe what is meant by Chronic Histiocytic Intervillositis [1]

Answer 33

Chronic histiocytic intervillositis is a rare cause of recurrent miscarriage, particularly in the second trimester. It can also lead to intrauterine growth restriction (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.