Foetal Death (Recurrent Miscarriage, Stillbirth) Flashcards
What is abortion?
Expulsion of the foetus prior to 20 weeks gestation
What is the incidence of spontaneous abortion?
15-25% (>80% in the first 12 weeks)
What causes many early spontaneous abortions?
50% due to chromosomal abnormalities, most of which are trisomy
What are the causes of second trimester abortions?
Not usually chromosomal:
- maternal systemic disease
- abnormal placentation or other anatomic considerations
Why is the distinction between early and second trimester abortions clinically significant?
Second trimester conditions can often be treated and therefore recurrent abortion can be prevented
What are the infectious aetiologies of spontaneous abortion?
Uncommon cause of early spontaneous abortion.
- Chlamydia trachomatis
- Listeria monocytogenes
- Mycoplasma hominis
- Ureaplasma urealyticum
- Syphilis
- HIV(1)
- GBS vaginal colonisation
What are the endocrine aetiologies of spontaneous abortion?
- Thyroid autoantibodies (even in absence of clinical hypothyroidism)
- TIDM (degree of metabolic control important)
What are the environmental aetiologies of spontaneous abortion?
- Smoking (linear with #/day)
- Alcohol (abortion + foetal abnormalities)
- Radiation (such as RT therapeutic dose)
What are the immunologic aetiologies of spontaneous abortion?
Genetic disorders of blood coagulation (increase risk of arterial and venous thrombosis); a/w recurrent miscarriage
- Factor V Leiden mutations
- Prothrombin G20210A
- Antithrombin 3
- Proteins C and S
- Hyperhomocysteinemia
What are the uterine factor aetiologies of spontaneous abortion?
- Large and multiple uterine leiomyomas (location usually more important than size)
- Intrauterine synechiae (Asherman syndrome)
What is the type of uterine leiomyoma more frequently implicated in miscarriage?
Submucous leiomyomata (?due to role on implantation)
What is Asherman syndrome?
Intrauterine synechiae - condition caused after curettage has denuded endometrium past layer of baseless so webs of scar tissue develop across the uterine cavity (the synechiae)
What is a threatened abortion?
Pregnancy complicated by vaginal bleeding prior to 20th week (incidence 25%)
How many women with threatened abortion progress to spontaneous abortion?
~50%
What are the risks when a threatened abortion is carried to viability?
-Low birth weight
-Preterm birth
No higher incidence of congenital malformations in these newborns
What is inevitable miscarriage?
Gross rupture of membranes in presence of cervical dilation (open os).
-uterine contractions usually commence promptly –> expulsion of products of conception
What is the risk of conservatively managing patients with inevitable abortion?
Significantly increases risk of maternal infection
What is an incomplete miscarriage?
- Pain and bleeding
- Internal cervical os opens and allows passage of blood. -Products of conception may extrude through dilated os.
What is a complete abortion?
Documented pregnancy that spontaneously passes all products of conception. Before 10 weeks foetus and placenta are expelled in toto.
-Pain, bleeding and passage of all products of conception; then reduction in bleeding, closure of cervix, empty uterus on scan
What is a missed miscarriage?
Retention of failed intrauterine pregnancy for an extended period (usually defined as more than 2 menstrual cycles). Usually no pain or bleeding.
What is recurrent pregnancy loss
More than three consecutive pregnancy losses
What is recommended when recurrent early abortion occurs?
karyotyping for both parents (early pregnancy loss usually genetic; 3% chance once parent is a symptomless carrier of a genetically balanced chromosomal translocation)
What is Asherman syndrome associated with clinically?
- amenorrhoea or irregular periods
- infertility
- recurrent pregnancy loss
Diagnosis of Asherman syndrome?
Hysterogram showing webbed pattern; or hysteroscopy
How is Asherman syndrome treated?
- Lysis of synechiae
- Post op oestrogen to encourage endometrial proliferation to re establish normal endometrial layer
What are anti phospholipid antibodies?
Family of autoantibodies that bind negatively charged phospholipids (e.g. Lupus anticoagulant, anti cardiolipin)
Treatment anti phospholipid antibodies in recurrent preganancy wastage?
- Low dose aspirin
- Unfractionated heparin
Treatment threatened abortion?
No intervention (even if bleeding + cramps) -if no evidence of abnormality of US -Pregnancy intact on US then reassure and allowed to continue normal activities
Treatment incomplete abortion?
Expectant, medical and surgical options.
- surgical invasive but decisive
- Expectant and medical a/w unpredictable bleeding, may progress to surgery
What are the immediate considerations in management of abortion?
- Control of bleeding
- Prevention of infection
- Pain relief (panadeine forte, NSAIDs)
- Rh imune globulin if Rh -ve
- Emotional support
- commence Ix
What are the signs of complete abortion?
- Uterus small and firm
- Cervix closed
- US shows empty uterus
What measures decrease risk of infection?
- Removal of products of conception
- Vaginal rest (no tampons, douches or intercourse)
what should be discussed at follow up appointment following abortion?
- Evaluate uterine involution
- Assess return of menses
- Discuss rep`roductive plans
- Causes (or lack of) discussed (one loss does not increase risk of future losses, multiple carries increased risk of future losses).
What are anatomical aetiologies of abortion?
- Mullerian abnormalities
- Fibroids
- Asherman’s syndrome
- Cervical incompetence
What are the Hx features to elicit in abortion evaluation?
- Bleeding (volume, colour, Sx of hypovolemia)
- Pain (site, severity)
- Passage POC
- Dating pregnancy
PEx features of abortion evaluation?
- General exam, vitals
- Features relevant to miscarriage: uterus size, open or closed cervix, adnexal tenderness or mass.
Ix miscarriage evaluation?
- Blood group and Abs (Rhesus)
- bHCG (doubling every 48h, more than 3000 seen on TVUS)
- US
- FBE (Hb)
- Histopath of PoC
HOW are recurrent miscarriages investigated?
- Chromosomal:
- Submit POC for chromosomal analysis if possible
- Parental karyotyping
- Anatomical: saline hysterosonography, MRI
- Maternal disease:
- Endocrine (DM, thyroid)
- Autoimmunity
what are the investigation for maternal autoimmune disease causing recurrent abortion?
- SLE: FBE, ANA, anti dsDNA
- Antiphospholipid syndrome: anti phospholipid antibodies (lupus anticoagulant), anticardiolipin antibody
How are chromosomal anomalies managed?
- Refer medical geneticist for individual prognosis on subsequent miscarriage and risk of foetal anomaly
- May consider donor egg / sperm
What is the most common chromosomal cause of abortion?
Random non dysjunction resulting in lethal aneuploidy
What is foetal death in utero?
Fetal demise after 20 weeks gestation but before onset of labour
What are the maternal aetiologies of foetal death in utero?
- Diabetes
- HTN (inc PIH, PET)
- SLE, CT disorders, anti phospholipid syndrome, thrombophilia
What are the foetal aetiologies of foetal death in utero?
- Malformation (structural, chromosomal)
- Infection
- Immune haemolytic disease
- Non immune foetal hydrops
- Metabolic disease
What are the placental aetiologies of foetal death?
- Abruption
- Placental insufficiency (IUGR, post term pregnancy)
- Twin Twin Tx
- Foeta-maternal transfusion
What are the cord aetiologies of foetal death?
Cord accident
What are the clinical features of foetal death in utero?
- Features of underlying condition
- Reduced or absent FM
- Unable to locate FH
- US confirms no FH movement, PM features e.g. Spalding’s sign
What are the complications of foetal death in utero?
Coagulopathy: 25% with FDIU >20w for over 4 weeks will develop chronic consumptive coagulopathy (decreased fibrinogen, plasminogen, aTIII, platelets)
-Spontaneously resolves within 48/24 of delivery
Maternal investigation of FDIU?
- RBG, HbA1C
- Rh antibodies
- Kleihauer
- ANA
- LAC, ACLA, thrombophilia screen
- TORCH
- fibrinogen, platelet count
Foetal investigation of FDIU?
- US to confirm FDIU (also examine for foetal/placental malformation / IUGR)
- post mortem most valuable (consider limited post mortem, swabs, chromosomal analysis if parents don’t agree)
Placental investigation of FDIU?
Histology, swabs
Mx FDIU wrt telling parents?
- Together, private room
- Be clear baby has died
- Explain cause if apparent
- Explain investigations generally
- Discuss delivery (no rush, methods of delivery, pain relief, post partum care)
- Pastoral care, SW, GP
What are the methods of labour and delivery in FDIU?
- Induction with PGs
- Induction with ARM and oxytocin
- Quiet, secluded room in labour ward
- Analgesia (epidural if no coagulopathy)
Post delivery management of FDIU?
- Pastoral care support (burial, funeral etc)
- Suppression of lactation
- Early discharge if well but good post natal support
- Review frequently post partum (2, 4, 6w)
- Discussion of next pregnancy
What is a septic miscarriage?
Serious uterine infection during or shortly after a miscarriage
What are the methods of dating a pregnancy?
- Gestation wheel / apps
- LNMP (1st day LN period; regular? cycle length?)
- Date of conception in known
- Date of embryo transfer for IVF
- USS CRL in T1, biometry if >T1 (use USS dates if
How may miscarriage present?
- Routine US
- Pain / bleeding
- Haemodynamic shock
- Cervical shock
- genital tract sepsis
What is cervical shock?
Bradycardia + hypotension
What are the Ddx of miscarriage presentations?
-Ectopic pregnancy until proven otherwise
When is miscarriage diagnosed on TV US scan?
- Gestational sac >25mm with no foetal pole
- Foetal pole >7mm with no FH
- Absence of embryo >2w after scan showed empty gestational sac (i.e. no yolk sac or embryo)
- Adnexae: corpus luteum, ectopic pregnancy, free fluid)
What are the principles of miscarriage management?
BIO: -stabilise pt -Evacuation of uterus: expectant, medical, surgical -Anti D if Rh- PSYCHOSOCIAL: -counselling: cause, guilt / grief, future risk, reversible RFx -partner -supports -LMO -What to expect, signs to return
When is Anti D given in T1? Dose?
T1 = 250IU:
- CVS
- miscarriage
- termination
- ectopic
When is Anti D given in T2? Dose?
T2 = 625IU
- APH
- Amniocentesis
- ECV
- Abdo trauma
- Prophylactically at 28 and 34 weeks
What are the management options for miscarriage?
- Conservative/ expectant
- Medical
- Surgical
What is conservative / expectant management of miscarriage?
- Wait for spontaneous expulsion of PoC
- Can take weeks - months (esp missed miscarriage)
- Follow up to check complete
What is medical management of miscarriage?
- 600 - 800mcg misoprostol STAT and 24h later
- Case selection
- 80% success, 20% further intervention
- Follow up to check complete
what is surgical management of miscarriage?
- Dilation and curettage +/-PV misoprostol to aid cervical dilation
- Risks: incomplete, perforation, bleeding, cervical trauma, adhesions, infection
- Benefit of being controlled and timed with predictable recovery
Aetiology recurrent pregnancy loss?
- Unexplained 40%
- Immunological (SLE, APLS, thyroid antibodies) 25%
- Endocrine 20% (PCOS, DM, thyroid)
- Uterine anomalies 20% (septate or bicornuate uterus, submucous fibroids, adhesions, cervical insufficiency)
- Genetic 3%
- Infection 6% (syphilis, malaria
Hx recurrent miscarriage?
- Timing
- Medical disorders
- Hx of uterine instrumentation
- FHx
What is the aetiology of mid trimester pregnancy loss?
- Cervical incompetence
- Genetic (aneuploidy etc)
- Other: IUGR, immunological, infection, placental
CFx cervical insufficiency?
-Relatively fast, painless premature labour (esp T2)
May be preceded by prolapsed or ruptured membranes
How is cervical insufficiency investigated?
TVUS. Empty bladder, fundal pressure.
Cervix
Mx cervical insufficiency?
- Conservative with serial measurements 16-28w
- Progesterone
- Cerclage: consider if previous PTB and short Cx (inserted T1 screening, clear swabs, GA, McDonalds versus Shirodkar, removal approx 36 weeks or at time of CS)
