Loss of a baby Flashcards
Threatened miscarriage
Symptoms of bleeding/ pain, intrauterine pregnancy present
Inevitable miscarriage
Bleeding/ pain, cervical os is open
Incomplete miscarriage
Bleeding, open os with some tissue remaining
Complete miscarriage
No tissue remaining
Missed miscarriage
No symptoms present, diagnosed at scan
Molar pregnancy
Fetus does not form in womb, development of abnormal size.
- Hydatidform mole
Can be potentially
Factors affecting miscarriage (risk) [9]
Age
Obesity, especially >30
Antiphospholipid syndrome
Systemic lupus erythematosus
- Affects placentation
Parental chromosomal translocation
Poorly controlled diabetes
Alcohol, smoking, recreational drug
Uterine anomaly
High levels of natural killer cells
Presentation
Bleeding and pain
Found in routine scan
Loss of pregnancy symptoms
Collapse
- Cervical shock
- Hypotension
- Too much blood loss= tachycardia
Sepsis
- Pyrexia
- Tachypnoea
- Hypotension
Management
Expectant management:
- Counselling
Medical
- Misoprostol to induce miscarriage
- Counselled on expectant symptoms
Surgical
- Suction curette to remove tissue from uterus
- Manual vacuum aspiration
- Risk of uterine perforation, infection, bleeding, cervical damage
Follow support
Recurrent miscarriage
3 or more miscarriage, <24 weeks,
1% of couple
Management
- Offer karyotyping
- Recurrent miscarriage clinic
- Blood tests
- Investigate uterine abnormalities
Blood tests in recurrent miscarriage
Thrombophilia screen
Anti-cadiolipin + Lupus anticoagulant (antiphospholipid syndrome, 15%)
Ectopic pregnancy
- Description
- Prevalence
Implanted embryo outside uterine cavity
- Mainly fallopian- 97%
- 2% Interstitial–> Inside myocardium
12000/ year
- Heterotopic pregnancy 1 in 30000 (higher in IVF), when there is intrauterine and
Ectopic pregnancy mortality
0.2 per 1000
Risk factors for ectopic pregnancy
Previous ectopic pregnancy
Previous tubal damage
- Surgery
- PID
- Endometriosis
Cystic fibrosis
Subfertility/ IVF
Classical ectopic pregnancy presentation
Pain/ bleeding
- 6-8 weeks
Positive pregnancy test
Empty uterus in US
Emergency ectopic pregnancy presentation
Collapsed
Hypotensive, tachycardia, acute peritonism
Managed with emergency surgery
Methotrexate
Medical treatment for small ectopic pregnancy
hCG monitoring in ectopic pregnancy
Serum hCG
- Doubles in normal intrauterine pregnancy, in 48 hours
- Less than 60% rise is suspicion ectopic pregnancy
Second trimester miscarriage
Loss of baby 12-24 weeks
- Death in utero or premature labour
Causes of in-utero death
Fetal abnormality
- Structural/ chromosomal
Infection
- Toxoplasmosis
Placental dysfunction/ growth/ dysfunction
- Autoimmune
- Thrombophilia
- Pre-eclampsia
SLE/ Antiphospholipid syndrome
Causes of pre-term labour
Cervical weakness/ incompetence
- Could be surgery, radiotherapy, after multiple miscarriage treatment
Infection (chorioamnionitis)
- Common cause
Uterine abnormality
Rupture of membranes
- Mainly due to infection
Bleeding
- From placenta–> uterine irritability
- Placenta tearing–> abruption
Screening/ invasive procedures
Presentation of second trimester miscarriage
Bleeding and contractions
Ruptured membranes
Examination and investigation second trimester miscarriage
Speculum
Scan for viability
Investigation:
Karyotyping
Postmortem
Infection, APS
Cervical sutures
- Indications
Past history of miscarriage
Cervical surgery history
Uterine anomaly
Cervical dilatation
Cervical sutures
Treatment for cervical incompetence
- Shortening of cervix
- Premature opening
Usually inserted after 12 weeks
- Tranvaginal/ transabdominal (laparoscopic)
Emergency
- 12-24 weeks
- Not put in with contractions or infection
- Still increases infection risk
- Can prolong pregnancy
Stillbirth
Baby delivery with no signs of life after 24 completed weeks
Early neonatal death
- Death within 7 days of delivery
Late neonatal death
- Death within 7-28 days
Causes of stillbirth
Growth restriction
- Placental factors
- Maternal medical problems
Bleeding
Fetal abnormality
Infection
Poorly controlled diabetes
Causes of neonatal death
Prematurity
Congenital abnormalities
Infection
Intrapartum asphyxia
Management of stillbirth
Patient placed in quiet room, scenario explained with doctor/ bereavement midwife
Advised fro vaginal delivery
Mifepristone–> Stimulates contractions
- First line
- Return 48 hours after administration
Offer bereavement room and analgesia after delivery
Investigations after stillbirth
Bloods
- Rule out possible causes
Post-mortem/ genetics from placenta
Infection screen
Memories/ funeral?
Reducing stillbirth rates
Reducing smoking in pregnancy
Improving risk assessment and fetal growth restriction
Raising awareness of reduced fetal movement
Effective fetal monitoring
Perinatal mortality review tool.
