Loss of a baby

Question 1

Threatened miscarriage

Answer 1

Symptoms of bleeding/ pain, intrauterine pregnancy present

Question 2

Inevitable miscarriage

Answer 2

Bleeding/ pain, cervical os is open

Question 3

Incomplete miscarriage

Answer 3

Bleeding, open os with some tissue remaining

Question 4

Complete miscarriage

Answer 4

No tissue remaining

Question 5

Missed miscarriage

Answer 5

No symptoms present, diagnosed at scan

Question 6

Molar pregnancy

Answer 6

Fetus does not form in womb, development of abnormal size.
- Hydatidform mole

Can be potentially

Question 7

Factors affecting miscarriage (risk) [9]

Answer 7

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

Question 8

Presentation

Answer 8

Bleeding and pain

Found in routine scan

Loss of pregnancy symptoms

Collapse

• Cervical shock
• Hypotension
• Too much blood loss= tachycardia

Sepsis

• Pyrexia
• Tachypnoea
• Hypotension

Question 9

Management

Answer 9

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

Question 10

Recurrent miscarriage

Answer 10

3 or more miscarriage, <24 weeks,

1% of couple

Management

• Offer karyotyping
• Recurrent miscarriage clinic
• Blood tests
• Investigate uterine abnormalities

Question 11

Blood tests in recurrent miscarriage

Answer 11

Thrombophilia screen

Anti-cadiolipin + Lupus anticoagulant (antiphospholipid syndrome, 15%)

Question 12

Ectopic pregnancy

• Description
• Prevalence

Answer 12

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

Question 13

Ectopic pregnancy mortality

Answer 13

0.2 per 1000

Question 14

Risk factors for ectopic pregnancy

Answer 14

Previous ectopic pregnancy

Previous tubal damage

• Surgery
• PID
• Endometriosis

Cystic fibrosis

Subfertility/ IVF

Question 15

Classical ectopic pregnancy presentation

Answer 15

Pain/ bleeding
- 6-8 weeks

Positive pregnancy test

Empty uterus in US

Question 16

Emergency ectopic pregnancy presentation

Answer 16

Collapsed

Hypotensive, tachycardia, acute peritonism

Managed with emergency surgery

Question 17

Methotrexate

Answer 17

Medical treatment for small ectopic pregnancy

Question 18

hCG monitoring in ectopic pregnancy

Answer 18

Serum hCG

• Doubles in normal intrauterine pregnancy, in 48 hours
• Less than 60% rise is suspicion ectopic pregnancy

Question 19

Second trimester miscarriage

Answer 19

Loss of baby 12-24 weeks

- Death in utero or premature labour

Question 20

Causes of in-utero death

Answer 20

Fetal abnormality
- Structural/ chromosomal

Infection
- Toxoplasmosis

Placental dysfunction/ growth/ dysfunction

• Autoimmune
• Thrombophilia
• Pre-eclampsia

SLE/ Antiphospholipid syndrome

Question 21

Causes of pre-term labour

Answer 21

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

Question 22

Presentation of second trimester miscarriage

Answer 22

Bleeding and contractions

Ruptured membranes

Question 23

Examination and investigation second trimester miscarriage

Answer 23

Speculum

Scan for viability

Investigation:

Karyotyping
Postmortem
Infection, APS

Question 24

Cervical sutures

- Indications

Answer 24

Past history of miscarriage

Cervical surgery history

Uterine anomaly

Cervical dilatation

Question 25

Cervical sutures

Answer 25

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

Question 26

Stillbirth

Answer 26

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

Question 27

Causes of stillbirth

Answer 27

Growth restriction

• Placental factors
• Maternal medical problems

Bleeding

Fetal abnormality

Infection

Poorly controlled diabetes

Question 28

Causes of neonatal death

Answer 28

Prematurity

Congenital abnormalities

Infection

Intrapartum asphyxia

Question 29

Management of stillbirth

Answer 29

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

Question 30

Investigations after stillbirth

Answer 30

Bloods
- Rule out possible causes

Post-mortem/ genetics from placenta

Infection screen

Memories/ funeral?

Question 31

Reducing stillbirth rates

Answer 31

Reducing smoking in pregnancy

Improving risk assessment and fetal growth restriction

Raising awareness of reduced fetal movement

Effective fetal monitoring

Perinatal mortality review tool.