Miscarriage Flashcards
What is a miscarriage?
The loss of a pregnancy <24weeks gestation
What is an early miscarriage?
1st trimester (<12 weeks)
What is a late miscarriage?
2nd trimester (13-24 weeks)
What percentage of pregnancies result in miscarriage?
20-25%
List the risk factors for miscarriage
Maternal age >30-35 (increase in chromosomal abnormalities) Previous miscarriage Obesity Chromosomal abnormalities Smoking Uterine anomalies (fibroids and adhesions) Previous uterine surgery Anti-phospholipid syndrome Coagulopathies
List the clinical features of misccariage
Vaginal bleeding - clots/products of conception
If heavy bleeding then haemodynamic instability - pallor, SOB, dizziness
Suprapubic cramping pain
List the signs of miscarriage on examination
Haemodynamic instability - pallor, tachycardia, tachypnoea, hypotension
Abdominal examination - Abdomen may be distended with localised areas of tenderness
Speculum examination - assess the diameter of the cervical os and observe for any products of conception in cervical canal or local areas of bleeding
Bimanual examination - assess any uterine tenderness and any adnexal masses or collections
List the differentials for miscarriage
Ectopic pregnancy
Hydatiform mole
Cervical/uterine malignancy
What is the main diagnostic investigation of miscarriage?
Transvaginal ultrasound
What can gestation be estimated by?
Foetal crown rump length
What is required if foetal crown rump length is <7mm and no foetal heart can be identified?
Repeat scan in 7 days
If a foetal pole is not visible but intrauterine pregnancy is confirmed with gestational sac and yolk sac, what does management depend on?
The mean sac diameter
>25mm - failed pregnancy
<25mm - repeat scan 1-14days later
What other investigations can be done for someone with suspected miscarriage?
Serum b-HCG - rule out ectopic
FBC
Blood group and rhesus status
Triple swabs and CRP if pyrexial
What is given regardless of treatment type to a woman experiencing a miscarriage?
Anti-D immunoglobulin if Rh-ve mother and >12weeks gestation or managed surgically regardless of gestation
What are the 3 definitive management options for miscarriage?
Conservative (expectant)
Medical
Surgical
Describe conservative (expectant) management
Allows the products of conception to pass naturally
What are the advantages of conservative management?
Can remain at home
No medication SE
No anaesthetic risk
No surgical risk
What are the disadvantages of conservative management?
Unpredictable timing
Heavy bleeding
Pain
Chance of being unsuccessful requiring further investigation and need for transfusion
What follow up is required for conservative management of miscarriage?
Depends on the unit
Some offer US in two weeks and others do a pregnancy test in 3 weeks
List the contraindications to conservative management of miscarriage
Infection
High risk of haemorrhage
Describe medical management of miscarriage
Mifepristone 24-48hours prior to administration of vaginal misoprostol
What class of drugs is misoprostol
Prostaglandin analogue
Describe what happens after vaginal misoprostol is given
Cervical ripening and myometrial contractions
What are the advantages of medical management of miscarriage?
Can be at home if patient desires with 24/7 access to gynae services, avoid anaesthetic and surgical risk
What are the disadvantages of medical management of miscarriage?
Vomiting Diarrhoea Heavy bledding Pain during passage or POC Chance of requiring emergency surgical intervention
What follow up is required in the medical management of miscarriage?
Pregnancy test 3 weeks after
Describe the surgical management of miscarriage
Manual vacuum aspiration with local anaesthetic if <12 weeks or evacuation of retained products of conception (ERPC)
Describe evacuation of retained products of conception
Patient under general anaesthetic
Speculum passed to visualise the cervix
Dilated allowing suction tube to be passed and remove the products of conception
Patients attend hospital as a day case
What are the definite indications for evacuation of retained products of conception?
Haemodynamically unstable
Infected tissue
Gestational trophoblastic disease
What are the advantages of evacuation of retained products of conception
Planned procedure
Unaware during process
What are the disadvantages of evacuation of retained products of conception
Anaesthetic risk Infection (endometritis) Uterine perforation Haemorrhage Ashermans syndrome Bladder/bowel damage Retained products of conception
Name the types of miscarriage
Threatened
Missed
Complete
Incomplete
Describe threatened miscarriage
Mild bleeding, pain, cervix closed
Viable pregnancy seen on TV USS
What is the management for threatened miscarriage?
If heavy bleeding - admit/observe, if not reassure and back to midwife
If >12 weeks and Rh-ve then AntiD
Describe missed miscarriage
Asymptomatic or Hx threatened miscarriage, ongoing discharge, small for dates uterus
No foetal heart pulsation in a foetus where crown rump length >7mm
How is missed miscarriage managed?
Rescan and second person to confirm
Manage conservatively, medially or surgically
If Rh-ve and >12 weeks then anti-D
Describe incomplete miscarriage
POC partially expelled
Symptoms of missed miscarriage or bleeding/clots
Retained POC with A/P endometrial diameter >15mm and prrof there was an intrauterine pregnancy previously present
Describe complete miscarriage
Hx of bleeding, passing clots and POC, pain, symptoms now settling
No POC seen in uterus with endometrium that is <15mm diameter and previous proof of intrauterine pregnancy
