MISCARRIAGE

Question 1

What weeks of gestation make up the first trimester?

Answer 1

0-12 weeks

Question 2

What weeks of gestation make up the second trimester?

Answer 2

13-27 weeks

Question 3

What weeks of gestation make up the third trimester?

Answer 3

28-40 weeks

Question 4

What are the different types of miscarriage?

Answer 4

Threatened

Inevitable

Missed/delayed/silent

Complete

Incomplete

Question 5

What is a threatened miscarriage?

Answer 5

Any bleeding that happens during the first 24 weeks of pregnancy, but where the pregnancy continues.

Question 6

On examination of a woman suffering a threatened miscarriage will the cervix be open or closed?

Answer 6

Closed

Question 7

What is an inevitable miscarriage?

Answer 7

This is bleeding during the first 24 weeks of pregnancy where the internal os of the cervix is found to be open. An inevitable miscarriage is what a threatened miscarriage has progressed to if cervical dilatation occurs.

Question 8

On examination of a woman suffering an inevitable miscarriage will the cervix be open or closed?

Answer 8

Open

Question 9

What is a missed/delayed/silent miscarriage?

Answer 9

A miscarriage where a scan reveals a non-viable fetus or an empty intrauterine gestation sac without the patient having or noticing the bleeding.

Question 10

On examination of a woman suffering missed/delayed/silent miscarriage will the cervix be open or closed? a ?

Answer 10

Closed

Question 11

What is a complete miscarriage?

Answer 11

A miscarriage where the scan reveals that there are no more products of conception left in the uterus where the patient has had bleeding.

Question 12

On examination of a woman suffering a complete miscarriage will the cervix be open or closed?

Answer 12

Closed

Question 13

What is an incomplete miscarriage?

Answer 13

A miscarriage where the scan reveals that there are still products of conception left in the uterus where the patient has had bleeding.

Question 14

On examination of a woman suffering an incomplete miscarriage will the cervix be open or closed?

Answer 14

Open

Question 15

What are the symptoms of a miscarriage rather than a rupture of an ectopic pregnancy?

Answer 15

Pain - like period pains or contractions

Bleeding - clots or passing of tissue

Nausea

Question 16

What are the risk factors that pre-dispose women to miscarriage? (Name at least 7)

Answer 16

Past history of miscarriage

Maternal age 23% of pregnancies in over 40 year olds

PID and bacterial vaginosis

Tubal surgery eg previous for ectopic pregnancy

Peritonitis or pelvic surgery

Endometriosis

Intrauterine contraceptive device

Fibroids

IVF pregnancy

Maternal illness: Antiphospholipid syndrome, Wilson’s disease, diabetes, thyroid disease (both hypo and hyper), renal disease

Fetal abnormality - eg trisomy

Question 17

After how many miscarriages would you start to investigate the cause of miscarriage?

Answer 17

3

Question 18

What blood tests would you do in a women who presented with bleeding during first trimester of pregnancy?

Answer 18

FBC - anaemia is more likely to be the result of rupture ectopic pregnancy than miscarriage

Serum hCG - reducing levels of hCG over hours/days will confirm that the pregnancy has terminated

Question 19

As well as blood tests, what other investigations would you perform in a women with bleeding during first trimester of pregnancy?

Answer 19

High vaginal swab - to check for infection

Ultrasound - to look for any products of conception in the uterus

Question 20

What should you tell a woman who has recently suffered a miscarriage when she asks you when she can start trying to get pregnant again?

Answer 20

Physically there is no reason why she cannot conceive with her next cycle. Mentally it may be better to have a few months to recover from the miscarriage.

Question 21

How do we manage patients who have suffered a miscarriage?

Answer 21

Pain relief

Warn patients of possibility of endometritis and safety net with symptoms to look for

The uterus can take some weeks to expel the products of conception. Women are therefore offered ERPC (evacuation of retained products of conception).

Discuss contraceptive options.

They should have a pregnancy test a week after experiencing bleeding to confirm that they are no longer pregnant and hence the differential of ectopic pregnancy can be ruled out.

Question 22

What is ERPC?

Answer 22

Evacuation of retained products of conception. This is a procedure that involves dilating the cervix and then passing a curettage device into the woman’s uterus to remove any products of conception.

Question 23

What are the complications of ERPC?

Answer 23

Perforated uterus - the pregnant uterus wall is much softer than the non-pregnant womb and hence it is easily perforated. Curettage must therefore be gentle.

Endometritis

Question 24

How can we minimise blood loss during ERPC procedure?

Answer 24

Syntocinon - synthetic oxytocin - given IV will encourage contraction and therefore minimise blood loss.

Question 25

What are the symptoms of endometritis?

Answer 25

Fever

Feeling unwell

Lower abdominal pain

Change in vaginal bleeding, which can become foul smelling and heavy

Question 26

After how many weeks of gestation would you start worrying about blood types and whether the mother was Rhesus negative, in a woman who suffers a miscarriage?

Answer 26

12 weeks (second trimester)

Question 27

What further tests can be performed for a couple who have had recurrent (more than 3 consecutive) miscarriages?

Answer 27

Karyotyping of both partners and products of conception where appropriate

High vaginal swab to screen for bacterial vaginosis

Antiphospholipid antibody assays on 2 occasions 6 weeks apart

Investigation for cervical weakness.