Miscarriage Flashcards
Define Miscarriage.
Pregnancy loss <24 weeks of gestation.
What are the types of miscarriage?
- Threatened - PV bleed with FH present → os must be closed
- Inevitable - PV bleed with open cervical os
- Incomplete - passage of products of conception but uterus isn’t empty on USS
- Complete - passage of products of conception and uterus is empty on USS
- Missed - USS diagnosis of miscarriage in absence of symptoms
What are the risk factors for miscarriage?
- Increasing maternal age
- Previous miscarriage
- Chronic conditions
- Uterine/cervix abnormalities
- Smoking
- Alcohol
- Illicit drugs
- Underweight or Obese
What should be thought of in patients with recurrent miscarriages?
- Structural abnormalities - fibroids, bicornuate or septate uteri
- Cervical incompetence - if later miscarriages (>13w)
- Medical conditions - renal, diabetes, SLE
- Clotting abnormalities - FV-L, AT-III deficiency, antiphospholipid syndrome
What are the signs and symptoms of miscarriage?
- PV bleeding (scanty, brownish/red)
- Cramping abdominal pain
- Fever
- O/E
- Speculum → quantity and location of bleeding, os open/closed
- PV exam → exclude ectopic - unilateral tenderness, cervical excitation, adnexal mass
- General → assess for signs of shock, pyrexia
What are the appropriate investigations for a suspected miscarriage?
- Pregnancy test → Speculum → TVUSS
- TVUSS:
- 1st = Look for FH
- 2nd = Foetal poles for CRL → if not foetal pole, look for GS:
- If no FH and CRL >7mm = Miscarriage
- If no FH and CRL <7mm = PUV → TVUSS in 7 days
- If GS >25mm + no foetus = Miscarriage
- If GS <25mm + no foetus = PUV → TVUSS in 7 days
What investigations should be done for women with recurrent miscarriages?
- Cytogenic analysis of products of conception
- Pelvic USS (structural abnormalities)
- Anti-phospholipid antibodies
- Anticardiolipin antibodies
- Screen for BV → explain that the cause is often never found
What is the management of a miscarriage <6 weeks?
- Expectant management → no USS, just send them on their way
- Do a pregnancy test in 1 week
- If positive result or symptoms persist follow-up in clinic in 2 weeks
- If RPC, proceed as per medical/surgical management
- If positive result or symptoms persist follow-up in clinic in 2 weeks
What is the management of a miscarriage >6 weeks?
- EPAU referral → USS and tests
- Viable pregnancy → expectant management
-
Complete missed miscarriage → council and go home
- Psychological awareness of patient’s state of mind
- Advice - Menstruation will begin in 4-8 weeks, try for another when mentally ready
- Miscarriage with retained products:
-
1st line = Expectant management for 7-14 days
- If bleeding/pain settle → pregnancy test after 3 weeks → return if +ve
- If bleeding/pain persist → follow-up clinic in 4 weeks
- Patient declines/Not appropriate if:
- Infection
- Coagulopathy
- Late 1st trimester
- Previous traumatic experience
-
2nd line - Medical = Misoprostol
- Indications = expectant failed, patients choice
- Advise - bleeding, pain, nausea
- Indications = expectant failed, patients choice
-
2nd line - Surgical
-
Manual vacuum aspiration (LA)
- Indicated: medical failed, pt. choice
- Surgical ERPC (GA)
-
Manual vacuum aspiration (LA)
-
1st line = Expectant management for 7-14 days
- If signs of ectopic or severe bleeding symptoms = admission → surgical management
When should anti-RhD be administered in the context of a miscarriage?
- BCSH guidelines
- Administer if mother rhesus -ve and >12w GA (any method of management)
- NICE guidelines
- Administer if mother rhesus -ve and not solely managed medically
What are the signs and symptoms of anti-phospholipid syndrome?
- VTE
- Arterial thrombosis
- Thrombocytopenia
- RMC
- Pre-eclampsia
- Assess for features of SLE
What are the appropriate investigations for suspected anti-phospholipid syndrome?
Lupus anticoagulant AB ± Anti-cardioliptin AB
What is the management of anti-phospholipid syndrome?
- Acute → warfarin + LMWH
- Chronic → DOAC
- Pregnancy → low-dose aspirin + LMWH
What is the prognosis of miscarriages?
- Most patients go on to have successful pregnancies
- 1 miscarriage → 85% chance next will be successful
- 2 miscarriages → 75% chance next will be successful
- 3 miscarriages → 60% chance next will be successful