Miscarriage Flashcards
What are the 5 types of miscarriage? Is the cervical os open in each case?
- Threatened miscarriage - closed, FHR present
- Missed miscarriage - closed
- Inevitable miscarriage - open
- Incomplete miscarriage - open
- Complete miscarriage - closed
Tip:“Open your I’s” = cervix open in inevitable and incomplete miscarriage
How does threatened miscarriage present? How common is it?
- painless vaginal bleeding occurring at <24 weeks, but typically ~6 - 9 weeks
- the bleeding is
- cervical os is closed
complicates up to 25% of all pregnancies
What is a missed miscarriage?
A gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
When is a missed miscarriage called a ‘blighted ovum’/’anembryonic pregnancy’?
When the gestational sac is > 25 mm and no embryonic/fetal part can be seen
How does missed miscarriage present?
- dead fetus before 20 weeks without the symptoms of expulsion
- mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
- cervical os is closed
How does inevitable miscarriage present?
- heavy bleeding with clots and pain
- cervical os is open
How does incomplete miscarriage present?
- not all products of conception have been expelled
- pain and vaginal bleeding
How do you manage vaginal bleeding in the first trimester (<6 weeks and _>_6 weeks)?
>= 6 weeks gestation
If the pregnancy is > 6 weeks gestation (or of uncertain gestation) and the woman has bleeding she should be referred to an early pregnancy assessment service
< 6 weeks gestation
If the pregnancy is < 6 weeks gestation and women have bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly. These women should be advised:
- to return if bleeding continues or pain develops
- to repeat a urine pregnancy test after 7–10 days and to return if it is positive
- a negative pregnancy test means that the pregnancy has miscarried
Define miscarriage.
Miscarriage is a pregnancy that ends spontaneously before 24 weeks’ gestation.
What is the most common sign of miscarriage?
Vaginal bleeding
How common is miscarriage?
10-20% pregnancies affected
Risk increases with maternal age
List 4 causes of miscarriage.
- Chromosomal abnormalities
- Medical/endocrine disorders
- Uterine abnormalities
- Infections
- Drugs/cheimicals
What are the USS findings in the different types of miscarriage?
- Threatened - IU pregnancy + FH
- Incomplete - retained products of conception
- Inevitable - IU pregnancy + no FH
- Missed - IU pregnancy + no FH
- Complete - empty uterus (check serum hCG to exclude ectopic)
What investigations should be done in miscarriage?
TVUSS/transabdominal - diagnostic if pregnancy is within the uterine cavity
Hb and ‘Group and Save’ - cross-match if the patient is severely compromised; measure to assess the degree of vaginal loss and rhesus status
What is expectant management? When is expectant management used in miscarriage?
= Waiting for a spontaneous miscarriage; involves waiting for 7-14 days for the miscarriage to complete spontaneously
First-line -
- Bleeding and pain should resolve within 7-14 days + most will require no further treatment
- If not resolved or bleeding is persisting/increasing then return for scan
- Advise to take pregnancy at 3 weeks
- Return if it is still positive
- Review patient 2 weeks after initial appointment
If expectant management is unsuccessful then medical or surgical management may be offered
When should you not consider expectant management as first line?
-
increased risk of haemorrhage
- she is in the late first trimester
- if she has coagulopathies or is unable to have a blood transfusion
- previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
- evidence of infection
OR if it is not acceptable to the patient.
What are 2 causes of increased risk of haemorrhage in expectant management of miscarriage?
- she is in the late first trimester
- if she has coagulopathies or is unable to have a blood transfusion
What is the medical management of miscarriage and when is it used?
=’Using tablets to expedite the miscarriage’
-
Vaginal misoprostol (800 mcg once only)
- The addition of oral mifepristone is not currently recommended by NICE in contrast to US guidelines
- Oral misoprostol if patient’s preference
- If bleeding hasn’t started in 24 hours advise to contact doctor.
- antiemetics and pain relief
-
After 3 weeks carry out urine pregnancy test
- If postive return for scan
What is the MOA of misoprostol?
Prostaglandin analogue,
Binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
What are the side effects of misoprostol?
- Pain
- Diarrhoea
- Nausea
Offer antiemetics and pain relief .
What is the surgical management of miscarriage?
= ‘Undergoing a surgical procedure under local or general anaesthetic’
The two main options are:
- Vacuum aspiration (suction curettage) - done under local anaesthetic as an outpatient
- Surgical management in theatre
What miscarriage management is used in a patient with haemodynamic instability?
In all cases of early pregnancy loss with haemodynamic instability –> urgent surgical evacuation of products of conception is required to minimise further blood loss. e.g. dilation and curettage is a common and controlled method of uterine evacuation.
Can you definitively diagnose miscarriage with one USS? What should you look for on USS?
No - it is not 100% correct and there may be a small chance that this is wrong.
- Look for fetal heartbeat
- Measure crown-rump length - if <7mm + no FH then rescan in minminum 7 days; if >7mm then get second opinion on viability +/- rescan in 7-14 days.
You should give women a 24 hr number to contact someone with experience of complications of pregnancy while they wait for the 2nd scan.
What should you say when counselling someone with miscarriage?
- I’m afraid I don’t have good news to deliver; would you like someone in the room with you?
- You’ve had a miscarriage
- I know its not what you wanted to hear so take as much time as you need.
- Miscarriage is very common and affects up to 1 in 5 women
- None of this is your fault
- I know this is going to be a lot of information to take in so I will give you a leaflet and please stop me to ask questions at any time.
- We are going to give you some medication which will cause your womb to contract to get the rest of the tissue out so you may experience heavy bleeding (don’t need to cover in too much detail as likely to be upset) DO NOT CALL IT A FETUS
- This bleeding can last for up to 2 weeks
- Doesn’t increase your chances of having a miscarriage in the future and does not affect your chances of having a baby
- However, we know this is difficult and advise that you only try for another baby once you and your partner are mentally and physically ready to do so.
- If you would like some help, I will give you a leaflet to explain this. You can also ask your GP to refer you to a counselling service.
