Miscarriage Flashcards
1
Q
What is the physiology of early pregnancy?
A
Oocyte fertilised in ampulla of fallopian tube=zygote
Divides as is swept towards uterus by ciliary action and peristalsis
Enters uterus day 4 as multicellular morulla
Morulla becomes blastocyst by developing a fluid filled cavity within
Outer layer of blastocyst forms trophoblast which will form placenta and from day 6-12 invades endometrium to achieve implantation
Trophoblast produces hormones – B-HCG (peaks at 12 weeks). (note invasion and B-HCG production GTD)
Endometrium becomes deciduous (rich in glycogen and lipids) under influence of oes/pro from corpus luteum (maintained by HCG)
Trophoblastic proliferation leads to formation of chorionic villi – this proliferates on endometrial surface of embryo – to form cotyledons of placenta for nutrient transfer
Placenta complete at 12 weeks.
Heart beat at 4-5 weeks. Visible on u/s at 6-7 weeks.
2
Q
What is the definition of miscarriage?
A
Pregnancy loss before 24 completed weeks of gestation
3
Q
What is the epidemiology of miscarriage?
A
- approx 15-20% of clinically recognised pregnancies spontaneously miscarry
- 14,000 per year in Ireland
4
Q
What are the majority of miscarriages gestation?
A
<12 weeks
5
Q
When does the rate of miscarriage increase?
A
With maternal age
6
Q
What are the different classifications of miscarriage?
A
- threatened
- inevitable
- incomplete
- complete
- septic
- missed
- recurrent
7
Q
How can you define the classification of miscarriage?
A
Bleeding/pain/tissue loss?
Uterine size / foetal HB
Os open/closed
8
Q
Where is the site of fertilisation?
A
Ampulla of Fallopian tubes
9
Q
What are clinically recognised pregnancies?
A
HCG +
10
Q
What is an early miscarriage?
A
First 12 weeks (first trimester)
11
Q
What are late miscarriages?
A
12-24 weeks
12
Q
What are Threatened Miscarriages?
A
- bleeding in early pregnancy
- not usually pain
- not usually tissue loss
- uterine size appropriate
- foetal heartbeat present
- cervical os closed
13
Q
What happens with threatened miscarriages?
A
75% will have normal pregnancy
Increased risk of congenital abnormalities and low birth weight
14
Q
What is seen in an inevitable miscarriage?
A
- bleeding
- pain
- no tissue loss
- foetal HB may no be present
- open os (>3cm)
15
Q
What is incomplete miscarriage?
A
- bleeding
- pain
- tissue loss
- uterine size could be appropriate
- no foetal HB
- open os
16
Q
What are complete miscarriages?
A
- would have had bleeding
- pain
- had tissue loss
- uterine size small for gestational age
- foetal HB not present
- closed os
17
Q
What are septic miscarriages? (6)
A
- contents of uterus has become infected - Endometritis
- Sign of sepsis
- offensive discharge
- high temperature
- tenderness or peritonism when palpating abdomen
- signs of shock
•
18
Q
What is a missed miscarriage?
A
- either no foetal development (just a gestational sac) or in utero death
- either bleeding or u/S diagnosed
- small uterine size
- closed os
- often seen at 12 week scan
19
Q
What are recurrent miscarriages?
A
3 or more miscarriages in succession (ie in a row)
- 1% of couples
20
Q
What is the etiology of miscarriages? (4)
A
- isolated chromosomal abnormalities (>60% of spontaneous miscarriages)
- anatomical factors (uterine, cervical)
- infection (of genital tract like BV, or others like STI, TORCH)
- antiphospholipid antibodies
21
Q
When are infections as the cause of miscarriage more common?
A
Late miscarriages
22
Q
What types of chromosal abnormalities are there seen in miscarriage?
A
- majority are numerical issues (eg trisomies)
- could also be parents who had balanced translocation
23
Q
How common are uterine abnormalities?
A
<5% of all women
25% with miscarriages or preterm
24
Q
What are some uterine abnormalities?
A
25
How do uterine abnormalities present in pregnancy? (4)
* abnormal lie, presentation
* miscarriage
* pre-term labour
* retained placenta
26
What is a common congenital uterine abnormality?
Incomplete fusion of malarian ducts in uterus
27
What is cervical incompetence?
Painless cervical dilatation, over 16 weeks (ie second trimester) = miscarriage
28
What do you need to diagnose anti-phospholipid syndrome?
One clinical and one laboratory criteria
29
What are the clinical criteria for antiphospholipid syndrome? (4)
* vascular thrombosis
* 1+ foetal death >10 weeks
* 3+ foetal deaths <10 weeks otherwise unexplained
* pre-eclampsia or IUGR needing delivery <34 weeks
30
What are the laboratory criteria (that must be present on two occasions) for antiphospholipid syndrome? (3)
* lupus anticoagulant
* anti cardiolipin abs
* antiB2 glycoprotein 1 Abs.
31
How can you optimise antiphospholipid syndrome to aid prevention of miscarried?
while trying to conceive = Low dose aspirin
Once + pregnancy test = LMWH (clexane)
32
What are the 3 most common clinical features in the history of someone presenting with miscarriage?
Bleeding
Pain
Tissue loss
33
What clinical features should be checked on examination of suspected miscarriage?
* general = BP, HR, temp (iMEWS)
* abdo: size of uterus, tenderness
* pelvic: VE/speculum - cervical os open, cervical exicitation, degree of bleeding/products
34
What is cervical excitation?
Cervical motion tenderness
Chandelier sign
35
What are the 2 DDx for cervical excitation?
PID
Ectopic
36
Why must the HCP be careful when doing a VE to check for miscarriage?
Placenta not fully developed so esp be careful in later miscarriages
37
What investigations would EPAC/ gynae on call do at the weekend with a suspected miscarriage?
* ultrasound
- ? Intrauterine pregnancy? Viable
- ? Retained products of conception
* blood tests
- FBC (+/- others CRP/ESR/U&E/LFTs/Coag screen)
- blood group and hold and rhesus group
- BHCG
38
What do you look at with the BHCG in a suspected miscarriage?
* discriminatory zone
* serial measurements: rise >63% in 48 hours in viable IUP
39
What is the discriminatory zone?
Level at which you would expect to see an inter uterine pregnancy if it was there - would worry about ectopic if higher than this and can’t see it
40
What is the level of the discriminatory zone?
> 1500 IU
41
When does the gestational sac appear on u/s?
~ 5 weeks
42
When does the foetal pole appear on u/s?
6 weeks
43
When does the heart beat appear on u/s?
~ 6-7 weeks (maybe earlier)
44
What measurements are considered non-viable on TVUS?
* IUGS >20mm (25mm NICE) with no foetus
OR
* CRL >7mm with no foetal HB
45
What feature seen on VE means a pregnancy is considered non-viable?
Cervix dilated (>3cm)
46
What is the pseudosac?
Breakdown of deciduous endometrium, centrally placed, no hyperechoic reaction, irregular shape with pointy edges
47
What is Decidua basalis?
Where the implantation takes place and the basal plate is formed
48
How can Decidua basalis be subdivided?
* zone compacta
* zone spongiosa
49
What happens in the zone spongiosa following birth?
Detachment of the placenta
50
What is the Decidua capsularis?
Lies like a capsule around the chorion
51
What is the Decidua partietalis?
On the opposite uterus wall
52
What is a viable intrauterine pregnancy?
Normally sited gestational sac, with a foetal pole and identified foetal heartbeat
53
What is a pregnancy of uncertain viability?
Gestational sac <20mm with no foetal pole or foetal pole <7mm with no foetal heart beat
54
What is Early pregnancy loss?
Gestational sac >20mm with no foetal pole
OR
Foetal pole >7mm with no foetal heartbeat
55
What u/s finding is seen in incomplete miscarriage?
Endometrial thickness >15mm
56
What u/s finding is seen in complete miscarriage?
Endometrial thickness <15mm
57
What is a pregnancy of undetermined location?
Positive pregnancy test, but no demonstrable intra or extra uterine pregnancy
58
What often happens after u/s esp. if for a pregnancy of uncertain viability?
Women are brought back after one week for further assessment - provided no signs of excessive bleeding or infection
59
In what circumstances should a second scan be considered? (4)
* first scan <8 weeks
* concern about reliability of first scan (eg TAS in obese lady, HCP not trained in EP u/s)
* long or irregular menstrual cycle
* woman requests it
60
What can be the outcomes of threatened miscarriage?
* viable IUP = 90% of threatened miscarriage with FHB on u/s @ 8 weeks will not miscarry
61
How do you manage non viable IUP?
** Expectant **
** Medical **
** Surgical **
62
What is done in expectant management of non-viable IUP?
Repeat scan within 2 weeks
63
What medical management can be used for non viable IUP?
Misoprostol PGE1
Follow up scan within 2 weeks
64
How does Misoprostol work for the medical management of miscarriages?
Ripens cervix & works on myometrium stimulating contractions
65
How is Misoprostol given for the medical management of miscarriage?
Oral (2 doses) or vaginal (2 doses)
66
How is miscarriage managed surgically?
SMM/ERPC (under anaesthetic vacuum asp)
67
What can be given prior to the surgical management of miscarriage?
Prostaglandin
68
What should be ruled out prior to the management of miscarriage surgically?
Molar pregnancy
69
When is surgical management for miscarriage indicated? (4)
* if woman wants
* heavy bleeding
* signs of infection
* abdominal pain
70
Why is tissue sent for histology after the surgical management of miscarriage?
make sure you have got the pregnancy - if you sent it off and positive test but negative histology could be a pseudosac
71
Who is not suitable for outpatient medical management of miscarriage?
MSD >50mm due to risk of increased bleeding
72
What are the success rates for expectant management of miscarriage?
Within 2-6 weeks:
* >80% success with incomplete
* 30-70% success with missed (less so if large intact GS)
73
What are the success rates for medical management of miscarriage?
* >80% incomplete, 40-90% missed
74
What are the success rates for surgical management of miscarriages?
* >95% for missed and incomplete
75
What anaesthetic is given for SMM/ERPC?
Spinal or general
76
Why is suction currettage preferred?
A/w/:
- less blood loss
- less pain
- shorter duration of produce
77
What are the complications with expectant and medical miscarriage management?
* vaginal bleeding
* pain
=> need for surgery 30% (10-40%)
78
How do infection rates compare between expectant, medical and surgical management?
Similar for all 3 modes
79
What are the complications of surgical management of miscarriage? (5)
* anaesthetic risks
* cervical trauma
* Asherman’s Syndrome - adhesions in uterine cavity
* perforation 1% (& trauma to other organs)
* failure <5%
80
How do longterm conception rates differ between the 3 modes of management of miscarriages?
They do NOT differ
81
When should you admit a patient undergoing acute management?
? Ectopic
Heavy bleeding
Infection
82
How should heavy bleeding during miscarriage management be handled?
* occasional resuscitation required
* remove POC from cervix using speculum and polyps forceps (cause pain and vasovagal shock)
* IM syntometrine or IV syntocinon
* fever
* HVS and IV antibiotics
83
Who needs Anti-D management for miscarriage?
Rhesus negative women
+ medical or surgical management
OR bleeding after 12 weeks
84
How should you signpost someone to support after a miscarriage?
Give condolences
Explain rates and figures
Not a result of anything they did, could not have prevented it
Reassurance re future pregnancies: no increased risk of miscarriage having had one miscarriage
Discuss burial or cremation arrangements – couples own or hospital
Support group (e.g. www.miscarriage.ie)
Inform GP
Miscarriage clinic
85
Which one of the following indicates EPL?
1. GS-20mm diameter, containing FP with CRL-3mm with absent FH
2. GS containing FP with CRL 10mm with absent FH
3. GS containing FP with CRL 5mm with absent FH
4. GS-50mm diameter, containing FP with CRL-10mm with FH
5. No identifiable intrauterine or extra-uterine pregnancy with HCG> 1500IU/L
2.
86
A 20 y/o woman 8 weeks pregnant presents with vaginal bleeding and lower abdominal pain. Her cervical os is 4cm dilated. Ultrasound shows a 16mm FP with absent FH. Which one of the following best describes her clinical situation?
1. Threatened miscarriage
2. Inevitable miscarriage
3. Incomplete miscarriage
4. Pregnancy of uncertain viability
5. Cervical incompetence
2.
87
What is defined as recurrent miscarriage?
≥ 3 miscarriages in succession (1% of couples)
88
What is the chance of miscarriage in the 4th pregnancy in a patient with recurrent miscarriage?
40% BUT need to investigate
89
What should be offered to those with recurrent miscarriage?
Support vital
Close monitoring in pregnancy
90
What is the etiology of recurrent miscarriage? (5+)
**Antiphospholipid antibodies (primary or SLE)**
- Likely due to thombosis in uteroplacental circulation
- Tx with aspirin and lmwh
**Chromosomal defects**
- Only found in 4%
- Parental karyotyping ➔ Balanced translocations: Referral to clinical geneticist
- Prenatal dx by CVS or amniocentesis offered
- Alternatives – donor sperm or oocytes, or preimplantation genetic screening of IVF embryos
**Anatomical factors**
- Dx on US (with MRI or HSG)
- Usually lead to late miscarriage or could be incidental findings
- Cervical incompetence
**Infection**
- Involved in preterm labour and late miscarriage
- Tx of BV reduces incidence of fetal loss
Others
- Higher maternal age
- Obesity
- Smoking
- Excess caffeine
- Maternal conditions like diabetes, hypothyroid, PCOS and renal failure
91
What investigations should be done for a woman with recurrent miscarriage?
Screen:
FBC/TFT/U+E (? Diabetic)
Parental Karyotyping (4%) (where testing of products reports problem)
Autoimmune screen (lupus anticoagulant, anticardiolipin antibodies)
Thrombophilia screen (protein S, protein C, antithrombin 3, Factor V leiden)
Ultrasound- if abnormal consider hysteroscopy/Hysterosalpinogram
Foetal tissue for karyotyping ((3rd consecutive miscarriage)
Also:
PCOS
Chronic maternal conditions
Drugs/cytotoxics
92
What treatment should be offered to a woman following recurrent miscarriage?
Reassure.
Low dose **aspirin +/- LMWH**
- aspirin before pregnancy, LMWH when + test
Evidence that **progesterone** supplementation in early pregnancy may be beneficial after 3 miscarriages
93
What can cervical incompetence cause?
Late miscarriage ~16 weeks
94
What pre-disposes a woman to cervical incompetence? (4)
* Previous traumatic birth
* cone biopsy
* LLETZ
* pregnancy with multiple gestations
95
What is cervical cerclage?
The insertion of 1 or more sutures into the cervix to strengthen it and keep it closed
96
When is cervical cerclage done?
* history indicated
* u/s indicated (cervix <25mm)
* ‘rescue’ cerclage
97
What type of suture is done for cervical cerclage?
Transvaginal cerclage (McDonald)
A transvaginal purse-string suture placed at the cervical isthmus junction, without bladder mobilization.4
High transvaginal cerclage requiring bladder mobilization (including Shirodkar)
A transvaginal purse-string suture placed following bladder mobilization, to allow insertion above the level of the cardinal ligaments.
98
Transvaginal cerclage (McDonald)
A transvaginal purse-string suture placed at the cervical isthmus junction, without bladder mobilization.4
High transvaginal cerclage requiring bladder mobilization (including Shirodkar)
A transvaginal purse-string suture placed following bladder mobilization, to allow insertion above the level of the cardinal ligaments.
5.
