Miscarriage

Question 1

Threatened miscarriage
-what?
-symptoms/signs?

Answer 1

threatened miscarriage = there are some mild symptoms of bleeding with the foetus retained within the uterus as the cervical os (opening) is closed
- US reveal that the foetus is present intrauterine
-Little/ no pain
-Vaginal Bleeding
-Closed cervix

Question 2

Inevitable miscarriage
-what?
-symptoms/signs?

Answer 2

Inevitable miscarriage = pregnancy can’t be saved
-Vaginal bleeding + often pain
- US shows foetus intrauterine
-Open cervix
-No passage of tissue

Question 3

Incomplete miscarriage
-what?
-symptoms/signs?

Answer 3

Incomplete miscarriage= retained products of conception remain in the uterus after the miscarriage
-Cervix may be open or closed

Question 4

Complete miscarriage
-what?
-symptoms/signs?

Answer 4

Complete miscarriage= all of pregnancy is expelled, uterus is empty on scan
-Usually closed cervix
-The patient may have been alerted to the miscarriage by pain and bleeding

Question 5

Missed miscarriage
-what?
-symptoms/signs?

Answer 5

Missed miscarriage= fetus died in womb and is still there but the mum had no symptoms
-Cervix is closed

Question 6

Early Fetal Demise/ Non Continuing Pregnancy (NCP)
-describe?

Answer 6

Early Fetal Demise/ Non Continuing Pregnancy (NCP)= pregnancy in situ, no heart beat: mean sac diameter> 25mm, fetal pole> 7mm

Question 7

Anembryonic Pregnancy
-describe?

Answer 7

-no fetus
-empty sac

Question 8

in what type of miscarriages is the cervix open?

Answer 8

Inevitable miscarriage= always open
Incomplete miscarriage= sometimes open sometimes closed

Question 9

what autoimmune condition causes recurrent miscarriages?

Answer 9

antiphospholipid syndrome

Question 10

what antibpdies are seen in antiphospholipid syndrome?

Answer 10

anticardiolipin
beta-2- glycoprotein1 antibodies
lupus anticoagulant

Question 11

what infections can cause a miscarriage?

Answer 11

-Cytomegalovirus (CMV)
-Rubella
-Toxoplasmosis
-Listeria
-Vaginal (bacterial) infections

Question 12

what type of test on the embryo increases risk of miscarriage?

Answer 12

chorionic villus sampling (CVS)

Question 13

what is classed as early and late miscarriage and which is more common?

Answer 13

Early miscarriage in first trimester (<12- 13 weeks) is more common than late miscarriage (13-24 weeks)

Question 14

what maternal age increases risk for miscarriage and why?

Answer 14

Maternal age >30-35 (largely due to an increase in chromosomal abnormalities)

Question 15

symptoms of miscarriage?

Answer 15

Vaginal bleeding= primary symptom (>cramping)

-‘Period type cramps’

Question 16

signs of miscarriage?

Answer 16

Excessive bleeding can lead to haemodynamic instability:
-Pallor, tachycardia, tachypnoea, hypotension

Abdominal examination:
-The abdomen may be distended, with localised areas of tenderness

Speculum examination:
-Assess the diameter of 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 (consider ectopic pregnancy)

Question 17

how is a definite diagnosis for miscarriage made?

Answer 17

via transvaginal US

Question 18

what tests are done for miscarriage?

Answer 18

transvaginal US (for definite diagnosis)
Bloods:
-serum hCG
-FBC
-Blood group and resus status

Question 19

treatment for miscarriage <6weeks gestation?

Answer 19

First line= Expectant management
(If they have no pain and no other complications or risk factors e.g. previous ectopic, miscarriage)

A repeat urine pregnancy test is performed after 7-10 days
* Negative= confirmed miscarriage

When bleeding continues, or pain occurs, referral and further investigation is indicated.

Question 20

treatment for miscarriage > 6 weeks gestation?

Answer 20

Expectant management= 1st line
(If they have no pain and no other complications or risk factors e.g. previous ectopic, miscarriage)

Medical management given before surgery:
-Misoprostol (oral or vaginal)
SE: heavier bleeding, pain, vomiting, diarrhoea
Misoprostol is a prostaglandin analogue, it binds to prostaglandin receptors, activates then and then the prostaglandins soften the cervix and stimulate uterine contraction.

Surgical management:
>10 weeks Electric vacuum aspiration (general anaesthetic)

<10 weeks Manual vacuum aspiration (local anaesthetic as outpatient)

Anti-D administration for rhesus negative women having surgical management

Question 21

what is treatment for incomplete miscarriage?

Answer 21

Retained products create risk of infection so required medical or surgical management

Question 22

treatment for pregnant women with antiphospholipid syndrome?

Answer 22

-Low dose aspirin
-Daily Fragmin (LMWH) injections

Question 23

complication of miscarriage?

Answer 23

cervical shock- this is an acute medical emergency!!

-when remnants of miscarriage have been left in the uterus

Question 24

how does cervical shock present?

Answer 24

N + V
Cramps
Sweating
Fainting

Question 25

treatment for cervical shock?

Answer 25

Resolves quickly if contents of cervix are removed

Resus with Intravenous infusion (IVI) and uterotonics may be required

Question 26

what is classed as recurrent miscarriages?

Answer 26

3 or more pregnancy losses
OR
2 losses in women >35yrs

Question 27

risks/causes for recurrent miscarriage?

Answer 27

RISKS:
-maternal age >30-35 years
-previous miscarriage
-antiphospholipid syndrome
-thrombophilia
-Balanced Translocation (rare)
-Uterine abnormality (usually seen late in first trimester)

Question 28

what medication should be given if there is a viable intrauterine pregnancy seen on a scan however the patient has a history of miscarriage?

Answer 28

Micronised Progesterone 400mg until 16 weeks

Question 29

what increases risk of miscarriage?

Answer 29

-Increased maternal age
-Smoking in pregnancy
-Consuming alcohol
-Recreational drug use
-High caffeine intake
-Obesity
-Infections and food poisoning
-Health conditions, e.g. thyroid problems, severe hypertension, uncontrolled diabetes
-Medicines, such as ibuprofen, methotrexate and retinoids
-Unusual shape or structure of womb
-Cervical incompetence