Miscarriage Flashcards
(47 cards)
1
Q
What is the definition of miscarriage?
A
the spontaneous termination of pregnancy before 24 weeks gestation
spontaneous termination after 24 weeks = stillbirth
2
Q
What is an early and late miscarriage?
A
early:
- occurs in the first 12 weeks of pregnancy
late:
- occurs between 12 - 24 weeks gestation
3
Q
What is a missed miscarriage?
A
- the foetus is no longer alive
- no symptoms have occurred
- often diagnosed through routine antenatal scans
also called a “silent miscarriage”
4
Q
What is a threatened miscarriage?
A
- there is vaginal bleeding with a closed cervix
- the foetus is still alive
- this does not necessarily mean that the patient will go on to have a miscarriage
5
Q
What is an inevitable miscarriage?
A
- there is a diagnosed non-viable pregnancy
- there is vaginal bleeding and an open cervical os
- the pregnancy will proceed to an incomplete or complete miscarriage
- pregnancy tissue still remains within the uterus at this stage
6
Q
What is an incomplete miscarriage?
A
- miscarriage occurs and bleeding has begun
- the cervical os is open
- there are retained products of conception in the uterus following miscarriage
7
Q
What is a complete miscarriage?
A
- a full miscarriage has occurred
- there are NO products of conception left in the uterus
- the bleeding has now stopped and the cervix is closed
8
Q
What is an anembryonic pregnancy?
A
a gestational sac is present but it contains no embryo
9
Q
How is a miscarriage diagnosed?
A
transvaginal USS
10
Q
What 3 features are looked for on transvaginal US to determine the viability of a pregnancy?
A
- mean gestational sac diameter
- foetal pole + crown-rump length
- fetal heartbeat
these appear sequentially so as each feature develops, the previous becomes less relevant in determining viability of a pregnancy
11
Q
When is a fetal heartbeat expected to be seen?
What does this mean for the pregnancy?
A
- fetal heartbeat is expected to be seen when CRL is 7mm or more
- the presence of a heartbeat means that the pregnancy is viable
12
Q
What is done when there is a CRL < 7mm and NO fetal heartbeat?
A
the scan is repeated after 1 week to ensure that a heartbeat develops
13
Q
What is done when the CRL is > 7mm and the fetal heartbeat is not present?
A
- the scan is repeated after 1 week
- if the fetal heartbeat still cannot be seen, this is deemed a non-viable pregnancy
14
Q
How is an anembryonic pregnancy diagnosed on transvaginal USS?
A
- a fetal pole is expected once mean gestational sac diameter is 25mm or more
- if the MGSD is >25mm and there is no fetal pole, scan is repeated after 1 week
- if the fetal pole is still not present, this is an anembryonic pregnancy
15
Q
What is the management for miscarriage occurring before 6 weeks gestation?
A
expectant management
- this involves awaiting the miscarriage without investigations / treatment
- as long as they do not have pain / complications / RFs
a scan is not performed as the pregnancy will be too small to be seen at this stage
16
Q
How can miscarriage be confirmed following expectant management?
A
- a repeat urine pregnancy test is performed after 7-10 days
- miscarriage is confirmed if it is negative
if bleeding continues or pain occurs, further investigation is needed
17
Q
What is the first stage in management of a suspected miscarriage after 6 weeks gestation?
A
- women are referred to an early pregnancy assessment unit if they have a positive PT and bleeding
- an USS is arranged to confirm the location + viability of the pregnancy
- this can also exclude ectopic pregnancy
18
Q
What are the 3 options for managing a miscarriage after 6 weeks gestation?
A
- expectant management
- medical management with misoprostol
- surgical management
19
Q
When is expectant management recommended following miscarriage > 6 weeks gestation?
A
- first-line option for women without RFs for heavy bleeding or infection
- 1-2 weeks are given to allow the miscarriage to occur spontaneously
- repeat urine PT performed 3 weeks after bleeding + pain settles to confirm the miscarriage is complete
20
Q
What is involved in medical management of a miscarriage?
A
- misoprostol is given to expedite the process of miscarriage
- this can be given orally or as a vaginal suppository
21
Q
How does misoprostol work?
A
- it is a prostaglandin analogue
- it binds to prostaglandin receptors to activate them
- this results in softening of the cervix and stimulation of uterine contractions
22
Q
What are the side effects of misoprostol?
A
- heavier bleeding
- pain
- vomiting
- diarrhoea
23
Q
What are the 2 surgical options for managing miscarriage?
A
- manual vacuum aspiration (MVA) under local anaesthetic
- electric vacuum aspiration (EVA) under general anaesthetic
24
Q
What is given to all patients prior to surgical management of miscarriage?
A
misoprostol
- prostaglandins are given to soften the cervix prior to surgical management
25
What is involved in manual vacuum aspiration (MVA)?
* **local anaesthetic** is applied to the cervix
* a tube attached to a syringe is inserted through the cervix into the uterus
* the syringe is used to **manually aspirate** the contents of the uterus
26
What are the criteria for performing MVA?
* women must be **below 10 weeks gestation**
* it is more appropriate for **parous women** (who have previously given birth)
27
What is involved in electric vacuum aspiration?
* performed under **general anaesthetic**
* the **cervix is gradually widened** using dilators
* the products of conception are removed through the cervix using an **electric-powered vacuum**
28
What needs to be administered to women prior to surgical management of miscarriage?
**anti-D** must be given to **rhesus negative** women prior to the procedure
29
What is the associated risk of an incomplete miscarriage?
* the **retained products of conception** remain in the uterus after conception
* this may be **fetal** or **placental tissue**
* retained products create a **risk of infection**
30
What are the 2 options for management of an incomplete miscarriage?
* medical management with misoprostol
* surgical management
31
What is involved in the surgical management of incomplete miscarriage?
**evacuation of retained products of conception (ERPC)**
* involves general anaesthetic
* the cervix is gradually widened using dilators
* the retained products are removed using **vacuum aspiration + curettage** (scraping)
32
What is the main risk associated with ERPC?
**endometritis** following the procedure
| (infection of the endometrium)
33
How is recurrent miscarriage defined?
when an individual has **3 or more consecutive miscarriages**
34
When are investigations for the underlying cause of miscarriage initiated?
* after **3 or more first-trimester** miscarriages
OR
* after **1 or more second-trimester** miscarriages
35
What are the potential underlying causes of recurrent miscarriage?
* **idiopathic** (especially in older women)
* **antiphospholipid syndrome**
* hereditary **thrombophilias**
* **uterine abnormalities**
* genetic factors in parents
* chronic histiocytic intervillositis
* chronic diseases
## Footnote
common chronic diseases = uncontrolled thyroid disease, diabetes + SLE
36
What is antiphospholipid syndrome?
* an autoimmune disorder associated with **antiphospholipid autoantibodies**
* the patient is in a **hypercoagulable state**
* it is associated with increased risk of **thrombosis** + **complications during pregnancy**
37
Who tends to be affected by antiphospholipid syndrome?
* it typically affects **women** around the **age of 30-40**
* it is associated with other autoimmune conditions, particularly **systemic lupus erythematosus** (SLE)
38
How is antiphospholipid syndrome diagnosed and managed?
* test for the presence of **antiphospholipid antibodies**
* managed with BOTH **low dose aspirin** and **low molecular weight heparin** (LMWH)
* this manages the risk of miscarriage and VTE
39
What hereditary thrombophilias are most commonly associated with recurrent miscarriage?
* Factor V Leiden
* factor II (prothrombin) gene mutation
* protein S deficiency
40
What uterine abnormalities can result in recurrent miscarriage?
* uterine septum
* unicornate uterus
* bicornate uterus
* didelphic uterus
* cervical insufficiency
* fibroids
41
What is a septate uterus?
a **thin tissue membrane (septum)** runs down the middle of the uterus, splitting it into **2 parts**
42
What is a unicornate uterus?
* a congenital abnormality in which **only half of the uterus forms**
* there is only **one working fallopian tube**
* there is a **smaller uterine cavit**y
## Footnote
also known as a "single horn" uterus
43
What is a bicornate uterus?
a uterus that is divided into **2 parts** by a **deep indentation** at the top
## Footnote
also called a "heart-shaped uterus"
44
What is a didelphic uterus?
* the presence of **2 uteruses**
* also called a "double uterus"
* the individual also has **2 cervixes**
## Footnote
this is different to a bicornate uterus, in which there is only one cervix
45
What is chronic histiocytic intervillositis?
* **histiocytes + macrophages** build up in the placenta
* the **mother's immune system reacts abnormally** to the pregnancy
* this causes **inflammation** + adverse outcomes
* causes recurrent miscarriage (usually 2nd trimester), IUGR + IUD
## Footnote
the condition is poorly understood and is rare
46
How is chronic histiocytic intervillositis diagnosed?
**placental histology**
* shows infiltrates of **mononuclear cells** in the **intervillous spaces**
* it commonly **recurs**, so needs specialist management
47
What investigations are performed in recurrent miscarriage?
* antiphospholipid antibodies
* testing for hereditary thrombophilias
* pelvic USS
* genetic testing of parents
* genetic testing of products of conception from 3rd or future miscarriages
