Miscarriage Flashcards
Definition of miscarriage
A spontaneous termination of pregnancy before 24 completed weeks of gestation, after which pregnancy loss is referred to as stillbirth. Affects around 20% of clinical pregnancies
Definitions of early and late miscarriage
- Early miscarriage is before 12 completed weeks of gestation
- Late miscarriage is between 13 and 24 weeks of gestation
When to suspect a miscarriage
- Suspect a miscarriage in women who are pregnant, or with symptoms of pregnancy (amenorrhoea, missed period, breast tenderness) presenting with vaginal bleeding in the first 24 weeks of pregnancy (bleeding is typically scnty and can be accompanied by lower abdominal or lower back pain)
What needs to be ruled out
Ectopic pregnancy
Classification of miscarriage
Missed- The foetus is no longer alive, in the absence of symptoms. TVUSS will show a non-viable or non-continuing pregnancy but the foetus will still be in the uterine cavity. Usually diagnosed on USS:
* Mean gestational sac diameter (MSD) >25 mm, without obvious yolk sac or foetal pole
* Foetal pole with crown-rump length (CRL) >7mm, without evidence of foetal heart activity
* Diagnosed by 2 separate people or at least one week apart on TVUSS
Threatened- Vaginal bleeding (usually painless, less than menstruation) with a closed cervix and a foetus that is still alive. Patient will present with unprovoked PV bleeding, but os will be closed on speculum and TVUSS will show intrauterine pregnancy. Common, 25% go on to miscarry
Inevitable- PV bleeding with an open cervical os. Bleeding will usually be heavy and painful with clots. Pregnancy will not continue, and will proceed to complete or incomplete miscarriage
Incomplete- Miscarriage with retained products of conception. Will present with PV bleeding and early pregnancy tissue partially expelled (heavy bleeding + clots/products), Os will be open on speculum ad TVUSS will show remaining tissue
Complete- A full miscarriage has occurred and there are no remaining roducts of conception in the uterus (bleeding has diminsed, Os closed and uterus no longer enlarged on TVUSS)
Septic- Present with signs of infection i.e. temperature, foul-smelling discharge, tachycardia, abdominal pain. May have light bleeding and os may be slightly open. Usually occurs with incomplete miscarriage with remaining tissue becoming septic. Requires IV antibiotics
Definition of recurrent miscarriage
loss of three or more consecutive pregnancies before 24 weeks gestation
Causes of miscarriage
50% are due to isolated non-recurring chromosomal abnormalities (‘one off’ miscarriages- if 3 or more miscarriages occur, other causes are more likely)
* Foetal malformations or placental abnormalities
* Infection (including Toxoplasmosis, Listeriosis and VZV)
* Maternal risk factors: extremes of age (including paternal), high alcohol consumption, subfertility, high BMI, medical conditions (antiphospholipid syndrome (15% recurrent miscarriage), PCOS, T2DM), cervical incompetence
* Caffeine, smoking, socieoeconomic status, moderate alcohol consumption, working whilst pregnant do NOT increase the risk of miscarriage
* Idiopathic in around 50% of cases of recurrent miscarriage
Investigations for a suspected miscarriage
Refer to EPAU for TVUSS (can also consider a transabdominal USS for women with an enlarged uterus or other pelvic pathology such as fibroids)
Inform women that the diagnosis of miscarriage using 1 USS cannot be 100% guaranteed to be accurate and that there is a small chance that the diagnosis may be incorrect, particularly at very early gestational ages
* Determine the viability of an intrauterine pregnancy by first looking to identify a foetal heartbeat. If non is visible, but there is a foetal pole, measure the CRL
* Only measure the gestational sac diameter if the foetal pole is not visible
* IF CRL < 7.0mm and no foetal heartbeat- perform a second scan 7 days after the first before making a diagnosis
* IF CRL > 7.0mm and no visible heartbeat seek a second opinion or repeat scan in 7 days before diagnosis (14 days if transabdominal)
* If the mean gestational sac diameter is < 25mm with TVUSS and there is no pole, repeat the scan in a minimum of 7 days
* If the mean gestational sac diameter is 25.0 mm or more on TVUSS scan and there is no visible fetal pole- seek a second opinion or repeat in 7 days (14 days for abdominal) before making a diagnosis
- Bloods- hCG levels should have a 63% increase every 48 hours in a viable pregnancy. In women who have a decrease of more than 50% after 48 hours inform them that the pregnancy is unlikely to continue
- Basic observations, Group and save, FBC, abdomino-pelvic examination (including speculum, bimanual)
When should hospital transfer be arranged for a women with suspected miscariage
- She has signs of haemodynamic instability (including pallor, tachycardia, hypotension, shock, and collapse). Resuscitate with intravenous fluids, if available.
- There is significant concern about the degree of bleeding or pain
(A-E management in this case)
Management of a threatened miscarriage
Advise a woman with a confirmed intrauterine pregnancy with a foetal heartbeat who presents with vaginal bleeding, but has no history of previous miscarriage that:
* If her bleeding gets worse, or persists beyond 14 days she should return for further assessment
* If the bleeding stops, she should start or continue routine antenatal care
* Offer vaginal progesterone 400mg twice daily if they have previously had a miscarriage
* If a foetal heartbeat is confirmed, continue progesterone until 16 completed weeks of pregnancy
* Anti-D not needed if bleeding stops before 12 weeks
Expectant management of miscarriage
Use expectant management for 7 to 14 days as the first-line management strategy for women with a confirmed diagnosis of miscarriage (incomplete, inevitable or missed)
* Give women information on what to expect, advice on analgesia and safety net
* If the bleeding and pain settle (suggesting complete miscarriage), the woman will be advised to take a urine pregnancy test after 3 weeks and to return to the hospital if it is positive.
* If the bleeding and pain persist or are increasing after 7 to 14 days (suggesting incomplete miscarriage), or if bleeding and pain has not started (suggesting a missed miscarriage), a repeat scan is done and expectant, medical, and surgical options are discussed. Woman who choose to continue expectant management are reviewed in 14 or more days.
* Most women will need no further treatment
Explore alternative management options if:
* The woman is at increased risk of haemorrhage
* She has had previous adverse/ traumatic experiences associated with pregnancy
* She is at increased risk from the affects of haemorrhage OR there is evidence of infection
Medical management of miscarriage
Should be offered if expectant management is not acceptable or according to patient’s wishes
* Offer vaginal misoprostol for the medical treatment of missed or incomplete miscarriage. Oral administration is an acceptable alternative
* For women with a missed miscarriage: single dose of 800ug misoprostol
* If bleeding has not started 24 hours after treatment, should contact a health professional
* For women with incomplete miscarriage: single dose of 600ug misoprostol
* Offer all women receiving medical management of miscarriage pain relief and anti-emetics as needed
* Warn women that they should expect to bleed in the next 4-48 hours, and that they should expect pain, diarrhoea and vomiting
* Women should take a pregnancy test 3 weeks after medical management unless they experience worsening symptoms (in which case they should return)- should return for review if this pregnancy test is positive
* 10% failure rate associated with
Surgical management of miscarriage
Where clinically appropriate, offer women undergoing a miscarriage a choice of:
* Manual vacuum aspiration under LA in an outpatient or clinic setting
* Surgical management in theatre under GA
Vaginal misoprostol is often used to ripen the cervix to facilitate cervical dilatation for suction insertion
Offer anti-D prophylaxis to all rhesus-negative women undergoing surgical management
Manual vacuum aspiration involves a LA applied to the cervix. A tube attached to a specially designed syringe is inserted through the cervix into the uterus. The person performing he procedure then manually uses the syringe to aspire the contents of the uterus- must be below 10 weeks gestation (more appropriate in parous women)
Electric vacuum aspiration is the traditional surgical management of miscarriage, involving the use of a general anaesthetic. The cervix is gradually widened using dilators, and the products of conception are removed through the cervix using an electric-powered vacuum.
