Miscarriage

Question 1

What is the most common cause of first trimester miscarriage?

Answer 1

Chromosomal abnormality (50-60%)

Question 2

What brief history should be taken for women with miscarriage?

Answer 2

• PV bleeding - amount, colour, clots
• Abdominal cramping
• Confirmation of IUP on USS
• Serial beta-hCG
• Past medical history - periods, anaemia
• Past obstetric history - previous pregnancies, miscarriages, previous deliveries, previous pregnancy complications such as APH or PPH
• Medications - blood thinners, anti-platelets
• Family history - bleeding disorders

Question 3

What is the management of acute bleeding in miscarriage?

Answer 3

Call for help

INITIAL ASSESSMENT
* Amount of bleeding
* Pale
* Responsiveness

AIRWAY
* Check airway patency
* Signs of life  breathing, chest rise

BREATHING
* RR, O2 sats
* Auscultate lungs, chest expansion, tracheal deviation, percussion

CIRCULATION
* HR, BP
* CRT, HS
* Estimate blood loss –> weigh pads and sheets. Keep wearing pads so blood loss can be measured
* 2x large bore IVL in ACF
* Bloods –> FBC, UCEs, VBG, coagulation screen, beta-hCG, X-match
* 500-1000mL IV 0.9% saline for fluid resuscitation
* Consider activation of the MTP and request X-match of 4u RBCs
* TXA 1g IV stat

DISABILITY
* AVPU, pupils, BGL

EXPOSURE
* Temperature
* Abdomen –> peritonism, tenderness, bowel sounds
* Speculum –> is cervical os open, check for POC in cervical os
* Remove RPOC from cervical os –> POC in the cervical os can lead to cervical shock due to vagal stimulation. Removal of the POC can often help improve bleeding

ONGOING MANAGEMENT
* Urgent senior review
* NBM and alert OT
* Ongoing monitoring of blood loss
* Ongoing monitoring of maternal vitals
* Fluid resuscitation +/- blood transfusion as required
* USS –> exclude RPOC or incomplete miscarriage
* Medical –> augmentation with misoprostol
* Surgical –> ERPOC
* Structured handover (ISBAR)

Question 4

What is the definition of recurrent miscarriage?

Answer 4

> 3 consecutive first-trimester miscarriages

Question 5

What is the prevalence of recurrence miscarriage?

Answer 5

Affects 1-2% of couples

Question 6

What are the potential causes of recurrent miscarriage?

Answer 6

• Chromosomal abnormalities in the parents (3-5%) –> most commonly a Robertsonian translocation
• Antiphospholipid syndrome –> antiphospholipid antibodies are present in 15% of women with recurrent miscarriage. Also test for anti-cardiolipin antibodies and anti-B2-glycoprotein antibodies
• Structural uterine abnormalities (10-25%)
• Fibroids
• Cervical incompetence –> often presents as late miscarriage with SROM or painless cervical dilatation
• Endocrine –> PCOS, uncontrolled DM
• Inherited thrombophilias –> increased risk of thrombosis in the uteroplacental circulation. Causes include Protein C and S deficiency and Factor V Leiden
• Infection –> BV is associated with 1st and 2nd trimester miscarriage
• Unexplained miscarriage –> has a good prognosis

Question 7

What investigations are required for recurrent miscarriage?

Answer 7

RCOG criteria
* Karyotype for both parents
* TFTs and anti-peroxidase antibodies
* HbA1c
* Antiphospholipid antibodies
* Inherited thrombophilias –> Factor V Leiden, factor II prothrombin gene mutation, protein C and S deficiency are not routinely tested
* Pelvic USS –> check for uterine abnormalities
* Genetic karyotyping of the POC of 3rd and subsequent miscarriages