Miscarriage Flashcards
What is miscarriage?
spontaneous termination of a pregnancy before 24 weeks
What is classed as early miscarriage?
<12 weeks
What is classed as late miscarriage?
12-24 weeks
Def: Missed miscarriage
the fetus is no longer alive, but no symptoms have occurred
Def: Threatened miscarriage
vaginal bleeding with a closed cervix and a fetus that is alive
Def: inevitable miscarriage
vaginal bleeding with an open cervix (Hasn’t occurred yet but will)
Def: Incomplete miscarriage
retained products of conceptionremain in the uterus after the miscarriage
Def: Complete miscarriage
a full miscarriage has occurred, and there are no products of conception left in the uterus
Def: Anembryonic pregnancy
a gestational sac is present but contains no embryo
Symptoms of miscarriage
- Vaginal bleeding after amenorrhoea
- Abdominal pain - Cramping
- Passage of tissue
- May be asymptomatic and only seen on USS
Key history points in miscarriage
- Parity and previous modes of delivery
- LMP and estimated gestational age
- Previous scans
- Co-morbidities
- Previous surgical history
Investigations for miscarriage
- Vaginal swabs
- Serum HCG
- USS
- If unstable, go straight to emergency surgical evacuation
What is the USS of choice for miscarriage?
Transvaginal US
What are the 3 features looked for on USS in miscarriage
- Mean gestational sac diameter
- Foetal poleandcrown-rump length
- Foetal heartbeat
What is required for a pregnancy to be classed as viable
Foetal heartbeat
When does a foetal heart beat occur?
Once the crown-rump length is 7mm or more
What should be done if miscarriage is suspected but CRL is <7mm?
Wait at leats one week to ensure the CRL is >7mm and re-ultrasound
What should be done if there is no foetal heart beat in a foetus with a CRL >7mm?
Repeat after 1 week to confirm non-viable pregnancy
When is a foetal pole expected on USS?
When mean gestational sac diameter is >25mm
What diagnosis is made if mean gestational sac diameter is >25mm but no foetal pole is found?
Anembryonic pregnancy
Management of miscarriage in those <6 weeks gestation?
Expectant management
Repeat urine HCG after 7-10 days to confirm miscarriage
3 options for managing miscarriage?
Expectant
Medical
Surgical
What occurs in expectant management of miscarriage
Offered 1st line if no other problems
1-2 weeks given to allow spontaneous miscarriage
Repeat HCG 3 weeks after bleeding and pain
Risks of expectant management of miscarriage
- 1/3 emergency admission
- Infection
- Require blood transfusion or surgery
- Retained tissue may require surgery
What medication is used in medical management of miscarriage
Misoprostol
Benefits of medical miscarriage management
Allows for a more predictable timeline
How is misoprostol given?
Vaginal suppository or oral dose
Side effects of misoprostol
Heavier bleeding
Pain
Vomiting
Diarrhoea
Risks of misoprostol
- 1/3 emergency admission
- Infection
- Require blood transfusion or surgery
- Retained tissue may require surgery
Contraindications of misoprostol
- Signs of septic miscarriage
- Haemorrhagic disorder
- Known IHD, MI or miltral stenosis
- Long term steroid therapy
- Suspected molar pregnancy
Cautions of misoprostol
- Severe IBD
- Moderate asthma
- Diabetes
What are the 2 surgical management options for miscarriage
Manual vacuum aspiration (Local anaesthetic)
Electric vacuum aspiration (general anaesthetic)
What is given prior to surgery for miscarriage
Misoprostol to soften the cervix
What is involved in manual vacuum aspiration
local anaestheticapplied to the cervix. A tube attached to a specially designed syringe is inserted through the cervix into the uterus. The person performing the procedure then manually uses the syringe to aspirate contents of the uterus.
Criteria for manual vacuum aspiration
Below 10 weeks gestation
Preferably parous
What is involved in electric vacuum aspiration
involves ageneral anaesthetic. The operation is performed through the vagina and cervix without any incisions. Thecervixis gradually widened using dilators, and the products of conception are removed through the cervix using an electric-powered vacuum.
Risks of surgical management of miscarriage
- Infection
- Lowest risk of heavy bleeding and retained tissue
- Surgical risk - Uterine perforation, cervical injury
Follow-up required after miscarriage
- Urinary pregnancy test in 3 weeks
- Call if HCG positive or concerns of pain/bleeding
Management options for incomplete miscarriage
- Medical management (misoprostol)
- Surgical management (evacuation of retained products of conception)
What is a complication of evacuation of retained products of conception
Endometritis
What is involved in evacuation of retained products of conception?
general anaesthetic. Thecervixis gradually widened using dilators, and the retained products are manually removed through the cervix usingvacuum aspirationandcurettage(scraping).
Management of threatened miscarriage
Micronised progesterone 400mg BD as vaginal suppositories increases chance of live birth
Criteria for progesterone treatment in threatened miscarriage
- Previous miscarriage
- Bleeding
- Normally sited pregnancy on scan
Def: Recurrent miscarriage
≥3 miscarriages
Risk of miscarriage with age
- 10% in women aged 20 – 30 years
- 15% in women aged 30 – 35 years
- 25% in women aged 35 – 40 years
- 50% in women aged 40 – 45 years
When are investigations into recurrent miscarriage started?
- Three or more first-trimester miscarriages
- One or more second-trimester miscarriages
Causes of recurrent miscarriages
- Idiopathic(particularly in older women)
- Anti-phospholipid syndrome
- Hereditary thrombophilias
- Uterine abnormalities
- Genetic factorsin parents (e.g.balanced translocationsin parental chromosomes)
- Chronic histiocytic intervillositis
- Other chronic diseases such asdiabetes, untreatedthyroid diseaseandsystemic lupus erythematosus
What is antiphospholipid syndrome?
Disorder associated withantiphospholipid antibodies, where blood becomes prone to clotting.
Complications of antiphospholipid syndrome
Thrombosis
Pregnancy complications
Recurrent miscarriage
Causes of antiphospholipid syndrome
Idiopathic
Autoimmune conditions (E.g. SLE)
Ways to reduce miscarriage risk in antiphospholipid syndrome
Low dose aspirin
Low molecular weight heparin
What are some forms of inherited thrombophilias that can cause recurrent miscarriage
- Factor V Leiden (most common)
- Factor II (prothrombin) gene mutation
- Protein S deficiency
Uterine abnormalities that increase risk of miscarriage
- Uterine septum(a partition through the uterus)
- Unicornuate uterus(single-horned uterus)
- Bicornuate uterus(heart-shaped uterus)
- Didelphic uterus(double uterus)
- Cervical insufficiency
- Fibroids
What is chronic histolytic intervillositis?
The condition is poorly understood.Histiocytesandmacrophagesbuild up in the placenta, causing inflammation and adverse outcomes.
Risks of chronic histolytic intervillositis
Recurrent miscarriage (Esp. 2nd trimester)
Intrauterine growth restriction (IUGD)
How is chronic histiocytic intervillositis diagnosed?
Infiltrates of mononuclear cells in the intervillous spaces on placental histology
Investigations required in recurrent miscarriage
- Antiphospholipid antibodies
- Testing for hereditary thrombophilias
- Pelvic ultrasound
- Genetic testing of theproducts of conceptionfrom the third or future miscarriages
- Genetic testing onparents
