Miscarriage

Question 1

Define miscarriage

Answer 1

Fetus dies or delivers dead prior to 24 completed wks pregnant

Question 2

Outline miscarriages epidemiology

Answer 2

• Majority <12wks
• 15% of recognised pregnancys spontaneously miscarry (more go unnoticed)
• Risk inc with maternal age

Question 3

Define a Threatened miscarriage

Answer 3

• Bleeding but fetus still alive
• Uterus is expected size & os is closed 25% go on to miscarry

Question 4

Define Inevitable miscarriage

Answer 4

• Heavy bleeding Cervical os open
• Fetus may be alive but miscarriage is about to occur

Question 5

Define Incomplete miscarriage

Answer 5

• Some fetal parts have been passed
• Os usually open

Question 6

Define Complete miscarriage

Answer 6

• All fetal tissue passed
• Bleeding diminished, uterus no longer enlarged, cervical os closed

Question 7

Define Septic miscarriage

Answer 7

• Contents of uterus infection causing endometritis
• Vaginal loss offensive, uterus tender
• Fever can be absent

Question 8

Define Missed miscarriage

Answer 8

• Fetus has not developed OR died in uterus but gone unnoticed
• Uterus smaller than expected & os is closed

Question 9

Outline the Aetiology of sporadic miscarriage

Answer 9

• >60% - Isolated non-recurring chromosomal abnormalities
• Exercise, intercourse, stress & emotional trauma do not cause miscarriage

Question 10

Outline the clinical presentation of miscarriage

Answer 10

• Bleeding
• Pain
• Passed tissue
• Examination:
  
  • Uterus size & cervical os dependant on type of miscarriage

Question 11

Draw a flow diagram depicting the investigations & diagnoses of a women presenting with pain & bleeding, query miscarriage

Answer 11

Question 12

Outline the management of non-viable intrauterine pregnancy

Outline the risks of each

Answer 12

1. Conservativen [expectant]
   
   • ​​Wait 2-8wks
   • Risks: DIC [disseminated intravascular coagulation]
2. Medical
   
   • ​​Mifepristine [progestogen antagonist]
   • Misoprostol [prostaglandin E₁ analog]
   • Risks: Bleeding & retained products
3. Theatre
   
   • ​​Evacuation of retained products of conception (ERCP)
   • Risks: Perforation of uterus

Question 13

Outline the management of a viable intrauterine pregnancy

eg Threatened miscarriage

Answer 13

90% will not miscarry

No ‘treatment’

Bed rest, hormone treatment [progesterone or hCG] do not help.

Question 14

When would you admit a patient with regards to miscarriage

Answer 14

• Ectopic suspected
• Septic miscarriage
• Heavy bleeding

Question 15

Outline symptomatic management regarding miscarriage

Answer 15

• IM Ergometrine: reduce bleeding by contracting uterus [only non-viable]
• Analgesia

Question 16

When is Anti-D given?

Answer 16

Mothers who are rhesus negative if miscarriage is treated surgically or medically, OR if bleeding is after 12wks

Question 17

Does counselling play a role after miscarriage?

Answer 17

Patients should be told it was not anything they did or did not do

Could not have been prevented

REASSURE of successful future pregnancies

Question 18

Define Recurrent miscarriage

Answer 18

3 or more miscarriages in succession

Question 19

Outline the epidemiology of Recurrent miscarriage

Answer 19

1% of couples

Chance of miscarriage in 4th pregnancy is only 40%

BUT recurring cause is more likely & investigations & support should be arranged

Question 20

Outline possible causes of Recurrent miscarriage

Answer 20

1. **Antiphospholipid ABs **[screen at 6wks]
   
   • Thrombosis in uteroplacental circulation
   • Treatment: Aspirin & low-dose LMWHeparin
2. Chromosomal defects
   
   • ​Parental karyotyping → refer to geneticist
   • Donor? Preimplantation genetic screening (PGS) of IVF embryos
3. Anatomical factors
   
   • Uterine abnormalities [USS]
   • Cervical incompetence [recurrent cause of late >16wks miscarriage & preterm labour
   • Treatment: Surgery? May lead to weakness/ adhesion
4. Infection
   
   • Recurrent cause of late >16wks miscarriage & preterm labour
5. Lifestyle/ other
   
   • ​​Obesity, smoking, PCOS, excess caffeine, higher maternal age