Miscarriage

Question 1

Definition

Answer 1

Expulsion of products of conception before 24w. Recurrent miscarriage: 3 or more miscarriages in succession.

Question 2

Epidemiology

Answer 2

15-20% early pregnancies. Spontaneous recurrent miscarriage in 1% of women

Question 3

Causes of recurrent miscarriage

Answer 3

Antiphospholipid syndrome; Endocrine: diabetes, thyroid, PCOS; smoking; uterine abn; parental chromosomal abn.

Question 4

Types:

1. Threatened
2. Missed
3. Inevitable
4. Incomplete
5. Complete
6. Septic

Answer 4

1. Light PV bleed, Normal uterine size, None to mild abdo pain, closed os, 25% go on to miscarry.
2. Uterus X expel products of conception. Initially asymptomatic, os closed, uterine size small, PV bleed later. Early fetal demise=uterine pregnancy on USS but no Fetal heartbeat. Anembryonic pregnancy=gestation sac on USS but X fetus. Blighted ovum.
3. Heavy PV bleed, Os open, cramping abdo pain.
4. Not all POC expelled, heavy PV bleed, cramping abdo pain.
5. All contents expelled spontaneously. PV bleed and abdo pain cease. Uterus non-pregnant size.
6. Usually after incomplete miscarriage/TOP. Pelvic pain, heavy PV bleed/purulent discharge, signs of shock, fevers/rigors. Usually E.coli and GNB.

Question 5

First trimester loss

Answer 5

1. Fetal problems(50% miscarried fetuses hv genetic/structural defects)
2. Parental genetic abn.(3-5% recurrent miscarriages)
3. Age(>35y)
4. Smoking/alcohol/drugs
5. Obesity
6. Caffeine

Question 6

Second trimester(14-26w)

Answer 6

Mother’s health:

1. Infections
2. Endocrine: thyroid, diabetes, PCOS
3. Abn. uterine cavity: fibroids, IUD, scarring
4. Amniocentesis, CVS
5. Cervical incompetence
6. Antiphospholipid antibodies

Question 7

Management

Answer 7

1. hCG
2. Bloods ie FBC
3. USS
4. Swabs and Ab if indicated ie fever
5. Anti-D for Rh- if >12w gestation, surgical evacuation
6. Expectant:
   - follow up USS in 2w
   -can take 2-6w
   -successful >80% incomplete miscarriage, 30-70% missed miscarriage.
7. Medical:
   -Mifepristone(anti PG) then misopropstol(PG analogue) 48h later
   -successful in >80% incomplete miscarriage, 49-90% missed miscarriage
   -X mifepristone in incomplete/missed miscarriage
   -follow up USS 2w later
8. Surgical
   -Evacuation of retained POC
   -Indications: chosen by mom, heavy bleeding/signs of infection(req Ab cover)
   Success rate >95% for incomplete and missed miscarriage.
   -risk of uterine perforation <1%l

Question 8

Management(recurrent miscarriage)

Answer 8

1. Antiphospholipid syndrome
   - low-dose aspirin when pregnancy confirmed
   - LMWH from detection of fetal hearbeat until 34w
2. Tx infections ie BV
3. Cervical/abdominad cerclage