Miscarriage Flashcards
What is a miscarriage?
Loss of pregnancy before 24 weeks gestation
How do miscarriages present?
Mostly in 1st trimester
PV bleeding
Pregnancy test may be +ve several days after pregnancy loss
What should you consider in early pregnancy bleeding?
Haemodynamically stable?
Blood loss?
Products of contraception in cervical canal?
Pain and bleeding worse than period?
Products seen?
Is uterine size appropriate for date?
Is she bleeding from a cervical lesion and not from within uterus
What is threatened miscarriage?
Inevitable miscarriage?
Incomplete miscarriage?
How do you manage profuse bleeding
Threatened:
- Symptoms are mild and cervical os is closed
Inevitable:
- symptoms are severe and cervical os is open
Incomplete:
- most of the products have already been passed
Manage profuse bleeding with ergometrine
What is missed miscarriage? Management?
Fetus dies but remains in utero
Bleeding and/or pain or no symptoms
Cervix is closed
Confirm with US
Mifepristone and misoprostol as medical management of miscarriage
What is pregnancy of uncertain viability?
Intrauterine gestation sac < 25mm with no feat pole or yolk sac
Or crown rump length < 7mm with no fetal heart activity
What is expectant management of miscarriage?
Advantages
Disadvantages
Follow up
Wait for natural delivery of conception prodcuts
Appropriate if the woman is not bleeding heavily
Effective for incomplete miscarriage but less so for missed miscarriage
Offer rescan in 2 weeks to ensure complete if there has been no significant bleeding
Advantages: Can remain at home, no side effects of medication, no anaesthetic or surgical risk.
Disadvantages: Unpredictable timing, heavy bleeding and pain during passage of POC, chance of being unsuccessful requiring further intervention and need for transfusion.
Follow-up: Some units will arrange a repeat scan in two weeks. Others will arrange a pregnancy test 3 weeks later.
Contraindications: Infection, high risk of haemorrhage ie. Coagulopathy, haemodynamic instability.
Describe medical management of miscarriage?
Advantages
Disadvantages
Follow up
Mifepristone (antiprogestagen) to prime
Then 24-48h later misoprostol either oral or PV
Bleeding may continue for 3 weeks following
Advantages: Can be at home if patient desires, with 24/7 access to gynaecology services, avoid anaesthetic and surgical risk.
Disadvantages: Side effects of medication: vomiting/diarrhoea, heavy bleeding and pain during passage of POC, chance of requiring emergency surgical intervention.
Follow-up: Pregnancy test 3 weeks later
What are indications of surgical management of miscarriage? Method?
Advantages
Disadvantages
Follow up
Heavy or persistent bleeding > 2 weeks
Unacceptable pain
Significant retained products on US
Patient choice
Suction evacuation used usually under GA and < 13 weeks
Advantages: Planned procedure (may help patient to cope with miscarriage), unaware during the process (patient under general anaesthetic).
Disadvantages: Anaesthetic risk, infection (endometeritis), uterine perforation, haemorrhage, Ashermen’s syndrome, bowel or bladder damage, retained products of conception.
What are causes if mid-trimester miscarriage?
Mechanical causes: Cervical weakness (rapid, painless delivery of a fetus) Uterine abnormaliteit Chronic maternal disease (DM, SLE) Infection e.g. CMV No cause
What should you consider after a miscarriage? What are causes of early pregnancy miscarriages
Parents space to grieve
Offer follow up
Fetal products should be incinerated but if the mother requests alternative disposal (to bury) respect her wishes
Give in opaque container
Most early pregnancy losses are due to aneuploidy and abnormal fatal development
What is recurrent miscarriage?
Loss of 3 or more consecutive pregnancies before 24 weeks gestation with the same biological father
What are possible causes of recurrent miscarriage?
Endocrine Infection: bacterial vaginosis associated with 2nd trimester loss Parental chromosome abnorality Uterine abnorlaity Antiphospholipid syndrome Thrombophilia Alloimmune causes
What chromosomal abnormality causes miscarriage?
Usually a balanced reciprocal or Robertsonian translocation
Parent is phenotypically normal but 50-75% of gametes will be unbalanced
Offer genetic counselling
What is antiphospholipid syndrome? What antibodies?
Autoimmune, hypercoagulable state caused by antiphospholipid antibodies. APS provokes blood clots (thrombosis) in both arteries and veins as well as pregnancy-related complications such as miscarriage, stillbirth, preterm delivery, and severe preeclampsia.
