Miscarriage

Question 1

Definition of recurrent miscarriage

Answer 1

3 or more consecutive, spontaneous miscarriages

occurring in the first trimester with the same biological father, which may or may not follow a successful birth.

Question 2

Investigations for recurrent 1st trimester or one or more 2nd trimester miscarriage

Answer 2

Anti-phospholipid antibody testing
Thrombophilia screen

For placenta (for the 3rd or more miscarried child)

• Placental karyotyping –> if abnormal, perform peripheral blood karyotyping
• placental histology
• Pelvic USS

Question 3

Investigations for 2nd trimester miscarriage

Answer 3

thrombophilia screening

Pelvic USS

Question 4

Treatment of anti-phospholipid syndrome

Answer 4

Low dose aspirin + heparin

Question 5

Causes of recurrent miscarriage

Answer 5

Maternal factors: alcohol + smoking
Inherited conditions: anti-phospholipid syndrome, thrombophilias
Anatomical weakness: Cervical weakness, uterine abnormalities
Genetic factors: Parental, embryonic
Infection: TORCH infection
Endocrine factors: PCOS

Question 6

Treatment for recurrent miscarriage attributed to cervical weakness

Answer 6

Cervical cerclage if cervix < 25mm before 24 weeks gestation

Question 7

Monitoring for history of second-trimester miscarriage and suspected cervical weakness who have not undergone cerclage

Answer 7

Cervical sonographic surveillance

Question 8

Types of miscarriages

Answer 8

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

Question 9

Os for the different types of miscarriages?

Answer 9

Os open:

1. Inevitable
2. Incomplete

Os closed:

1. Threatened
2. Complete
3. Missed

Question 10

What ultrasound findings indicates missed miscarriage?

Answer 10

Empty gestational sac (suggests blighted ovum)

Absent fetal heart activity (baby died in utero)

Question 11

Test to monitor progress of miscarriage?

Answer 11

B-hCG (falling or plateauing in miscarriage)

Question 12

Three types of Tx for miscarriage

Answer 12

1. Expectant
2. Misoprostol (prostaglandin analogue)
3. Surgical evacuation

Question 13

Post-miscarriage things to do

Answer 13

1. Offer counselling
2. Anti-D injections
3. For women who want to get pregnant again, advise they can start to try when they feel psychologically ready
4. Advise to avoid intercourse until all miscarriage symptoms are gone

Question 14

A 30-year-old female who is 10 weeks pregnant presents to the emergency gynaecology unit after noting 2 episodes of foul-smelling red vaginal discharge. There is associated lower back pain and she has a temperature of 39ºC. Blood pressure is 85/65 mmHg. A transvaginal ultrasound confirms an inevitable miscarriage. What is the most appropriate management in this case?

A. Mifepristone
B. Vaginal misoprostol
C. Expectant management
D. Surgical Mx
E. Methotrexate

Answer 14

Surgical Mx - because of risk of developing septic miscarriage and haemodynamic instability

Question 15

A 28-year-old woman attends the early pregnancy assessment unit at 7 weeks gestation due to heavy vaginal bleeding. Ultrasound confirms an intra-uterine miscarriage.

After 14 days of expectant management the patient attends for follow up. She describes ongoing light vaginal bleeding. There are no signs of ectopic pregnancy and she is haemodynamically stable. Ultrasound scan confirms incomplete miscarriage.

What is the most appropriate next step?

A. Admission and observation
B. Manual evacuation under local anaesthetic
C. Oral methotrexate
D. Surgical Mx under GA
E. Vaginal misoprostol

Answer 15

E. Vaginal misoprostol

Medical management is offered if expectant management is not clinically appropriate or a woman has ongoing symptoms after 14 days of expectant management.