MISCARRIAGE Flashcards
What weeks of gestation make up the first trimester?
0-12 weeks
What weeks of gestation make up the second trimester?
13-27 weeks
What weeks of gestation make up the third trimester?
28-40 weeks
What are the different types of miscarriage?
Threatened
Inevitable
Missed/delayed/silent
Complete
Incomplete
What is a threatened miscarriage?
Any bleeding that happens during the first 24 weeks of pregnancy, but where the pregnancy continues.
On examination of a woman suffering a threatened miscarriage will the cervix be open or closed?
Closed
What is an inevitable miscarriage?
This is bleeding during the first 24 weeks of pregnancy where the internal os of the cervix is found to be open.
An inevitable miscarriage is what a threatened miscarriage has progressed to if cervical dilatation occurs.
On examination of a woman suffering an inevitable miscarriage will the cervix be open or closed?
Open
What is a missed/delayed/silent miscarriage?
A miscarriage where a scan reveals a non-viable fetus or an empty intrauterine gestation sac without the patient having or noticing the bleeding.
On examination of a woman suffering missed/delayed/silent miscarriage will the cervix be open or closed? a ?
Closed
What is a complete miscarriage?
A miscarriage where the scan reveals that there are no more products of conception left in the uterus where the patient has had bleeding.
On examination of a woman suffering a complete miscarriage will the cervix be open or closed?
Closed
What is an incomplete miscarriage?
A miscarriage where the scan reveals that there are still products of conception left in the uterus where the patient has had bleeding.
On examination of a woman suffering an incomplete miscarriage will the cervix be open or closed?
Open
What are the symptoms of a miscarriage rather than a rupture of an ectopic pregnancy?
Pain - like period pains or contractions
Bleeding - clots or passing of tissue
Nausea
What are the risk factors that pre-dispose women to miscarriage? (Name at least 7)
Past history of miscarriage
Maternal age 23% of pregnancies in over 40 year olds
PID and bacterial vaginosis
Tubal surgery eg previous for ectopic pregnancy
Peritonitis or pelvic surgery
Endometriosis
Intrauterine contraceptive device
Fibroids
IVF pregnancy
Maternal illness: Antiphospholipid syndrome, Wilson’s disease, diabetes, thyroid disease (both hypo and hyper), renal disease
Fetal abnormality - eg trisomy
After how many miscarriages would you start to investigate the cause of miscarriage?
3
What blood tests would you do in a women who presented with bleeding during first trimester of pregnancy?
FBC - anaemia is more likely to be the result of rupture ectopic pregnancy than miscarriage
Serum hCG - reducing levels of hCG over hours/days will confirm that the pregnancy has terminated
As well as blood tests, what other investigations would you perform in a women with bleeding during first trimester of pregnancy?
High vaginal swab - to check for infection
Ultrasound - to look for any products of conception in the uterus
What should you tell a woman who has recently suffered a miscarriage when she asks you when she can start trying to get pregnant again?
Physically there is no reason why she cannot conceive with her next cycle. Mentally it may be better to have a few months to recover from the miscarriage.
How do we manage patients who have suffered a miscarriage?
Pain relief
Warn patients of possibility of endometritis and safety net with symptoms to look for
The uterus can take some weeks to expel the products of conception. Women are therefore offered ERPC (evacuation of retained products of conception).
Discuss contraceptive options.
They should have a pregnancy test a week after experiencing bleeding to confirm that they are no longer pregnant and hence the differential of ectopic pregnancy can be ruled out.
What is ERPC?
Evacuation of retained products of conception. This is a procedure that involves dilating the cervix and then passing a curettage device into the woman’s uterus to remove any products of conception.
What are the complications of ERPC?
Perforated uterus - the pregnant uterus wall is much softer than the non-pregnant womb and hence it is easily perforated. Curettage must therefore be gentle.
Endometritis
How can we minimise blood loss during ERPC procedure?
Syntocinon - synthetic oxytocin - given IV will encourage contraction and therefore minimise blood loss.
What are the symptoms of endometritis?
Fever
Feeling unwell
Lower abdominal pain
Change in vaginal bleeding, which can become foul smelling and heavy
After how many weeks of gestation would you start worrying about blood types and whether the mother was Rhesus negative, in a woman who suffers a miscarriage?
12 weeks (second trimester)
What further tests can be performed for a couple who have had recurrent (more than 3 consecutive) miscarriages?
Karyotyping of both partners and products of conception where appropriate
High vaginal swab to screen for bacterial vaginosis
Antiphospholipid antibody assays on 2 occasions 6 weeks apart
Investigation for cervical weakness.
Name 3 Fetal causes of miscarriage
- Fetal abnormality - 50% of miscarried fetuses are gentically ( trisomy ) or structurally ( neural tube defects ) abnormal
- Infection of fetus - toxoplasma/rubella/tb
- bacterial vaginosis : change in the natural flora of the vagina linked to second trimester miscarriage.
Name 3 maternal causes of miscarriage
- Maternal age - miscarriage rate increases after 35 years of age
- Abnormal uterine cavity - fibroids/septums/adhesions/presence of intrauterine contraceptive devices
- Maternal illness - poorly controlled diabetes/Wilson’s disease
- Antiphospholipid antibodies
- Cervical weakness ‘incompetence’
Surgical management of miscarriage
- Operative route - evacuation of retained products of conception.
- The cervix is dilated to allow suction or sharp curettage
- Syntocinon : given intravenously during procedure to encourage uterine contraction and minimum blood loss
- Products of conception are sent for histolog
Expectant management
Expectant management - risk of infection with retained products
- wait for uterus to expel products of conception
- may take weeks if left to happen spontaneously
- booked for follow up appointment and scan to confirm uterus is empty
Medical management of miscarriage
- Prostaglandin analogues- Gemeprost or Misoprostol
When used alone in high doses the prostaglandin analogues will induce expulsion of products of conception - Mifepristone
increases the sensitivity of the myometrium to
prostaglandins by 5 times with maximal effect on uterine
contractility and cervical ripening at 36–48 hours
following treatment
How does Gemeprost work?
Prostaglandin analogue which will induce expulsion of products of conception
How does MIfepristone work?
Anti progesterone which increases the sensitivity of the myometrium to
prostaglandins by 5 times with maximal effect on uterine
contractility and cervical ripening
When is expectant management the best choice?
Incomplete miscarriage
Causes of recurrent miscarriage
- Parental genetic abnormality - 3 - 5%
- Uterine abnormality - submucosal/spetal/fibroid
- PCOS
- Antiphospholipid antibodies
- Thrombophillic defects - factor V Leiden
mutation/Protein s/Antithrombin - Cervical weakness/incompetence- secondary to cervical trauma caused by damage to child birth
- operation causes forcible dilatation for late termination of pregnancy - Bacterial vaginosis - imbalance of vaginal flora with lack of lactobacilli results in vaginosis
