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*GYNAE - > MISCARRIAGE > Flashcards

MISCARRIAGE Flashcards

1
Q

What weeks of gestation make up the first trimester?

A

0-12 weeks

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2
Q

What weeks of gestation make up the second trimester?

A

13-27 weeks

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3
Q

What weeks of gestation make up the third trimester?

A

28-40 weeks

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4
Q

What are the different types of miscarriage?

A

Threatened

Inevitable

Missed/delayed/silent

Complete

Incomplete

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5
Q

What is a threatened miscarriage?

A

Any bleeding that happens during the first 24 weeks of pregnancy, but where the pregnancy continues.

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6
Q

On examination of a woman suffering a threatened miscarriage will the cervix be open or closed?

A

Closed

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7
Q

What is an inevitable miscarriage?

A

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.

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8
Q

On examination of a woman suffering an inevitable miscarriage will the cervix be open or closed?

A

Open

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9
Q

What is a missed/delayed/silent miscarriage?

A

A miscarriage where a scan reveals a non-viable fetus or an empty intrauterine gestation sac without the patient having or noticing the bleeding.

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10
Q

On examination of a woman suffering missed/delayed/silent miscarriage will the cervix be open or closed? a ?

A

Closed

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11
Q

What is a complete miscarriage?

A

A miscarriage where the scan reveals that there are no more products of conception left in the uterus where the patient has had bleeding.

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12
Q

On examination of a woman suffering a complete miscarriage will the cervix be open or closed?

A

Closed

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13
Q

What is an incomplete miscarriage?

A

A miscarriage where the scan reveals that there are still products of conception left in the uterus where the patient has had bleeding.

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14
Q

On examination of a woman suffering an incomplete miscarriage will the cervix be open or closed?

A

Open

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15
Q

What are the symptoms of a miscarriage rather than a rupture of an ectopic pregnancy?

A

Pain - like period pains or contractions

Bleeding - clots or passing of tissue

Nausea

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16
Q

What are the risk factors that pre-dispose women to miscarriage? (Name at least 7)

A

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

17
Q

After how many miscarriages would you start to investigate the cause of miscarriage?

A

3

18
Q

What blood tests would you do in a women who presented with bleeding during first trimester of pregnancy?

A

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

19
Q

As well as blood tests, what other investigations would you perform in a women with bleeding during first trimester of pregnancy?

A

High vaginal swab - to check for infection

Ultrasound - to look for any products of conception in the uterus

20
Q

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?

A

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.

21
Q

How do we manage patients who have suffered a miscarriage?

A

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.

22
Q

What is ERPC?

A

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.

23
Q

What are the complications of ERPC?

A

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

24
Q

How can we minimise blood loss during ERPC procedure?

A

Syntocinon - synthetic oxytocin - given IV will encourage contraction and therefore minimise blood loss.

25
Q

What are the symptoms of endometritis?

A

Fever

Feeling unwell

Lower abdominal pain

Change in vaginal bleeding, which can become foul smelling and heavy

26
Q

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?

A

12 weeks (second trimester)

27
Q

What further tests can be performed for a couple who have had recurrent (more than 3 consecutive) miscarriages?

A

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.

28
Q

Name 3 Fetal causes of miscarriage

A
  1. Fetal abnormality - 50% of miscarried fetuses are gentically ( trisomy ) or structurally ( neural tube defects ) abnormal
  2. Infection of fetus - toxoplasma/rubella/tb
    - bacterial vaginosis : change in the natural flora of the vagina linked to second trimester miscarriage.
29
Q

Name 3 maternal causes of miscarriage

A
  1. Maternal age - miscarriage rate increases after 35 years of age
  2. Abnormal uterine cavity - fibroids/septums/adhesions/presence of intrauterine contraceptive devices
  3. Maternal illness - poorly controlled diabetes/Wilson’s disease
    - Antiphospholipid antibodies
    - Cervical weakness ‘incompetence’
30
Q

Surgical management of miscarriage

A
  1. Operative route - evacuation of retained products of conception.
  2. The cervix is dilated to allow suction or sharp curettage
  3. Syntocinon : given intravenously during procedure to encourage uterine contraction and minimum blood loss
    - Products of conception are sent for histolog
31
Q

Expectant management

A

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
32
Q

Medical management of miscarriage

A
  1. Prostaglandin analogues- Gemeprost or Misoprostol
    When used alone in high doses the prostaglandin analogues will induce expulsion of products of conception
  2. 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
33
Q

How does Gemeprost work?

A

Prostaglandin analogue which will induce expulsion of products of conception

34
Q

How does MIfepristone work?

A

Anti progesterone which increases the sensitivity of the myometrium to
prostaglandins by 5 times with maximal effect on uterine
contractility and cervical ripening

35
Q

When is expectant management the best choice?

A

Incomplete miscarriage

36
Q

Causes of recurrent miscarriage

A
  1. Parental genetic abnormality - 3 - 5%
  2. Uterine abnormality - submucosal/spetal/fibroid
  3. PCOS
  4. Antiphospholipid antibodies
  5. Thrombophillic defects - factor V Leiden
    mutation/Protein s/Antithrombin
  6. Cervical weakness/incompetence- secondary to cervical trauma caused by damage to child birth
    - operation causes forcible dilatation for late termination of pregnancy
  7. Bacterial vaginosis - imbalance of vaginal flora with lack of lactobacilli results in vaginosis

*GYNAE - (56 decks)

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