Miscarriage Flashcards
Bleeding in early pregnancy
Bleeding in early pregnancy associated with Miscarriage, Ectopic, Gestational Trophoblastic Disease or rarely, Gynaecological Lower Tract Pathology (E.g. Chlamydia, Ca Cervix, Polyp)
How common is miscarraige
Miscarriage is common; 15 – 20% of Pregnancies; Possibly 40% of Conceptions
o Most women who miscarry will have non-elevated risk after; Rare few recurrent
What is definition of miscarriage
=Expulsion of Pregnancy, Embryo or Foetus at a stage where it is incapable of independent survival; Includes losses before 24 weeks (Majority before 12 weeks)
What are early pregnancy assessment units for?
Readily available Transvaginal Ultrasound and Serum hCG measurement; Definitive diagnosis of Pregnancy and Miscarriage
How does hCG change in miscarriage?
hCG might be positive for up to 3 weeks after as renal excretion occurs
Risk factors for miscarriage
Chromosomal Problems, Placental Disorders, Maternal Age, Obesity, Smoking,
Drug Abuse, Caffeine intake (>2 cups coffee), ETOH, Diabetes, HTN, SLE, Thyroid issues, Infections (TORCHES), Food Poisoning (E.g. Listeriosis, Salmonella) Teratogenic Drugs,
Fibroids, Cervical Incompetence
Threatened Miscarriage
Bleeding and Abdo Pain; Cervix Undilated
o Anti-D prophylaxis should be given if >12wks or heavy bleeding/pain
o Gestation sac, Foetal Poles and Heart Activity on Ultrasound
Complete Miscarriage
Bleeding and Pain ceased; Cervix Undilated
o Anti-D prophylaxis if >12 wks; Serum hCG to exclude ectopic if any doubt
o Empty Uterus, Thinning Endometrium on Ultrasound
Incomplete Miscarriage
Bleeding and Pain; Cervix possibly dilated
Management of Expectant Management
If not heavily bleeding; Repeat TVUSS at 2 weeks to ensure complete; Offered surgical management if unsuccessful
Management of Medical Management
Prostaglandin Analogues (Misoprostol) usually with Antiprogesterone priming (Mifepristone); Bleeding might continue up to 3/52 after Uterine Evacuation; Might be associated with Pain and Heavy Bleeding in some; Admission might be required\
Management of Surgical Management
ERPC if excessive or persistent bleeding, or Request surgical management; Suction Curettage
Prostaglandins (E.g. Misoprostol, Gemeprost) minimises Trauma
Complications of surgical management
Infection, Haemorrhage, Uterine Perforation, RPOC, Intrauterine Adhesions (Asherman’s Syndrome), Cervical Tears, Intra-abdominal tears
Other support for miscarriage
Miscarriage is very distressing; Appropriate support, counselling and written information
Define recurrent miscarriage
≥3 Consecutive, Spontaneous miscarriages in First Trimester with same biological father
o Incidence 1 – 2%; Half unexplained
Antiphospholipid syndrome
Antiphospholipid Syndrome – 15% of women with Recurrent Miscarriages
o Anticardiolipin Antibodies or Lupus Anticoagulant Antibodies on two separate
occasions, with miscarriages/<34weeks prem with severe Pre-eclampsia
Genetic Disorders
Robertsonian Translocation of parent; Carrier phenotypically normal but
50 – 75% of gametes will be unbalanced; or Foetal Chromosomal Abnormalities
Reproductive Anatomical Risk factors for recurrent miscarriage
Uterine Abnormalities (Septae, Bicornate), Fibroids (Little data to support assertion)
Thrombophilia
Factor V Leiden and Factor II PT G20210A; Protein C, Protein S deficiency
have weak association
Infections
Bacterial Vaginosis; More likely to cause recurrent second trimester losses
Management of Recurrent Miscarriage
• Parental Karyotyping, Cytogenetic Analysis of POC (Post-miscarriage)
• Pelvic Ultrasound for structural abnormalities
• Thrombophilia Screening, Lupus Anticoagulant testing (dRVVT/aPTT), Anticardiolipin
Antibodies (aCL IgG and IgM)
• Insufficient evidence to screen if asymptomatic for Thyroid, Diabetes, Hyperprolactinaemia;
TORCH screening not helpful
• For Antiphospholipid Syndrome – Aspirin and Heparin commenced as soon as Foetal Viability
confirmed in first Trimester
• Proven Bacterial Vaginosis – Regular swabs and Rotating Prophylactic Abx (e.g. Clinda, Amox)
