Miscarriage Flashcards
What is a miscarriage? - think of time frame
Loss of pregnancy <24 wks
Define missed miscarriage
Fetus dies but is retained
Define early pregnancy loss
Loss < 6 wks
Define anembryonic pregnancy
Empty gestational sac
Define threatened miscarriage
Mild symptoms and OS closed
Define inevitable miscarriage
Severe symptoms and OS open, which will progress to incomplete or complete miscarriage
Define incomplete miscarriage
Not all products passed, but no fetal HR - OS may be open or closed
Define complete miscarriage
Symptoms over, empty uterus and os closed
What are most due to?
Chromosomal abnormal fetuses
Symptoms:
Why type of PV discharge do they get?
Where may they get pain? - 2
Signs:
What at the cervix may indicate an imminent miscarriage?
What may speculum show?
What about the fetal measurement could have indicated imminent miscarriage?
PV bleeding - usually greater than period blood
Passage of products of conception
Open os
Show pregnancy tissue or other cause of the bleed
Small for gestational age fetus
Risk factors:
Diseases?
Abnormalities?
Coagulopathies also increase risk.
SLE
Age
Diabetes
Smoking
BV (Bacterial vaginosis)
Uterine or cerRvical abnormality, including fibroids
DDx of PV bleeding in early pregnancy
Miscarriage
Ectopic pregnancy - usually more painful, with darker and heavier bleeding
Molar pregnancy - uterus may be large for dates
Local lesion (e.g. polyps, cancer)
Cervicitis
Investigations:
Bedside and bloods:
- How long does urine and serum beta-hCG remain positive for?
- What will the serum levels show?
- What do you need to check for because they have been bleeding?
- What may you also need to check to prevent sensitisation?
Imaging:
- What is done?
Up to 3 wks
Falling level
Anaemia
TVUS - confirms viable pregnancy, miscarriage, and rules out other bleeding causes
Mid-trimester:
What may cause it?
Mechanical causes:
- Cervical weakness
- Uterine abnormalities
- Chronic maternal disease
Infection
Management - Conservative:
What type of miscarriage is this usually appropriate for?
What does it increase the risk of?
What should be checked 3 wks later?
Threatened miscarriage
Increased risk of premature labour
Pregnancy test - checking beta-hCG
Management - Inevitable, incomplete, or missed miscarriage:
How is the visual pregnancy tissue removed?
What drug is given to induce uterine contractions and open the cervical os?
What should you warn the patient about?
What should you give patients for the pain?
What can also be done if symptoms and/or tissue is minimal?
Manually or with sponge-holding forceps
Misoprostol PV or PO
Warn women they may bleed for up to 3 wks after
Analgesia
Trial conservative - WATCH & WAIT
Management - Surgical:
What is ERPC?
Indications
Procedures
What should be given if they are Rhesus negative?
Complications
Evacuation of retained products of conception
Heavy bleeding
Severe pain
Lots of tissue
Vacuum aspiration under LA
Vacuum or curettage under GA
Anti-D prophylaxis
Infection
Bleeding
Uterine perforation
Trauma
Adhesions
Counselling:
Offer follow up!!!
How many miscarriages would they have before they are classed as high risk of miscarriage?
What need to be reassured to them?
How long should they wait before trying for another baby, so they don’t confuse the gestational age?
Offer follow up
3 consecutive miscarriages
Tell them it is common and there is nothing they did wrong
Wait until next period
Recurrent miscarriages causes:
Infection - what vaginal issue may increase the risk of miscarriage?
Parental chromosomal abnormality - what is it?
What might be wrong with the uterus that increases risk?
BV - 2nd trimester
Unbalanced gametes
Robertsonian translocation (ROB) is a chromosomal abnormality wherein a certain type of a chromosome becomes attached to another. It is the most common form of chromosomal translocation in humans, affecting 1 out of every 1,000 babies born.
Uterine abnormalities - septae etc.
Recurrent miscarriages causes:
Antiphospholipid syndrome:
- What is it?
- Why does it cause miscarriage?
- When would this be investigated?
- How is it investigated?
- How is it treated?
An immune system disorder that increases the risk of blood clots.
Clots affecting blood flow to the foetus
If they have had recurrent OR late miscarriages
2 positive tests, 12 wks apart
Blood thinners - enoxaparin or aspirin - started once they know they are pregnant
Recurrent miscarriages causes:
Thrombophilia:
- why does it cause miscarriage?
- how is this picked up?
Recommendations:
- Where are women with recurrent miscarriages referred to?
- What is done to assess uterus?
- What should be done for the miscarriages occurring 3 times and more?
Some research suggests that clots can cause abnormal blood flow to the uterus and make miscarriage more likely.
Thrombophilia screening
Specialist recurrent miscarriage clinic
Pelvic USS
Karyotype fetal products (3rd and subsequent fetal losses)
