Miscarriage

Question 1

What is a miscarriage? - think of time frame

Answer 1

Loss of pregnancy <24 wks

Question 2

Define missed miscarriage

Answer 2

Fetus dies but is retained

Question 3

Define early pregnancy loss

Answer 3

Loss < 6 wks

Question 4

Define anembryonic pregnancy

Answer 4

Empty gestational sac

Question 5

Define threatened miscarriage

Answer 5

Mild symptoms and OS closed

Question 6

Define inevitable miscarriage

Answer 6

Severe symptoms and OS open, which will progress to incomplete or complete miscarriage

Question 7

Define incomplete miscarriage

Answer 7

Not all products passed, but no fetal HR - OS may be open or closed

Question 8

Define complete miscarriage

Answer 8

Symptoms over, empty uterus and os closed

Question 9

What are most due to?

Answer 9

Chromosomal abnormal fetuses

Question 10

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?

Answer 10

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

Question 11

Risk factors:

Diseases?

Abnormalities?

Coagulopathies also increase risk.

Answer 11

SLE
Age
Diabetes
Smoking

BV (Bacterial vaginosis)

Uterine or cerRvical abnormality, including fibroids

Question 12

DDx of PV bleeding in early pregnancy

Answer 12

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

Question 13

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?

Answer 13

Up to 3 wks

Falling level

Anaemia

TVUS - confirms viable pregnancy, miscarriage, and rules out other bleeding causes

Question 14

Mid-trimester:

What may cause it?

Answer 14

Mechanical causes:
- Cervical weakness
- Uterine abnormalities
- Chronic maternal disease

Infection

Question 15

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?

Answer 15

Threatened miscarriage

Increased risk of premature labour

Pregnancy test - checking beta-hCG

Question 16

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?

Answer 16

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

Question 17

Management - Surgical:

What is ERPC?

Indications

Procedures

What should be given if they are Rhesus negative?

Complications

Answer 17

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

Question 18

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?

Answer 18

Offer follow up

3 consecutive miscarriages

Tell them it is common and there is nothing they did wrong

Wait until next period

Question 19

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?

Answer 19

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.

Question 20

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?

Answer 20

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

Question 21

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?

Answer 21

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)