Miscarriage Flashcards
What is a miscarriage?
Loss of a pregnancy at less than 24 weeks gestation
What is an early miscarriage?
Loss in the first trimester (weeks 1-12)
What is a late miscarriage?
Loss between weeks 13-24
What are risk factors for miscarriage?
Maternal age >30-35 Previous miscarriage Obesity Maternal/paternal chromosomal abnormalities Smoking Uterine anomalies Antiphospholipid syndrome
What are the clinical features of miscarriage?
Vaginal bleeding
Abdominal cramping
What examinations are indicated in a potential miscarriage?
Assess for haemodynamic instability
Abdominal exam
Speculum exam
Bimanual examination
What are differential diagnoses for miscarriage?
Ectopic pregnancy
Hydatidiform mole
Cervical/uterine malignancy
Where are most patients with a suspected miscarriage investigated?
Early pregnancy units
What investigations are done for a suspected miscarriage?
Transvaginal ultrasound
- mean sac diameter
- > 25mm = failed pregnancy
- <25mm = repeat scan in 10-14 days
How are miscarriages managed conservatively?
Allow the products of conception to pass naturally
What are the advantages of conservative management?
Can remain at home
No medication side effects
What are the disadvantages of conservative management?
Unpredictable timing
Heavy bleeding + pain
Chance of needing further intervention
What is the follow up of conservative management?
Repeat scan in 2 weeks
Pregnancy test 3 weeks later
What is the medical management of miscarriage?
Use of vaginal misoprostol (prostaglandin analogue)
- stimulate cervical ripening
- stimulate myometrial contractions
Usually preceded by mifepristone 24-48 hours before
What are the advantages to medical management?
Can be at home if desired
What are the disadvantages of medical management?
Medication side effects
- D+V
Heavy bleeding + pain
What is the follow up for medical management?
Pregnancy test 3 weeks later
What is the surgical management of miscarriages?
<12 weeks = manual vacuum aspiration with local anaesthetic
Evacuation of retained products of conception
What are indications for surgical management?
Haemodynamic instability
Infected tissue
Gestational trophoblastic disease
What are the advantages of surgical management?
Planned procedure
Patient unaware during procedure
What are disadvantages of surgical management?
Anaesthetic risk Infection Uterine perforation Haemorrhage Asherman's syndrome Retained products of conception
What is Asherman’s syndrome?
Existence of scar tissue/adhesions in uterus
What are the types of miscarriage?
Threatened Inevitable Missed Complete Incomplete Septic
What are the clinical features of a threatened miscarriage?
Mild bleeding
+/- pain
Cervix closed
What does transvaginal USS show in a threatened miscarriage?
Viable pregnancy
What is the management of a threatened miscarriage?
Reassure
Heavy bleeding = admit/observe
> 12 weeks + Rhesus neative = anti-D
What are the clinical features of an inevitable miscarriage?
Heavy bleeding
Clots
Pain
Cervix open
What does a transvaginal ultrasound show in an inevitable miscarriage?
Internal os open
Foetus can be viable or non viable
How is an inevitable miscarriage managed?
Offer conservative/medical/surgical options - likely to proceed to incomplete/complete miscarriage
> 12 weeks + Rhesus negative = anti-D
What is a missed miscarriage?
Miscarriage found incidentally on ultrasound
What are the clinical features of a missed miscarriage?
Asymptomatic
Hx of threatened miscarriage
On-going discharge
Uterus small for dates
What does a transvaginal ultrasound show in a missed miscarriage?
No foetal heart pulsation in a foetus where the crown length >7mm
How is a missed miscarriage managed?
Rescan + second person to confirm
Manage conservatively, medically or surgically
> 12 weeks + Rhesus negative = anti-D
What is an incomplete miscarriage?
Miscarriage where the products of conception have been partially expelled
What are the clinical features of an incomplete miscarriage?
Products of conception partially expelled
Bleeding
What does a transvaginal ultrasound show in an incomplete miscarriage?
Retained products of conception
A/P endometrial diameter >15mm
Proof there was an intrauterine pregnancy
How is an incomplete miscarriage managed?
Manage conservatively, medically or surgically
> 12 weeks + Rhesus negative = anti-D
What is a complete miscarriage?
Miscarriage where the products of conception are completely expelled
What are the clinical features of a complete miscarriage?
Hx of bleeding
Passing clots/products of conception
Pain
Symptoms settling
What does a transvaginal ultrasound show in a complete miscarriage?
No POC seen in uterus
Endometrium <15mm diameter
Previous proof of intrauterine pregnancy
How is a complete miscarriage managed?
Discharge to GP
Manage conservatively, medically or surgically
> 12 weeks + Rhesus negative = anti-D
What is a septic miscarriage?
Infected products of conception
What are the clinical features of a septic miscarriage?
Infected products of conception Fever Rigors Uterine tenderness Bleeding/discharge Pain
What does a transvaginal ultrasound show in a septic miscarriage?
Features of complete/incomplete miscarriage
What will blood results show in a septic miscarriage?
Leucocytosis
Raised CRP
How is a septic miscarriage managed?
Medical + surgical management
IV antibiotics
IV fluids
> 12 weeks + Rhesus negative = anti-D
What is recurrent miscarriage?
3 or more consecutive miscarriages
What can cause recurrent miscarriage?
Idiopathic Antiphospholipid syndrome Genetic problems Uterine abnormalities Hereditary thrombophilias
How is recurrent miscarriage investigated?
Antiphospholipid antibodies
Thrombophilia screen
Pelvic USS
Genetic testing
- parents
- POC from 3rd miscarriage onwards
What are the antiphospholipid antibodies?
Anticardiolipin
Lupus anticoagulant
How is recurrent miscarriage managed?
Treat underlying cause
How is antiphospholipid syndrome managed?
Low dose aspirin + LMWH
