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Reproductive Health > Miscarriage > Flashcards

Miscarriage Flashcards

1
Q

What is a miscarriage?

A

Spontaneous loss of pregnancy before 24 weeks of gestation

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2
Q

When do most miscarriages tend to occur?

A

In the first trimester

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3
Q

What percentage of all women who become pregnant will have 1 or more miscarriages?

A

25%

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4
Q

What is the major cause of first trimester miscarriages?

A

Chromosomal abnormalities

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5
Q

What percentage of the population has recurrent miscarriages?

A

About 1%

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6
Q

What classifies as recurrent miscarriage?

A

3 or more consecutive miscarriages

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7
Q

What is an early miscarriage?

A

<13 weeks

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8
Q

What is a late miscarriage?

A

13-24 weeks

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9
Q

What types of miscarriages are there?

A 
Threatened
Inevitable
Incomplete
Complete 
Septic 
Missed
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10
Q

Describe a threatened miscarriage

A

Bleeding and or pain up to 24/40m but TVUSS shows a foetal heart (viable pregnancy)
Closed cervical os
75% will settle
Carry high risk of preterm delivery and preterm rupture of membranes

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11
Q

Describe an inevitable miscarriage

A 
Non viable pregnancy
Vaginal bleeding (heavy, clots, pain) 
Open internal cervical os 
Products of conception have not been passed, but they inevitably will
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12
Q

Describe an incomplete miscarriage

A

Some products of conception passed
Some tissues and blood remain within uterus
Cervix stays open until all tissue passed

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13
Q

Describe a complete miscarriage

A

All products of conception passed
History of bleeding, passing clots and POC and pain that have now stopped
Cervix closed
No POC seen in uterus with endometrium than is <15mm diameter and previous proof of intrauterine pregnancy ie scan

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14
Q

What is a missed (delayed) miscarriage?

A

A gestational sac which contains a dead fetus before 20 weeks without symptoms of expulsion
Mother may have light bleeding/discharge
Cervical os closed
When the gestational sac >25mm and no fetal part can be seen - described as a blighted ovum or anembryonic pregnancy

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15
Q

What causes are there?

A

In most cases no identifiable cause
Abnormal fetal development - chromosomal and structural abnormalities (trisomy = most common abnormality, trisomy 16 especially)
Maternal conditions:
- infections e.g BV, CMV, rubella, HSV, toxoplasmosis, parvovirus B19
- antiphospholipid syndrome
- SLE
- thrombophilia
- endocrine problems e.g PCOS, thyroid disease, DM, hyperprolactinaemia
- genetic abnormalities in the parents
Uterine conditions
Incompetent cervix - previous cervical surgery
Iatrogenic - amniocentesis, CVS
Social factors - smoking, alcohol, cocaine

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16
Q

What uterine factors can cause miscarriages?

A

Septate, bicornuate or acute uterus can affect development of growing foetus
Cervical incompetence- not allowing normal development
Fibroids - can distort the uterus

17
Q

What risk factors are there?

A

Advanced maternal age
Previous miscarriage (especially 2)
Lifestyle - smoking, obesity, alcohol, drug use (NSAIDS and street drugs)
Folate deficiency e.g methotrexate
Consanguinity
Paternal factors - tight (bottom) clothing, sperm abnormalities, old paternal age
Environmental- high dose radiation, heavy metal exposure

18
Q

Describe the pathophysiology

A

Haemorrhage occurs in the decidua basalis leading to necrosis and inflammation
Ovum unable to continue development- initiates uterine contractions, cervix dilates causing loss of fetus and pregnancy tissue

19
Q

Why is a complete miscarriage more likely before 12 weeks?

A

The placenta is unlikely to have been independently developed - thus being expelled with fetus

20
Q

Why is an incomplete miscarriage more likely to occur if the miscarriage occurs between 12-24 weeks?

A

The gestation sac is more likely to rupture and the fetus then expelled while parts of the placenta remain in the uterus

21
Q

What are the clinical features?

A

Vaginal bleeding - vary from brownish light spotting to heavy bright red blood with clots
Lower abdominal cramping pain
Vaginal fluid/discharge/tissue discharge
Loss of pregnancy symptoms - no more nausea, breast tenderness
Lower back pain
A missed miscarriage often does not present with any symptoms

22
Q

What investigations should be done?

A

Urine pregnancy test
Transvaginal USS - if unable to determine status of fetus a repeat scan will be done after minimum 7 days
If the crown rump length is <7mm and no fetal heart, a conclusive diagnosis of miscarriage cannot be made - so repeat scan in at least 7 days
Serum beta-human chorionic gonadotropin (bhCG) levels
FBC, blood group and rhesus status
Triple swabs and CRP if pyrexial

23
Q

If serum bhCG is > 1500 and nothing seen in uterus, what does this suggest?

A

Chances of ectopic high

24
Q

If bhCG level is low what should be done?

A

Further bhCG 48 hours later - establish if pregnancy developing properly
A rise by 63% - most likely intrauterine pregnancy, but 10% of ectopics have a normally rising bhCG so should not be falsely reassured - bring patient back 1 week later for USS

25
Q

If second bhCG does not rise by 63%, what is likely?

A

Ectopic

Could be intrauterine not developing properly

26
Q

What produced bhCG?

A

The placenta, so bhCG levels will decrease after miscarriage

27
Q

What differentials are there?

A 
Ectopic pregnancy - but pain usually unilateral, more severe and before bleeding presents, bleeding darker and less heavy
Molar pregnancy 
Ruptured ovarian corpus luteum cyst
Ovarian torsion 
Fibroid degeneration 
Non pregnancy related:
Cervicitis 
Cervical ectropian 
Cervical polyps 
Cancers 
Haemorrhoids
28
Q

What 3 types of management options are there?

A

Expectant
Medical
Surgical

29
Q

Describe the expectant approach

A

Waiting for spontaneous miscarriage
Waiting for 7-14 days
Need 24 hour access to gynae services
Advantages: at home, avoid risk of surgery/medication
Disadvantages: pain and bleeding unpredictable, takes longer, may be unsuccessful
Follow up: repeat scan in 2 weeks or pregnancy test 3 weeks later

30
Q

Describe medical management

A

Drugs used to encourage pregnancy to come away
Vaginal misoprostol - prostaglandin analogue
Stimulates cervical ripening and myometrial contractions
Give with antiemetics and pain relief
Advantages: avoid surgery, done as outpatient
Disadvantages: pain and bleeding, side effects of drug, 5% emergency SERPC
Follow up: pregnancy test 3 weeks later

31
Q

How does misoprostol work?

A

Binds to myometrial cells for cause strong contractions leading to expulsion of tissue

32
Q

What is the surgical option?

A

Suction curette to empty uterus
5 minutes under GA
Can do via local - NVA

33
Q

What are the disadvantages of surgical option?

A

Perforation of bowel/bladder
Cervix damage
Asherman’s
Anaesthesia risk

34
Q

What complications can occur with miscarriage?

A

Incomplete
Haemorrhagic shock due to excessive bleeding
Infection - retained tissue
Psychological complications
HDN - give anti-D to Rhesus neg women who have had surgical intervention
Increased risk of another miscarriage

35
Q

What should be done 3 weeks after medical management?

A

Pregnancy test

If positive return for a review to ensure there is no molar or ectopic pregnancy

36
Q

How should a threatened miscarriage be managed?

A

If heavy bleeding, admit/observe, if not reassure and back to GP/midwife
If more than 12w and rhesus negative: anti D

37
Q

When can fetal cardiac activity be observed via TVUSS?

A

5 and 1/2 to 6 weeks gestation

38
Q

Who required anti d prophylaxis?

A

Rhesus neg women, fetus greater than 12w gestation or managed surgically

39
Q

When may you be advised to have surgery immediately?

A

Heavy bleeding
Signs of infection
Coagulopathy or unable to have blood transfusion

Reproductive Health (70 decks)

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