Miscarriage and still brith Flashcards
Early and late definitions
Early = <12 weeks (85%) Late = 13-24 weeks
Total = 12-24% of confirmed pregnancies
Threatened miscarriage
Mild PV bleeding with NO (or little) pain
Os = closed
50% –> miscarriage
Inevitable miscarriage
Heavy bleeding + clots + pain
Os = open
Incomplete miscarriage
Heavy bleeding, pain but products of conception partially retained
Os = open
Complete miscarriage
Heavy bleeding+clots - subsequent USS shows no products of conception
Os = closed
Missed miscarriage
Hx of threatened miscarriage - persistent, dark-brown discharge
Uterus small for dates, dead foetus retained (no fetal HR)
Sx of pregnancy reduced or gone
NB. pregnancy test can remain +ve for days/weeks
Recurrent miscarriage
x3 in a row
Biochemical loss
Pregnancy confirmed only in serum and urine HCG
Sac loss
USS only shows gestation sac but no foetus
Causes
Foetal:
Chromosomal abnormality
Multiple pregnancy
Maternal: Uterine abnormality PCOS Incompetent cervix Antiphospholipid syndrome Infection Poorly controlled HTN/DM
1st trimester - chromosomal abnormality
2nd trimester - cervical incompetence (surgery/LLETZ)
Risk factors:
Smoking Increased age of mother and/or father Excess alcohol Low BMI Fertility problems illicit drug use Uterine surgery CT disorder (lupus, antiphospholipid synd) Uncontrolled DM Stress, anxiety
Differentials
Ectopic - pain usually unilateral, preceded bleeding, milder bleeding
Implantation - short lived bleeding/spotting, dark with pinkl/brown tint, 6-12 days after conception
Cervical polyps - PCB, may have PV discharge
Investigations
TVS - no visible HR
Serum hCG - two tests 48hrs apart - exclude ectopic
Expectant management
70% = No intervention and urine hCG 7-14 days after presentation
- Risk of haemorrhage - not advised in high risk patients
Counsel:
- Missed/incomplete - reabsorption of fetal tissue with little bleeding or loss of foetal tissue vaginally (heavy bleeding and pain)
- Higher risk of emergency intervention and blood transfusion
Medical management
Vaginal/PO misoprostol - only used in early miscarriage
Counsel: Bleeding can continue for 3 weeks Pregnancy test at 3 weeks Can cause more pain and bleeding than surgical but avoids use of GA Successful = 80%
Surgical management
Evacuation of retained products of conception - success = 95%
Indications:
- Persistent excessive bleeding
- Haemodynamically unstable
- Infected retained tissue
- Suspected gestational trophoblastic disease
- Women’s preference
Choice of:
- Manual vacuum aspiration under LA
- Surgical evacuation under GA
Complications of surgery
Perforation Cervical tears Intra-abdominal trauma Intrauterine adhesions (ashermans) Haemorrhage
Recurrent miscarriage
Unexplained = 50%
Genetic :
- parenteral: balanced = 50-70% have healthy baby, unbalanced = 5-10% child with disability
- Foetal 70% early miscarriage, 20% late miscarriage. 75% chance of subsequent successful pregnancy
Anatomical - uterine abnormality, cervical incompetence
Immunological - APS (15% with recurrent miscarriage)
Thrombophilic - inherited (e.g. factor V leiden)
Endocrine: PCOS (treat with metformin during pregnancy), Hyperprolactinaemia, uncontrolled thyroid disease, DM
Infective: BV, rubella, CMV, herpes listeria, toxoplasmosis
Environmental:
- chemicals
- alcohol and smoking - foetal alcohol syndrome
Investigations for recurrent miscarriage
Bloods: FBC, blood group+antibodies, antiphospholipid antibodies, TFTs, glucose, prolactin
Screen for thombophilia
Ascertain karyotype of miscarried fetus
Antiphospholipid antibody syndrome (APS)
Autoimmune, hypercoagulable state –> blood clots, miscarriage, stillbrith, preterm delivery and preeclampsia
Requires 2 +ve blood tests (3 months apart) for lupus anticoagulant or anti-B2-glycoprotein-I
Investigations for stillbirth
RFM –> USS - no HR seen
Management of stillbirth
2-3 days - mother indiced via vaginal PG
Mother: Screen for pre-eclampsia Temp Cervical and vaginal swabs --> MC+S Blood: FBC, clotting, Kleihauer test, HbA1c, cultures, serology, cytogenetics
Bereavement care
- May want funeral arrangements - trained bereavement midwives
- Require consent for post-mortem examination
- Inform GP, register still-birth
