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Obstetrics > Miscarriage and still brith > Flashcards

Miscarriage and still brith Flashcards

1
Q

Early and late definitions

A 
Early = <12 weeks (85%)
Late = 13-24 weeks

Total = 12-24% of confirmed pregnancies

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2
Q

Threatened miscarriage

A

Mild PV bleeding with NO (or little) pain
Os = closed
50% –> miscarriage

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3
Q

Inevitable miscarriage

A

Heavy bleeding + clots + pain

Os = open

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4
Q

Incomplete miscarriage

A

Heavy bleeding, pain but products of conception partially retained
Os = open

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5
Q

Complete miscarriage

A

Heavy bleeding+clots - subsequent USS shows no products of conception
Os = closed

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6
Q

Missed miscarriage

A

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

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7
Q

Recurrent miscarriage

A

x3 in a row

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8
Q

Biochemical loss

A

Pregnancy confirmed only in serum and urine HCG

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9
Q

Sac loss

A

USS only shows gestation sac but no foetus

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10
Q

Causes

A

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)

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11
Q

Risk factors:

A 
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
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12
Q

Differentials

A

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

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13
Q

Investigations

A

TVS - no visible HR

Serum hCG - two tests 48hrs apart - exclude ectopic

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14
Q

Expectant management

A

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
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15
Q

Medical management

A

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%
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16
Q

Surgical management

A

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
17
Q

Complications of surgery

A 
Perforation
Cervical tears
Intra-abdominal trauma
Intrauterine adhesions (ashermans)
Haemorrhage
18
Q

Recurrent miscarriage

A

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
19
Q

Investigations for recurrent miscarriage

A

Bloods: FBC, blood group+antibodies, antiphospholipid antibodies, TFTs, glucose, prolactin

Screen for thombophilia

Ascertain karyotype of miscarried fetus

20
Q

Antiphospholipid antibody syndrome (APS)

A

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

21
Q

Investigations for stillbirth

A

RFM –> USS - no HR seen

22
Q

Management of stillbirth

A

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

Obstetrics (29 decks)

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