Miscarriage (Complete) Flashcards
Define miscarriage
Loss of pregnancy prior to 24 weeks gestation
What percentage of pregnancies lead to miscarriage?
10%
What are the main causes of miscarriage?
Maternal factors:
Old age
Infections (e.g. bacterial vaginosis)
Uterine abnormalities
* Septate uterus
* Uterine fibroids
* Intrauterine adhesions
Cervical incompetence
PCOS
Poorly controlled diabetes
Anti-phospholipid syndrome
Poorly controlled thyroid disease
Foetal factors:
Genetic disorders
Abnormal development (e.g. neural tube defecs, anencephaly)
Placental failure
Often cases are IDIOPATHIC
What are the most common causes of first-trimester pregnancy?
Chromosomal abnormalities
What is a common cause of late miscarriages?
Bacterial vaginosis
What are the 4 main types of miscarriage?
Missed miscarriage
Threatened miscarrage
Inevitable miscarriage
Complete miscarriage
What is considered missed miscarriage?
Woman is assymptomatic (hence missed)
Cervical os closed
Uterus contains foetal tissue but no foetal cardiac activity
What is considered threatened miscarriage?
Mild symptoms of bleeding
Foetus retained within the uterus
Cervical os closed
Ultrasound reveals that there is an intrauterine foetus present.
There is the “threat” of a miscarriage, but it is not certain
What is considered inevitable miscarriage?
Cervical os open
Heavy bleeding and pain
Ultrasound reveals that the foetus is present intrauterine
What is considered complete miscarriage?
All products of conception expelled (empty uterus)
Cervical os closed
Patient may have been alerted to the miscarriage by pain and bleeding.
What are the main clinical features of miscarriage?
Vaginal bleeding (variable)
* Brownish light spotting
* Heavy bright red with clots
Abdominal pain
* Lower
* Cramping
Vaginal fluid/tissue discharge
Lower back pain
What investigations should be conducted in patients suspected of having a miscarriage?
Bedside:
Speculum examination: Check for passage of content and cervical os opening
Pregnancy test: Can consider if patient not aware of pregnancy
Bloods:
FBC: Check for anaemia
Beta-hCG: Falling titres
Imaging:
Trans-vaginal ultrasound: Check for foetal content / loss of foetal hearbeat
What additional investigations should be considered if patient has recurrent miscarriages?
Lupus anticoagulant/anticardiolipin antibodies : Check for Antisphopholipid syndrome
Parental karyotype
Cytogenetic analysis on products of conception
What is the first-line management of miscarriage?
Expectant management: waiting for 7-14 days for the miscarriage to complete spontaneously
What are the main features of expectant management?
Monitor for 7-14 days
Written and verbal information on expectant management
Analgesia
Pregnancy test to use after 3 weeks of resolution of pain/bleeding during moinitoring period, if positive required return
Offer repeat transvaginal US if incomplete pregancy suspected:
- Pain and bleeding symptoms have not started after 7-14 days
- Pain and bleeding symptoms not resolved/worsening after 7-14 days
What should be advised for woman who have a positive pregnancy test >3 weeks since symptoms resolved?
Advised to return (suggests incomplete miscarriage)
When should repeat transvaginal ultrasound be offered?
Pain and bleeding symptoms have not started after 7-14 days
Pain and bleeding symptoms not resolved/worsening after 7-14 days
Suggests incomplete miscarriage
Medical/surgical management is given first-line in which individuals? (4)
Increased risk of haemorrhage (e.g. late first trimester)
Increased risks of effects of haemorrhage (e.g. coagulopathy)
Previous traumatic pregnancy experiences (e.g. miscarriage, stillbirth)
Evidence of infection
Woudl require medical/surgical interventions
There is increased risk of haemorrhage from miscarriage if occuring in which stage of pregnancy?
Late first trimester
When is medical management offered for miscarriage?
Ongoing symptoms after expectant management
Expectant management clinically inappropriate
How are woman with miscarriage medically managed?
Missed miscarriage:
* 200 mg oral mifepristone
* 800 micrograms misoprostol (vaginal, oral or sublingual) 48 hours later
Incomplete miscarriage:
- 600-800 micrograms misoprostol (vaginal, oral or sublingual) ONLY
Required to do pregnancy test 3 weeks later and return if positive
When is surgical management indicated?
If medical management failed
If symptomatic after 14 days of expectant management
How are patients with miscarriage surgically managed?
Either option depending on preference:
- Manual vacuum aspiration under local anaesthetic (in outpatient or clinic setting)
- Surgical management under general anaesthetic (Evacuation of retained products of conception [ERPC])
What are some complications of surgical management?
Incomplete evacuation of the uterus: continued vaginal bleeding and lower abdominal pain.
Post-uterine evacuation bleeding: May occur following the procedure as tissue in this area is highly vascularised.
Asherman’s Syndrome: Adhesions that obstruct the uterine cavity and lead to recurrent miscarriage
Summary of miscarriage management
Conservative:
Expectant management (First-line)
Offer all women written and verbal information about miscarriage
Analagesia + anti-emetics as required
Pregnancy test to be completed 3 weeks after monitoring period
Psychological support: If required
Medicine: (Second-line)
Missed miscarriage:
* 200 mg oral mifepristone
* 800 micrograms misoprostol (vaginal, oral or sublingual) 48 hours later
Incomplete miscarriage:
* 600-800 micrograms misoprostol (vaginal, oral or sublingual) ONLY
Surgical: (Second-line)
Outpatient setting: Manual vacuum aspiration under local anaesthetic
Hospital setting:
Surgical management under general anaesthetic (Evacuation or retained products of conception [ERPC])
What is the effect of mifepristone in management of miscarriage
Inhibits effects of progesterone which is important in maintaining uterine lining in pregnancy
What is the effect of misoprostol in management of miscarriage?
Mimics the effects of prostaglandins which promotes uterine contraction
