Miscarriage, Ectopics & ToP

Question 1

What are the 5 conditions for termination of pregnancy?

Answer 1

1. Risk to mothers life if pregnancy continues
2. Termination is necessary to prevent permanent grave injury to physical/mental health of the woman
3. Continuation risks injury to the physical/mental health of the woman greater than if terminated (<24 weeks)
4. Continuation risks injury to the physical/mental health of existing children of the woman greater than if terminated (<24 weeks)
5. Substantial risk that if the child were born they would suffer such physical or mental abnormality as to be seriously handicapped

Question 2

What drugs are used in medical termination of pregnancy?

Answer 2

1. Mifepristone (Antiprogestagen) to prime the cervix

2. Misoprostol (Prostaglandin)

Question 3

What are the options for surgical termination of pregnancy?

Answer 3

Vacuum aspiration

Dilatation and evacuation

Question 4

When can dilatation and evacuation be used to terminate pregnancy?

Answer 4

13-24 weeks

Question 5

When can vacuum aspiration be used to terminate pregnancy?

Answer 5

• 7-14 weeks: electrical or manual vaccum aspiration
• <7 weeks: check gestational sack in aspirate, follow up with bHCG
• 14-16 weeks: vacuum aspiration with large bore cannula

Question 6

When can Mifepristone and Misoprostol be used to terminate pregnancy?

Answer 6

<9 weeks: Mifepristone + 1 dose of misoprostol

9-24 weeks: Mifepristone + multiple doses of misoprostol

Question 7

What is a threatened miscarriage?

Answer 7

Painless vaginal bleeding

Cervical os is closed

Question 8

When does a threatened miscarriage typically occur?

Answer 8

6-9 weeks

Question 9

What is a missed miscarriage?

Answer 9

Gestational sac containing a dead fetus > 20 weeks without symptoms of expulsion
Cervical os closed

Question 10

What is an inevitable miscarriage

Answer 10

Heavy bleeding with clots and pain

Cervical os open

Question 11

What is an incomplete miscarriage?

Answer 11

Not all products of conception have been expelled
Pain and vaginal bleeding
Cervical os open

Question 12

What is a pregnancy of uncertain viability?

Answer 12

When intrauterine gestation sac <25mm with no foetal pole/yolk sac,
Or crown-rump length <7mm with no foetal heart beat

Question 13

What are the management options of miscarriage?

Answer 13

Expectant
Medical
Surgical

Question 14

When would expectant management of miscarriage be appropriate?

Answer 14

Woman not bleeding heavily
Incomplete miscarriage (not missed miscarriage)
Offer rescan in 2 weeks

Question 15

What is the medical management of miscarriage?

Answer 15

Mifepristone + Misoprostol 24-48 hours later

Question 16

How long might bleeding last after medical management of miscarriage?

Answer 16

3 weeks

Question 17

When would surgical management of miscarriage be appropriate?

Answer 17

If heavy or persistent bleeding > 2 weeks

Patient choice

Question 18

What is the surgical management of miscarriage?

Answer 18

Suction evacuation, usually under GA

Question 19

What may cause mid-trimester miscarriage?

Answer 19

Mechanical causes (cervical weakness)
Uterine abnormalities
Chronic maternal disease (DM, SLE)
Infection (e.g. CMV)

Question 20

What are the common causes of early pregnancy miscarriage?

Answer 20

Aneuploidy
Abnormal fetal development
10% maternal illness

Question 21

Which genital infection had been implicated in miscarriage?

Answer 21

Bacterial vaginosis

Question 22

What is the definition of recurrent miscarriage?

Answer 22

3 or more consecutive pregnancies before 24 weeks gestation with the same biological father

Question 23

What are possible causes of recurrent miscarriage?

Answer 23

Endocrine
Infection (BV)
Parental chromosomal abnormality 
Uterine abnormality 
Antiphospholipid syndrome
Thrombophilia
Alloimmune causes