Miscarriage - GM Flashcards
define miscarriage
spontaneous loss of intrauterine pregnancy before 24 weeks gestation
how often does miscarriage occur
10-24% of all clinical pregnancies
risk decreases as gestational age increases
common causes of miscarriage
- chromosomal abnormality
- fetal malformations (eg. neural tube defects)
- chronic maternal health factors: thrombophilia, antiphospholipid syndrome, systemic lupus erythematosus, PCOS, poorly controlled diabetes mellitus, thyroid dysfunction
- active maternal infection (rubella, CMV, herpes, listeria infection, toxoplasmosis, parvovirus)
- iatrogenic causes: amniocentesis and chorionic villus sampling
- lifestyle factors
- environmental toxins
- advanced maternal age
early miscarriage
before 13 weeks
late miscarriage
between 13 and 24 weeks
threatened miscarriage
vaginal bleeding but the cervical os is closed, and ultrasound shows viable intrauterine pregnancy
inevitable miscarriage
veginal bleeding with an open cervical os, with or without cramping abdominal pain
pregnancy loss will occur/is inevitable
incomplete miscarriage
when there is vaginal bleeding, an open cervical os and products of conception are seen on examination
complete miscarriage
when the products of conception have passed, but the cervical os is closed and US shows an empty uterine cavity
missed miscarriage
the presence of a nonviable intrauterine pregnancy that has not yet resulted in symptoms or the passage of the products of conception
recurrent miscarriage
the occurence of three or more miscarriages
typical symptoms of miscarriage
vaginal bleedings
cramping abdominal pain
passage of any fetal tissue or clots
symptoms of ectopic pregnancy
unilateral abdominal pain
nausea and vomiting
pre-syncope or syncope
back pain
shoulder tip pain
rectal pressure or pain
risk factors for ectopic pregnancy include
previous ectopic pregnancy
previous pelvic inflammatory disease
intrautuerine contraception
previous tubal surgery including sterilisation
fertility treatment
clinical examination of presentation with symptoms of miscarriage
vital signs
abdo exmination for signs of acute abdomen which may be suggestive of ectopic
speculum exmination to asses the cervical os, rule out other sources of bleedings, quantify bleeding and assess for visible products of conception
bimanual examination if ectopic pregnancy is suspected
adnexal tenderness or a mass, and cervical motion tenderness, may be present in ectopic pregnancy
lab investigations
FBC: in patients who have significant blood loss and/or evidence of hypovolaemia
beta HCG: provides an indication as to whether the pregnancy is progressing
group and save / cross match: if significant bleeding
antibody screen: rhesus negative women undergoing a surgical proceduse to manage miscarriage will require anti d rhesus prophylaxis
imageing for vaginal bleeding presentations
transvaginal US - assess for an intrauterine pregnancy or evidence of an ectopic pregnancy (adnexal pathology or the presence of free fluid in the abdomen)
if the ultrasound scan is inconclusive
if the US is inconclusive for intrauterine pregnancy ie. there is pregnancy of unknown location
serial beta HCG measurements should be performed
serum beta HCG levels should increase by more than 63% in 48 hours in a progressive pregnancy - the does does exclude ectopic pregnancy but makes it unlikley
Changes in beta HCG levels
serum beta HCG levels should increase by more than 63% in 48 hours in a progressive pregnancy - the does does exclude ectopic pregnancy but makes it unlikley
beta HCG levels that fall by more than 50% in 48 hours indicate a failing pregnancy (potential miscarriage)
beta HCG levels that fall by less than 50% or fail to rise by more than 63% over 48 hours require clinical review to exclude an ectopic pregnancy
beta HCG levels that fall by less than 50% or fail to rise by more than 63% over 48 hours
require clinical review to exclude an ectopic pregnancy
beta HCG levels that fall by more than 50% in 48 hours indicate
indicate a failing pregnancy (potential miscarriage)
emergency managemnt of a haemodynamically unstable patient
patients with significant haemorrhage or haemodynamic instability
required ABCDE approach and senior input from OBGYN
speculum examination should be performed and products of conception should be removed
products of conception in the cervical os can lead to
cervical shock due to vaginal stimulation
two options for surgical management of miscarriage
- manual vacuum aspiration (MVA) can be performed under local anaesthetic on the ward, involves manual suction aspiration of the uterus
- surgical evacuation: usually performed in theatre under GA
when should surgical management be conducted
in patients with significant bleeding who have retained products of conception
surgical management is also used and medical or expectant management is unsuccessful
rhesus negative patients durig surgical management of miscarriage
require anti-D rhesus prophylaxis
medical management
prostaglandin agent (misopristol) to induce uterine contractions and effacement of the cervix
follow up after medical management
a pregnancy test should be performed three weeks after medical management
if positive, imaging for retained products of conception will be required
expectant management
waiting for spontaneous passage of the products of conception, without any medical or surgical intervention
follow up after expectant management
a pregnancy test should be performed three weeks after medical management
if positive, imaging for retained products of conception will be required
if no bleeding occurs, or worsening of pain or bleeding, women require repeat assessment and alternative management
recurrent miscarriage is defined as
three or more miscarriages
these patients require specialist review for underlying cause
causes of recurrent miscarriage
increased maternal age
parental genetic factors (balanced translocations, mosiacism)
thrombophilic disorders
endocrine disorders (diabetes melitus, thyroid disorders, PCOS)
structural uterine abnormalities
relevant investiagtions for recurrent miscarriages include
cytogenic analysis performed on the products of conception of the third and any subsequent miscarriages
parental karyotyping and genetic counselling
blood tests: HbA1c, antiphospholipid/thrombophilia screen, thyroid funtion tests
pelvic US
complications of miscarriage include
infection
retained products of conception: may still require surgical management
asherman’s syndrome (uterine adhesions): a complication of repeated surgical management
psychological impact: depression or anxiety
risk of recurrence
no increased risk of second miscarriage after the first miscarriage
25% risk of subsequent miscarriage after 2
40% risk of subsequent miscarriage after 3
management of complete miscarriage
check FBC, blood group
check need for Rh immunoglobulin
provide information sheet
discharge to GP
Fax the discharge letter to the GP and give the patient a copy
offer councelling
advise to report if bleeding
which miscarriage method is best for long term fertility
the method of miscarriage management does not affect long-term pregnancy
4 out of 5 women give birth within 5 years of the index miscarriage
recognition certificate
women may apply to the registry of births, deaths nd marriages for a recognition cetrificate for pregnancy loss <20 weeks
misoprostol regime
800mcg misoprostol given vaginally or sublingually
use only water as lubricant
arrange EPAS appointment for 14 days to confirm empty uterus
advise to present to EPAS if no pain/bleeding in 7 days (consider repeat dose)
if POC still in situ at 14 days, arrange D&C
do women have to return to EPAS with medical management
if they pass all POC and pain/bleeding ceases, they do not have to return to EPAS on day 14
these women should do a repeat pregnancy test at week 3
if positive, return to EPAS to rule out ectopic or molar pregnancy
reasons why expectant management may not be appropriate
increased risk of haemorrhage eg. late first trimester, coagulopathies, unable to have blood transfused
infection suspected
previous adverse traumatic pregnancy
