Miscarriage - GM

Question 1

define miscarriage

Answer 1

spontaneous loss of intrauterine pregnancy before 24 weeks gestation

Question 2

how often does miscarriage occur

Answer 2

10-24% of all clinical pregnancies
risk decreases as gestational age increases

Question 3

common causes of miscarriage

Answer 3

1. chromosomal abnormality
2. fetal malformations (eg. neural tube defects)
3. chronic maternal health factors: thrombophilia, antiphospholipid syndrome, systemic lupus erythematosus, PCOS, poorly controlled diabetes mellitus, thyroid dysfunction
4. active maternal infection (rubella, CMV, herpes, listeria infection, toxoplasmosis, parvovirus)
5. iatrogenic causes: amniocentesis and chorionic villus sampling
6. lifestyle factors
7. environmental toxins
8. advanced maternal age

Question 4

early miscarriage

Answer 4

before 13 weeks

Question 5

late miscarriage

Answer 5

between 13 and 24 weeks

Question 6

threatened miscarriage

Answer 6

vaginal bleeding but the cervical os is closed, and ultrasound shows viable intrauterine pregnancy

Question 7

inevitable miscarriage

Answer 7

veginal bleeding with an open cervical os, with or without cramping abdominal pain
pregnancy loss will occur/is inevitable

Question 8

incomplete miscarriage

Answer 8

when there is vaginal bleeding, an open cervical os and products of conception are seen on examination

Question 9

complete miscarriage

Answer 9

when the products of conception have passed, but the cervical os is closed and US shows an empty uterine cavity

Question 10

missed miscarriage

Answer 10

the presence of a nonviable intrauterine pregnancy that has not yet resulted in symptoms or the passage of the products of conception

Question 11

recurrent miscarriage

Answer 11

the occurence of three or more miscarriages

Question 12

typical symptoms of miscarriage

Answer 12

vaginal bleedings
cramping abdominal pain
passage of any fetal tissue or clots

Question 13

symptoms of ectopic pregnancy

Answer 13

unilateral abdominal pain
nausea and vomiting
pre-syncope or syncope
back pain
shoulder tip pain
rectal pressure or pain

Question 14

risk factors for ectopic pregnancy include

Answer 14

previous ectopic pregnancy
previous pelvic inflammatory disease
intrautuerine contraception
previous tubal surgery including sterilisation
fertility treatment

Question 15

clinical examination of presentation with symptoms of miscarriage

Answer 15

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

Question 16

lab investigations

Answer 16

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

Question 17

imageing for vaginal bleeding presentations

Answer 17

transvaginal US - assess for an intrauterine pregnancy or evidence of an ectopic pregnancy (adnexal pathology or the presence of free fluid in the abdomen)

Question 18

if the ultrasound scan is inconclusive

Answer 18

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

Question 19

Changes in beta HCG levels

Answer 19

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

Question 20

beta HCG levels that fall by less than 50% or fail to rise by more than 63% over 48 hours

Answer 20

require clinical review to exclude an ectopic pregnancy

Question 21

beta HCG levels that fall by more than 50% in 48 hours indicate

Answer 21

indicate a failing pregnancy (potential miscarriage)

Question 22

emergency managemnt of a haemodynamically unstable patient

Answer 22

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

Question 23

products of conception in the cervical os can lead to

Answer 23

cervical shock due to vaginal stimulation

Question 24

two options for surgical management of miscarriage

Answer 24

• 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

Question 25

when should surgical management be conducted

Answer 25

in patients with significant bleeding who have retained products of conception
surgical management is also used and medical or expectant management is unsuccessful

Question 26

rhesus negative patients durig surgical management of miscarriage

Answer 26

require anti-D rhesus prophylaxis

Question 27

medical management

Answer 27

prostaglandin agent (misopristol) to induce uterine contractions and effacement of the cervix

Question 28

follow up after medical management

Answer 28

a pregnancy test should be performed three weeks after medical management
if positive, imaging for retained products of conception will be required

Question 29

expectant management

Answer 29

waiting for spontaneous passage of the products of conception, without any medical or surgical intervention

Question 30

follow up after expectant management

Answer 30

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

Question 31

recurrent miscarriage is defined as

Answer 31

three or more miscarriages
these patients require specialist review for underlying cause

Question 32

causes of recurrent miscarriage

Answer 32

increased maternal age
parental genetic factors (balanced translocations, mosiacism)
thrombophilic disorders
endocrine disorders (diabetes melitus, thyroid disorders, PCOS)
structural uterine abnormalities

Question 33

relevant investiagtions for recurrent miscarriages include

Answer 33

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

Question 34

complications of miscarriage include

Answer 34

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

Question 35

risk of recurrence

Answer 35

no increased risk of second miscarriage after the first miscarriage
25% risk of subsequent miscarriage after 2
40% risk of subsequent miscarriage after 3

Question 36

management of complete miscarriage

Answer 36

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

Question 37

which miscarriage method is best for long term fertility

Answer 37

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

Question 38

recognition certificate

Answer 38

women may apply to the registry of births, deaths nd marriages for a recognition cetrificate for pregnancy loss <20 weeks

Question 39

misoprostol regime

Answer 39

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

Question 40

do women have to return to EPAS with medical management

Answer 40

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

Question 41

reasons why expectant management may not be appropriate

Answer 41

increased risk of haemorrhage eg. late first trimester, coagulopathies, unable to have blood transfused
infection suspected
previous adverse traumatic pregnancy