Miscarriage/Recurrent

Question 1

Define miscarriage

Answer 1

Loss of a pregnancy at less than 24 weeks’ gestation

early = <12-13w

late = 13-24w

Question 2

What are the RF for miscarriage?

Answer 2

• Maternal Age >30-35 (increase in chromosomal abnormalities)
• Previous miscarriage
• Obesity
• Chromosomal abnormalities (maternal or paternal)
• Smoking
• Uterine anomalies
• Previous uterine surgery
• Anti-phospholipid syndrome
• Coagulopathies
• DM

Question 3

What are the signs and symptoms of a miscarriage?

Answer 3

• Asymptomatic
• Vaginal bleeding (+/- clots, products of conception)
• Excessive bleeding = dizziness, pallor, SOB, tachycardia, hypotension
• Suprapubic cramping pain
• Abdo distention, tenderness
• Uterine tenderness

Question 4

What are the main DDx to exclude when suspecting a miscarriage?

Answer 4

Ectopic pregnancy

Hydatidiform mole

Cervical/uterine malignancy

Question 5

How should a suspected miscarriage be investigated?

Answer 5

Investigated in an Early Pregnancy Assessment Unit

Transvaginal US = fetal cardiac activity (observed from 5 1/2w) + crown rump length (CRP + no fetal heart = repeat US 7d)

Mean sac diameter (MSD)

• > 25mm = failed pregnancy
• <25mm = repeat US in 10-14 days

Serum beta-hCG (need to exclude ectopic) - discriminatory level >1500, fails to rise by 63%

Serum progesterone

Blood group

Question 6

How is a miscarriage managed?

Answer 6

Rh-ve = anti-D prophylaxis

1) conservative = products of conception (POC) pass naturally
2) medical = vaginal misoprostol (prostaglandin analogue) to stimulate cervical ripening and myometrial contractions
3) surgical = manual vacuum aspiration with LA if <12w, evacuation of retained products of conception (ERPC) under GA

Question 7

How can a miscarriage be classified?

Answer 7

Threatened = mild bleeding, pain, cervix closed, viable preg

Inevitable = heavy bleeding, clots, pain, cervix open

Missed = asymptomatic, no fetal heart in CRL >7mm

Incomplete = POC partially expelled

Complete = hx of bleeding, clots, POC, pain, sx settling/settled now

Septic = infected POC

Question 8

Define recurrent miscarriage

Answer 8

3 or more consecutive pregnancies with the SAME partner, that end in miscarriage of the fetus before 24 weeks of gestation

Question 9

What factors have been associated with recurrent miscarriage?

Answer 9

Antiphospholipid syndrome

Parental chromosomal rearrangements = one of the partners carries a balanced reciprocal or Robertsonian l chromosomal translocation

Embryonic chromosomal abnormalities

DM

Thyroid disease

PCOS

Anatomical =

• uterine malformations
• cervical weakness
• acquired uterine abnormalities

Infection

Inherited thrombophilias = Factor V Leiden, prothrombin gene mutation and deficiencies of protein C/S and antithrombin III

Question 10

How should recurrent miscarriage be investigated?

Answer 10

Bloods

• Antiphospholipid Abs
• Inherited thrombophilia screen

Genetic tests

• Cytogenetic analysis
• Parental peripheral blood karyotyping

Pelvic US

Question 11

How is a patient with recurrent miscarriages managed?

Answer 11

Genetic abnormalities = clinical geneticist, counselling, chromosome studies

Anatomical abnormalities = cervical cerclage for cervical weakness

Inherited thrombophilia = heparin

Antiphospholipid syndrome = low-dose aspirin plus heparin

Question 12

What are the possible complications of smoking in pregnancy?

Answer 12

• miscarriage
• SGA
• prematurity
• birth defects (cleft lip, cleft palate)

Question 13

What are the possible complications of alcohol in pregnancy?

Answer 13

• FAS (thin upper lip, small jaw, smooth philtrum)
• SGA
• prematurity
• brain damage
• birth defects (heart, hearing, vision)