Miscarriage/Recurrent Flashcards
Define miscarriage
Loss of a pregnancy at less than 24 weeks’ gestation
early = <12-13w
late = 13-24w
What are the RF for miscarriage?
- 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
What are the signs and symptoms of a miscarriage?
- Asymptomatic
- Vaginal bleeding (+/- clots, products of conception)
- Excessive bleeding = dizziness, pallor, SOB, tachycardia, hypotension
- Suprapubic cramping pain
- Abdo distention, tenderness
- Uterine tenderness
What are the main DDx to exclude when suspecting a miscarriage?
Ectopic pregnancy
Hydatidiform mole
Cervical/uterine malignancy
How should a suspected miscarriage be investigated?
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 sec 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
How is a miscarriage managed?
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
How can a miscarriage be classified?
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
Define recurrent miscarriage
3 or more consecutive pregnancies with the SAME partner, that end in miscarriage of the fetus before 24 weeks of gestation
What factors have been associated with recurrent miscarriage?
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
How should recurrent miscarriage be investigated?
Bloods
- Antiphospholipid Abs
- Inherited thrombophilia screen
Genetic tests
- Cytogenetic analysis
- Parental peripheral blood karyotyping
Pelvic US
How is a patient with recurrent miscarriages managed?
Genetic abnormalities = clinical geneticist, counselling, chromosome studies
Anatomical abnormalities = cervical cerclage for cervical weakness
Inherited thrombophilia = heparin
Antiphospholipid syndrome = low-dose aspirin plus heparin
