Miscarriage_Management_Flashcards

Question 1

What are the three types of management for miscarriage discussed in the 2023 NICE guidelines?

Answer 1

The three types of management for miscarriage discussed in the 2023 NICE guidelines are expectant management, medical management, and surgical management.

Question 2

What is expectant management for miscarriage?

Answer 2

Expectant management for miscarriage involves waiting for a spontaneous miscarriage to occur.

Question 3

How long does expectant management typically last?

Answer 3

Expectant management typically lasts for 7-14 days.

Question 4

What happens if expectant management is unsuccessful?

Answer 4

If expectant management is unsuccessful, medical or surgical management may be offered.

Question 5

When might medical or surgical management be preferred over expectant management?

Answer 5

Medical or surgical management might be preferred in cases of increased risk of haemorrhage, late first trimester, coagulopathies, inability to have a blood transfusion, previous adverse pregnancy experiences, or evidence of infection.

Question 6

What is the medical management for a missed miscarriage?

Answer 6

Medical management for a missed miscarriage involves administering oral mifepristone followed by misoprostol 48 hours later.

Question 7

How does mifepristone work in the context of miscarriage management?

Answer 7

Mifepristone is a progesterone receptor antagonist that weakens attachment to the endometrial wall, softens and dilates the cervix, and induces uterine contractions.

Question 8

What is the role of misoprostol in miscarriage management?

Answer 8

Misoprostol is a prostaglandin analogue that binds to myometrial cells, causing strong myometrial contractions and expulsion of the products of conception.

Question 9

What should be done if bleeding has not started within 48 hours after misoprostol treatment for a missed miscarriage?

Answer 9

If bleeding has not started within 48 hours after misoprostol treatment, the patient should contact their healthcare professional.

Question 10

What is the medical management for an incomplete miscarriage?

Answer 10

Medical management for an incomplete miscarriage involves a single dose of misoprostol (vaginal, oral, or sublingual).

Question 11

What additional treatments should be offered to women undergoing medical management for miscarriage?

Answer 11

Women undergoing medical management for miscarriage should be offered antiemetics and pain relief.

Question 12

When should a pregnancy test be performed after medical management for an incomplete miscarriage?

Answer 12

A pregnancy test should be performed 3 weeks after medical management for an incomplete miscarriage.

Question 13

What does surgical management for miscarriage involve?

Answer 13

Surgical management for miscarriage involves undergoing a surgical procedure under local or general anaesthetic.

Question 14

What are the two main options for surgical management of miscarriage?

Answer 14

The two main options for surgical management of miscarriage are vacuum aspiration (suction curettage) and surgical management in theatre.

Question 15

How is vacuum aspiration performed?

Answer 15

Vacuum aspiration is performed under local anaesthetic as an outpatient procedure.

Question 16

How is surgical management in theatre performed?

Answer 16

Surgical management in theatre is performed under general anaesthetic and was previously referred to as ‘Evacuation of retained products of conception’.

Question 17

summarise miscarriage management

Answer 17

Miscarriage: management

In the 2023 NICE guidelines, 3 types of management for miscarriage were discussed:

Expectant management
‘Waiting for a spontaneous miscarriage’
First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously
If expectant management is unsuccessful then medical or surgical management may be offered

Some situations are better managed medically or surgically. NICE list the following:
increased risk of haemorrhage
she is in the late first trimester
if she has coagulopathies or is unable to have a blood transfusion
previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
evidence of infection

Medical management:
missed miscarriage
oral mifepristone. Mifepristone is a progesterone receptor antagonist → weakening of attachment to the endometrial wall + cervical softening and dilation + induction of uterine contractions
48 hours later, misoprostol (vaginal, oral or sublingual) unless the gestational sac has already been passed. Misoprostol is a prostaglandin analogue, binds to myometrial cells → strong myometrial contractions → expulsion of products of conception
if bleeding has not started within 48 hours after misoprostol treatment, they should contact their healthcare professional
incomplete miscarriage
a single dose of misoprostol (vaginal, oral or sublingual)
women should be offered antiemetics and pain relief
a pregnancy test should be performed at 3 weeks

Surgical management
‘Undergoing a surgical procedure under local or general anaesthetic’
The two main options are vacuum aspiration (suction curettage) or surgical management in theatre
Vacuum aspiration is done under local anaesthetic as an outpatient
- Surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’

Question 18

A 30-year-old female who is 10 weeks pregnant presents to the emergency gynaecology unit after noting 2 episodes of foul-smelling red vaginal discharge. There is associated lower back pain and she has a temperature of 39ºC. Blood pressure is 85/65 mmHg. A transvaginal ultrasound confirms an inevitable miscarriage. What is the most appropriate management in this case?

Mifepristone
Vaginal misoprostol
Expectant management
Surgical management
Methotrexate

Answer 18

Surgical management

Miscarriage - expectant management is not suitable if evidence of infection or increased risk of haemorrhage

NICE guidelines recommend expectant management as first line in the treatment of miscarriage, unless one of the following factors is present: there is an increased risk of bleeding, there are previous adverse experiences associated with pregnancy, there is increased risk from the effects of haemorrhage or there is evidence of infection. The most appropriate option in the above case, which represents an infected miscarriage with the patient progressing to septic shock, is to evacuate the pregnancy as soon as possible through surgical management.

Methotrexate is used in ectopic pregnancies and mifepristone is not to be used in the medical management of miscarriage.