Miscarriages Flashcards
What is a miscarriage?
A miscarriage, or spontaneous abortion, is the loss of a pregnancy before 20 weeks of gestation.
but in Malawi it is any pregnancy loss before 28 weeks gestation, the age of viability in Malawi, or with a fetus <1000 g.
what are risk factors (9)
- Maternal systemic infection – UTI, Malaria, TORCH
- Maternal age > 35 years
- Trauma
- Abnormalities of the uterus (fibroids)
- Immunological disorders e.g. SLE
- Endocrine disorders e.g. Diabetes
- Psychological factors – stress
- Previous miscarriage
- Chromosomal abnormalities e.g. Trisomy
What are the types of miscarriage? (6)
- Threatened miscarriage (vaginal bleeding with closed cervix)
- Inevitable miscarriage (vaginal bleeding with open cervix)
- Incomplete miscarriage (retained products of conception, cervix is open)
- Complete miscarriage (all products of conception expelled, cervix is closed)
- Missed miscarriage (retention of a non-viable fetus with closed cervix)
- Septic miscarriage (infection associated with miscarriage)
what do you see in threatened miscarriage (5)
- Pregnancy still viable and may continue.
- minimal bleeding
- minimal/ no abdominal pain
- closed cervix
- uterine size+ GA
what investigations do you do for threatened miscarriages (2)
- ultrasound for viability
- grouping and save
what management do you give for threatened miscarriage (3)
- self limiting rx
- avoid heavy lifting/ work
- pelvic rest/ avoid coitus
what is an inevitable miscarriage
Pregnancy may still be viable but will inevitably proceed to incomplete or complete abortion
what are the s/s of inevitable miscarriage (4)
- Heavy bleeding but no passage of POCs
- Abdominal pains/cramping
- Open cervix
- Uterine size=GA
what investigations do you do for an inevitable miscarriage (2)
- blood sample for Hb, grouping and save
- check vital signs for signs of infection
what management do you give for inevitable miscarriage (8)
- Expectant management (in hospital) for up to 2 days
- Medical management
- For <13weeks: misoprostol 400 mcg SL or 600 mcg orally
- For >13weeks can consider misoprostol 400 mcg PV/SL every 3hrs x 5 doses - Surgical Management (still give misoprostol for cervical ripening and dilatation)
- MVA preferred if <9 weeks GA, D & C if MVA not available - Bereavement counseling
- Syphilis testing, offer HIV testing
- Iron supplement if needed
- FP: can start immediately
- for suspected infection treat with DCN 100 mg orally BD X 7days plus Metronidazole 800 mg stat
what s/s do you see in an incomplete miscarriage(5)
- Heavy bleeding
- Abdominal pain/cramping
- Open cervix
- Uterine size<GA
- POCs are partially expelled
what investigations do you do for incomplete miscarriage
Blood samples for Hb, grouping and save/cross match as needed
what management do you give for incomplete miscarriage (9)
- Expectant management (in hospital) for up to 2 days
- Medical management
- For <13weeks: misoprostol 400 mcg SL or 600 mcg orally
- For >13weeks can consider misoprostol 400 mcg PV/SL every 3hrs x 5 doses - Surgical Management (still give misoprostol for cervical ripening and dilatation)
- MVA preferred if <9 weeks GA, D & C if MVA not available - Bereavement counseling
- Syphilis testing, offer HIV testing
- Iron supplement if needed
- FP: can start immediately
- for suspected infection treat with DCN 100 mg orally BD X 7days plus Metronidazole 800 mg stat
- If in shock, resuscitate with IV fluids and/or blood transfusion proceed with surgical management
what are the s/s pf complete miscarriage (6)
- POCs are completely expelled
- Minimal bleeding
- History of passage of POCs
- Minimal abdominal pain
- Closed cervix
- Small uterus
what investigations do you do for complete miscarriage (2)
- Blood samples for Hb, grouping and save
- Ultrasound to confirm empty uterus (no gestational sac)
what is the management for complete miscarriage (5)
- Evacuation not necessary
- Bereavement counselling
- Syphilis testing, offer HIV testing
- Iron supplement if needed
- FP: can start immediately if passage of POCs within 2 past weeks
what are the s/s for missed miscarriage (5)
- Pregnancy is no longer viable but no POCs have been expelled
- No history of bleeding
- No abdominal pains
- Closed cervix
- Loss of pregnancy symptoms (Nausea /vomiting, breast tenderness/engorgement)
what investigations do you do for missed miscarriage (2)
- Blood for Hb, grouping and save
- Ultrasound to confirm non-viability
what is the management of missed miscarriage (8)
- Expectant management in the hospital up to 2wks
- Medical management
- For <12 wks: Misoprostol 800mcg PV or 600mcg SL, may be repeated every 3hrs, up to 2 additional doses
- For 12-24 wks, Misoprostol 400 mcg PV every 6hrs until uterine contractions are fully establshed
- For 24-28 wks, Misoprostol 200mcg PV every 4 hrs until uterine contractions are fully established - Surgical Management: (Still give misoprostol to for cervical ripening before surgical intervention)
- 1st TM: MVA preferred, if not available D& C
- Consider cervical ripening with Misoprostol 400mcg PV or SL 2-3hrs prior to procedure
- 2nd TM: dilation and evacuation - Bereavement counseling
- Syphilis and HIV testing
- Iron supplementation if needed
- FP can start immediately
- DCN 400mg STAT, Metronidazole 400mg STAT if infection suspected
what s/s do you see in a septic miscarriage (4)
any of the miscarriages with (incomplete/ missed/ inevitable) :
- T ≥ 38°C
- Maternal PR > 100 bpm
- Purulent vaginal discharge/POCs
- Pelvic pain/tenderness
what investigations do you do for septic miscarriage (3)
- FBC
- Grouping & save/crossmatch
- Bedside clotting time
what is the management for septic miscarriage (5)
- Resuscitation: IV fluids +/- blood transfusion
- Monitor Vital Signs and urine output
- Benzyl Penicillin 2 MU IV Q6H, Gentamycin 320mg IV OD, Metronidazole 500mg IV Q8H
- Switch to DCN 100mg BD plus Metronidazole 400mg TDS X 7 days when able to take oral drugs
- Evacuation by experienced doctor to avoid perforation
