Miscarriages

Question 1

When a patient present with bleeding in early pregnancy, ________ is considered to the the cause until proven otherwise?

Answer 1

Ectopic Pregnancy

Question 2

What are the 3 questions that need to be answered when evaluating a patient with bleeding in early pregnancy?

Answer 2

1. Is the patient actually pregnant?
2. Is the pregnancy intrauterine?
3. Is the pregnancy viable?

Question 3

How do you assess whether the pregnancy is intrauterine?

Answer 3

Use beta-hCG and U/S to localise the pregnancy. Cannot use just U/S because you cannot visualise a pregnancy when beta-hCG is below 2000

Question 4

How do you simply assess whether a pregnancy is vianle once it is established that it is intrauterine?

Answer 4

Need to confirm the presence of FETAL HEART ACTIVITY

Question 5

What are the 3 criteria for a failed pregnancy/missed miscarriage?

Answer 5

1. Mean gestational sac >25mm but NO fetal pole
2. Fetal pole >7mm and NO fetal heart activity
3. Inadequate growth of gestation sac or fetal pole over a course of a week

Question 6

Scenario 1: A patient’s beta-hCG

Answer 6

You are unable to determine whether the pregnancy is early intrauterine of it is a extrauterine pregnancy. Beta-hCG doubles every 48 hours in intrauterine pregnancies so you need to reassess the patient’s beta-hCG levels after 48 hours. If no double, then need to be highly suspicious of an ectopic pregnancy. However, if doubled then repeat U/S in a week.

Question 7

Scenario 2: A patient’s beta-hCG >1500 and the pregnancy is unlocalised, discuss the considerations in this patient’s management.

Answer 7

In this particular patient, you are highly suspicious of an ectopic pregnancy. With a beta-hCG > 1500 you would expect to visualise an intrauterine pregnancy if it were present.

Question 8

Define miscarriage. How often does this occur in pregnancy?

Answer 8

Presence of non-viable intrauterine pregnancy before 20 weeks. This occurs in 15% of pregnancies.

Question 9

What are the 7 causes of miscarriage? What are the most common causes?

Answer 9

1. Chromosomal abnormalities – (most common, non-recurring)
2. Endocrine – (pre-existing uncontrolled diabetes, thyroid, hyperandrogenism)
3. Thrombopilia – (antiphospholipid syndrome, cause of recurrent miscarriage)
4. Uterine Abnormality – (malformations, fibroids, endometrial scarring)
5. Chronic Maternal Disease – (cardio, renal, connective tissue etc.)
6. Toxins – (smoke, drink, meds)
7. Trauma – (CVS or amniocentesis)

Question 10

What are the 3 clinical features on history of a patient with a potential miscarriage?

Answer 10

• Bleeding
• Pain
• Passage of the products of conception

Question 11

Discuss the bleeding that is involved in miscarriage.

Answer 11

The bleeding is variable depending on the type of miscarriage. In COMPLETE miscarriage - variable bleeding through process BUT then ceases entirely. In THREATENED miscarriage - pregnancy usually continues uneventfully BUT the risk of loss is proportional to amount of bleeding which means that if the bleeding continues then the prognosis is worse.

Question 12

Discuss the pain that is involved in miscarriage.

Answer 12

The pain involved is the uterus contracting, the cervix dilating and the products of pregnancy being passed. There is a cramp like feeling which follows the bleeding. This is unlike the pattern of pain and bleeding in an ectopic pregnancy.

Question 13

Discuss the passage of products of conception in miscarriage

Answer 13

This passage of products of conception occurs in complete and incomplete miscarriage.

Question 14

Explain the classification of miscarriage. There are 5 different types of miscarriage. Explain, using the initial parameters, how they all differ.

Answer 14

3 paramenters: Cervix, Products Passed?, U/S findings.

1. Threatened - Closed, No, Viable Intrauterine Pregnancy
2. Missed - Closed, No, Non-viable intrauterine pregnancy
3. Inevitable - Open, No, Non-viable intrauterine pregnancy; often low in the uterus
4. Incomplete - Open, Yes, Retained products of conception
5. Complete - Closed, Yes, Empty uterus; no extrauterine pregnancy

Question 15

Explain the initial general management of a patient who has had a miscarriage.

Answer 15

1. Assessment - Hx, Ex + Ix (blood group, quantitative beta-hCG, U/S)
2. Generic Treatment - Resuscitation, passive anti-D for Rh-neg women (because small amount of fetal blood circulating in 1st trimester), explanation and support.

Question 16

Explain the further management of a threatened miscarriage.

Answer 16

Admission is rarely needed due to the ongoing viability.

Question 17

Explain the further management of a complete miscarriage (how do you confirm a complete miscarriage).

Answer 17

On assessment, if a history of significant bleeding, pain and passage of products of conception is present AND there is a closed cervix and significant reduction in pain now AND the uterus is empty on U/S following localisation of pregnancy as intrauterine or pathologic confirmation of complete passing of the products of conception -COMPLETE MISCARRIAGE CAN BE CONFIRMED.

Question 18

Explain the further management of an inevitable miscarriage.

Answer 18

Patient will go onto pass products of conception with variable amounts of pain and bleeding. Expectant or medical management is most appropriate.

Question 19

Explain the further management of an incomplete miscarriage

Answer 19

Common to have bleeding and shock. Can actually get cervical shock if the products of conception, on passing, are trapped in the cervix. This presents as bleeding, significant pain + vaginal/PNS symptoms. Need to remove those products with a curette.

Question 20

Explain the general principles of the further management of a missed miscarriage.

Answer 20

1. Expectant Management – Increased days of bleeding, decreased amount of pain than medical Mx, non-invasive, uncertain of timing + emotional
2. Medical Management – misoprostol @ hospital/home, pain is worse then expectant Mx but the bleeding is similar but is longer in duration than surgical Mx
3. Surgical Management - cervical dilation + suction curette - definitive Mx in both complete and incomplete miscarriage. Decreased bleeding and period-like pain. Usual anaesthetic risk

Question 21

Explain what septic miscarriage is.

Answer 21

This type of miscarriage is associated with all types of miscarriages but is mostly restricted to types where there are retained products of conception. Most commonly found in criminal abortions. Will have vaginal discharge, abdominal pain and fever. Treat with ABx + suction curette.

Question 22

What is the prognosis of a patient who has experienced a miscarriage?

Answer 22

Bleeding in the presence of viable pregnancy is benign. Could lead to increased pregnancy complications including increased risk of PPROM, preterm, APH and IUGR.

Question 23

Define recurrent miscarriage and explain the investigations involved.

Answer 23

Recurrent miscarriages are when there are more than 3 consecutive miscarriages. Mostly idiopathic. Imaging of the uterus, endocrine profiling, thrombophilic screening, karyotyping are all involved.