Miscarriages Flashcards
What is a miscarriage?
A Miscarriage is one of the most common gynaecological problems a medical practitioner will encounter
What is the definition of recurrent miscarriages?
The consecutive miscarriages happening >3 times before 20 weeks gestational age
What are the risk factors associated with miscarriages?
- Maternal age >40% chance in above 40 years
- Previous spontaneous miscarriage >20% increase
- Smoking and alcohol while pregnant
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What investiagations do we need to do if we encounter a late miscarriage?
- Serology for syphilis
- Lupus anticoagulant
- Hystersonography (u/s)
- Antinuclear factor
If hystersonography is abnormal then do laparoscopy and hysteroscopy
What are the miscellaneous causes of late miscarriage?
- Syphillis -especially recurrent miscarriages
- Cytomegalovirus, rubella, toxoplasmosis
- Chlamydia and mycoplasma infections
- Hypothyroidism and diabetes mellitus should not cause recurrent miscarriages
What are the causes of early trimester miscarriages?
- Chromosomal abnormalities (60%)-aneuploidy(abnormal number of chromosomes)
- Environmental factors:
- smoking, alcohol, caffeine and cocaine consumption, maternal age - Poor placentation
- uterine septum placentation
- autimmune (SLE, antiphospholipid syndrome)
- HLA status(human lymphocytic antigen)
What are the causes of late trimester miscarriage?
- Inability of the uterus to hold the pregnancy
- cervical incvompetence
- uterine didelphys
- leimyomas - Poor placentation
- pre-eclampsia
- infections
- inadequate trophoblastic invasaion of the uterine spiral arteries
- SLE
What are the causes of recurrent miscarriages?
- Genetic abnormalities
- Structural abnormalities
- Infection
- Thromobophilic infections
- Anti-phospholipid syndrome
What is the genetic abnormality seen in recurrent miscarriages?
A balanced reciprocal translocation or robertsonian translocation
What are the structural abnormalities seen in recurrent miscarriages?
- Uterine structural abnormalities (uterine septal or bicornuate uterus)
- Cervical incompetence
What infections tend to cause recurrent miscarriages?
Bacterial vaginosis and syphillis because they remain asymptomatic most of the time
What is anti-phospholipid syndrome?
It is one of the causes of recurrent miscarriages
- (directed at phospholipid binding plasma proteins)
- we treat antiphospholipid syndrome with heparin and low dose aspirin
What thromobolititc disorders are associated with recurrent miscarriage?
- Factor V Leiden, prothrombin G20210A, and activated protein C resistance
What are the 5 clinical presentations of a miscarriage?
- Threatened miscarriage
- Inevitable miscarriage
- Complete miscarriage
- Incomplete miscarriage
- Missed miscarriage
What is a threatened miscarriage?
A threatened miscarriage is when
- there is light vaginal bleeding with or without backache or abdominal pain
- the cervix is closed and the foetus is alive
What is the differential diagnosis of a threatened miscarriage?
- Blighted ovum
- Implantation bleeding
- Ectopic pregnancy
What should a patient do for the next couple of days to prevent worse prognosis for a threatened miscarriage?
Avoid exertional activities for a few days
When can we expect foetal heart sounds ?
By 5 to 6 weeks or at a BHCG level of 10 000IU
What percentage of threatened miscarriages do not end up aborting?
60%
What is should we worry about in the second trimester if a threatened miscarriage occurs?
Preterm labour and pregnancy and we should observe the patient and mom accordingly
What is an inevitable miscarriage?
It is a miscarriage that presents with vaginal bleeding , increasing pain and the uterus may be tender and there might be cervical dilation
What is the management of a shocked patient with inevitable miscarriage?
Start resus with crystalloids fluids and blood transfusion if needed
Oxytocin to allow for uterine contraction
1st trimester: suction curettage or vacuum aspiration
2nd trimester: oxytocin, analgesia, abort spontaneously followed by vacuum aspiration or curettage
What is an incomplete miscarriage?
It is a miscarriage where there are products of conception that are passed
-the cervical os is open and the uterus is smaller than the expected gestational age
How do we manage patients with incomplete miscarriages?
- We manage them by removing remaining products with an ovum forceps
Then we can use a vacuum aspiration if not bigger than 12 weeks then a curretage
What is a complete miscarriage?
This is diagnosed when the clinician has seem the foetal parts him/herself
No evacuation is necessary but we must still watch out for post-abortion haemorrhage
What should we investigate if it is a fresh miscarriage?
Congenital abnormalities
-blood from the foetal Heart must be aspirated
What should we suspect if the it is a macerated miscarriage?
Infection or poor placentation and investigate the tissue biopsy for possible chorioamnionitis
What is a missed miscarriage?
It is a miscarriage where the foetus is still in the uterus but has no cardiac activity
There is no bleeding and the cervical os is closed and there’s no pain
<12 weeks dilatation and curettage or manual vacuum aspiration of the uterus is performed
>14 weeks misoprostol needs to be used before and then dilation
What special investigations do we need to always do in patients with miscarriages?
- Syphilis
- Rhesus status and if mom is Rhesus negative give anti-D immunoglobulin in second trimester
- Cervical intra-epithelial neoplasia
What are the advantages of suction curettage over sharp curettage?
Less pain Less bleeding Less operation time Less long term endometrial damage Less uterine perforation
What analgesia do we give to women who are going to have a suction curettage?
- Fentanyl, midazolam and intracervical block using bupivicaine of about 0,5%
