Miscarriages and ectopic pregnancy

Question 1

What is a miscarriage?

Answer 1

• Miscarriage is an involuntary, spontaneous loss of a pregnancy before 24 weeks. After the cut-off, the loss would be defined as a stillbirth.
• Miscarriage is associated with unprovoked vaginal bleeding with or without suprapubic pain.

Question 2

Causes of miscarriages

Answer 2

Embryonic factors: 
Chromosome abnormalities 
Embryonic malformations
Maternal factors: 
Maternal genital tract dysfunction ( ascending infection from the lower genital tract)
Systemic illness.
Toxic agents 
Irradiation 
Chemotherapy 
Major endocrinopathies 
Immunological diseases 
Trans-placental infections
Bacterial vaginosis

Question 3

Pathophysiology of miscarriages

Answer 3

• Vaginal bleeding originates from the decidual implantation site or from the placenta.
• The onset of bleeding may follow or precede fetal demise. Immunogenic, hypoxic, and vascular causes lead to a final common pathway of severe villous or placental dysfunction resulting in embryonic or fetal demise.

Question 4

Classification of miscarriages

Answer 4

Threatened miscarriage 
Inevitable miscarriage 
Incomplete miscarriage 
Complete miscarriage 
Missed miscarriage 
Recurrent miscarriage

Question 5

What is threatened miscarriage?

Answer 5

A threat of miscarriage that exists when unprovoked vaginal bleeding, with or without lower abdominal pain, occurs in a pregnancy of 20-24 weeks (gestation depends on country), and where pregnancy may continue.

Question 6

What is inevitable miscarriage?

Answer 6

A miscarriage deemed inevitable when specific clinical features indicate that a pregnancy is in the process of physiological expulsion from within the uterine cavity (pregnancy will not continue and will proceed to incomplete or complete miscarriage).

Question 7

What is incomplete miscarriage?

Answer 7

A miscarriage in which early pregnancy tissue is partially expelled. It is possible that many incomplete miscarriages are unrecognised missed miscarriages.

Question 8

What is complete miscarriage?

Answer 8

A miscarriage in which early pregnancy tissue is completely expelled.

Question 9

What is missed miscarriage?

Answer 9

A miscarriage with ultrasound features consistent with a non-viable or non-continuing pregnancy, even in the absence of clinical features.

Question 10

What is recurrent miscarriage?

Answer 10

The spontaneous loss of ≥3 consecutive pregnancies before 20-24 completed weeks (gestation depends on country) is regarded as recurrent miscarriage.

Question 11

What are the risk factors for a miscarriage?

Answer 11

Older parental age 
Uterine malformation 
Bacterial vaginosis 
Parental chromosomal anomaly
Vitamin D deficiency 
Thrombophilia

Question 12

Signs and symptoms of a miscarriage?

Answer 12

• Vaginal bleeding with or without clots.
• Suprapubic pain- Cramp-like discomfort may signify the process of expulsion of the foetus. Pain without vaginal bleeding does not suggest a miscarriage (but may suggest an ectopic pregnancy).
• Low back pain
• Recent post-coital bleed

Question 13

What are the investigations for a miscarriage?

Answer 13

• Trans-vaginal ultrasound scan- a miscarriage should be considered when trans-vaginal ultrasound reveals a gestational sac with mean diameter ≥25 mm with no visible yolk sac or fetal pole. It is also likely when the crown-rump length of the embryo measures 7 mm or more, with no obvious fetal heart activity.
• Serum beta hCG titres

Question 14

Differentials for miscarriage

Answer 14

• Ectopic pregnancy
• Hydatidiform mole
• Cystitis
• Pregnancy co-exiting with a bleeding cervical polyp.

Question 15

Management for miscarriage

Answer 15

Conservative management
Medical management
Surgical management

Question 16

Treatment for threatened miscarriage

Answer 16

Analgesics plus counselling with anti-D immunoglobulin

Question 17

What is conservative management?

Answer 17

o A significant number of women prefer conservative (or expectant) management allowing early pregnancy tissue to be expelled spontaneously.
o It may be continued as long as the patient is willing and provided there are no signs of infection such as vaginal discharge, excessive bleeding, pyrexia, or abdominal pain.

Question 18

What is medical management?

Answer 18

o The main drug therapy for non-surgical management of miscarriage is misoprostol, a prostaglandin analogue.
o The patient, however, needs to be informed that the surgical option may still be necessary if bleeding gets heavier or is persistent beyond a reasonable time.
o Vaginal bleeding after misoprostol therapy seems to be more prolonged and heavier, but seldom requires blood transfusion compared with after surgical evacuation.

Question 19

What is surgical management?

Answer 19

o A flexible or rigid plastic cannula is connected to a controlled suction outlet. It is important to ascertain the axis of the uterus before inserting the cannula.
o Because suction evacuation of the uterus is undertaken with some form of regional or parenteral/general anaesthetic, the risks of perforation are high.
o The most critical safeguards to this are to ascertain the cervico-uterine axis and to assess the approximate cervico-uterine cavity length.
o The use of routine antibiotic prophylaxis in women with incomplete miscarriage and no signs of infection is controversial.

Question 20

What are the complications of a miscarriage?

Answer 20

• Incomplete evacuation of the uterus
• Post-evacuation uterine bleeding
• Sepsis
• Uterine or cervix perforation
• Recurrent miscarriage
• Asherman’s syndrome
• Psychological dysfunction

Question 21

What is ectopic pregnancy?

Answer 21

• A fertilised ovum implanting and maturing outside of the uterine endometrial cavity, with the most common site being the fallopian tube (97%), followed by the ovary (3.2%) and the abdomen (1.3%).
• Typically presents 6 to 8 weeks after last normal menstrual period, but can present earlier or later.

Question 22

What can happen if an ectopic pregnancy is undiagnosed?

Answer 22

• If undiagnosed or untreated, it may lead to maternal death due to rupture of the implantation site and intraperitoneal haemorrhage.

Question 23

What are the causes of ectopic pregnancies?

Answer 23

• Two broad categories of conditions lead to ectopic pregnancy: 1) conditions that hamper the transport of a fertilised oocyte to the uterine cavity, and 2) conditions that predispose the embryo to premature implantation.
• However, more than half of diagnosed ectopic pregnancies are not associated with any known risk factors.

Question 24

Classification of ectopic pregnancies

Answer 24

• Tubal pregnancy
• Ovarian pregnancy
• Cervical pregnancy
• Interstitial pregnancy
• Hysterotomy scar pregnancy
• Abdominal pregnancy
• Heterotopic pregnancy

Question 25

What is tubal pregnancy?

Answer 25

• may implant in ampulla, isthmus, fimbria

Question 26

How does cervical pregnancy present?

Answer 26

• often presents with profuse and painless bleeding

Question 27

What is interstitial pregnancy?

Answer 27

• Trophoblast implants at junction of proximal fallopian tube and muscular wall of the uterus.

Question 28

What is hysterectomy scar pregnancy?

Answer 28

• Implantation into the myometrial defect at the site of a previous uterine incision.

Question 29

Why does abdominal pregnancy occur?

Answer 29

• May be primary from direct implantation of the blastocyst or secondary from expulsion of the embryo from the fallopian tube.

Question 30

What is heterotypic pregnancy?

Answer 30

• Two concurrent pregnancies, one intrauterine and the other ectopic.

Question 31

Signs and symptoms of ectopic pregnancy

Answer 31

• Abdominal pain.
• Amenorrhoea
• Vaginal bleeding
• Abdominal tenderness
• Adnexal tenderness or mass
• Blood in vaginal vault
• Haemodynamic instability, orthostatic hypotension

Question 32

Risk factors for ectopic pregnancy

Answer 32

o Previous ectopic pregnancy 
o Pervious tubal sterilisation surgery 
o IUD use 
o Previous genital infections
o Chronic salpingitis 
o Infertility 
o Multiple sexual partners 
o Smoking

Question 33

Investigations for ectopic pregnancy

Answer 33

• Urine or serum pregnancy test
• Transvaginal ultrasound
• Transabdominal ultrasound

Question 34

Differentials for ectopic pregnancy

Answer 34

• Miscarriage
• Acute appendicitis
• Ovarian torsion
• Pelvic inflammatory disease (PID) or tubo-ovarian abscess.
• Ruptured corpus luteal cyst or follicle
• Nephrolithiasis
• UTIs

Question 35

`Management of ectopic pregnancy

Answer 35

• Surgery- Preferred method is laparoscopy with either salpingostomy or salpingectomy, depending on the status of the contralateral tube and the desire for future fertility.
• Methotrexate post-surgical- If serum chorionic gonadotrophin levels do not return to undetectable after surgery, methotrexate is given.
• Fluid-resuscitation- Haemodynamic instability associated with a ruptured ectopic pregnancy results from severe hypovolaemia secondary to blood loss.
• Rapid volume repletion with isotonic solution and blood products is of paramount importance to avoid ischaemic injury and multi-organ damage.
• Medical management- methotrexate
• Conservative management- only if asymptomatic/ falling HcG

Question 36

Complications of an ectopic pregnancy?

Answer 36

• Adverse effects associated with methotrexate therapy
• Persistent trophoblast
• Damage to surrounding organs or vasculature resulting from surgical intervention.
• Recurrent ectopic pregnancy.