Misscarriage Flashcards
Define
Definition = pregnancy loss <24 weeks gestation (PV bleeding >24w is APH)
Prevalence = 10-20% of recognised pregnancies (i.e. 1 in 5 pregnancies)
- Threatened PV bleed with FH (Foetal Heartbeat) present (<24/40 GA) à the cervical os must be closed
- Inevitable PV bleed with open cervical os
- Incomplete Passage of products of conception but uterus not empty on USS
- Complete Passage of products of conception, uterus empty on USS
- Missed USS diagnosis of miscarriage in absence of symptoms
- Recurrent (RMC) ≥3 consecutive miscarriages · No cause found in 50% (RFs: advancing maternal age, previous miscarriage) · Prognosis for future successful pregnancy is 75%
Aetiology
90% result from chromosomal abnormalities in the embryo – trisomy 16
Risk factors – increasing maternal age, previous miscarriage (more than 95% occur in 1st trimester), chronic conditions, uterine/cervix abnormalities, smoking, alcohol, illicit drugs, underweight/obese
If RMC, think of:
- Structural abnormalities (fibroids, bicornuate or septate uteri (incomplete fusion of paramesonephric ducts)
- Cervical incompetence (later miscarriages = >13w)
- Medical conditions (renal, diabetes, SLE)
- Clotting abnormalities (FV-L, AT-III deficiency, antiphospholipid syndrome / APLS)
Signs and symptoms
PV bleeding (scanty, brownish/red), cramping abdominal pain, fever
- Speculum -> quantity and location of bleeding, os open/closed, can remove any products
- PV exam -> exclude ectopic (unilateral tenderness, cervical excitation, adnexal mass)
- General – assess for signs of shock, pyrexia
FH = Foetal Heartrate CRL = Crown-Rump Length
GS = Gestational Sac YS = Yolk Sac
Investigations
Pregnancy test -> speculum (inspect Os) à TVUSS (FH à CRL/foetal pole or GS/YS)
TVUSS: N.B. a foetal pole may not be seen until 9 weeks
Dating pregnancies using USS:
- CRL (end-to-end measure of foetal pole) used to date pregnancies <14 weeks
- AC, HC, FL used to date pregnancies >14 weeks
- Need yolk sac and gestational sac to be a viable IUP; otherwise PUL (Pregnancy of Unknown Location)
- Process of TVUSS = 1st: look for FH à 2nd: foetal poles for CRL à if not foetal pole, look for GS:
- If no FH and CRL >7mm à miscarriage
N.B. cannot be diagnosed as miscarriage on 1 USS alone à get 2nd opinion / re-scan
If no FH and CRL <7mm à PUV (Pregnancy of Unknown Viability) à TVUSS in 7 days
If GS >25mm + no foetus à miscarriage
- N.B. cannot be diagnosed as miscarriage on 1 USS alone -> get 2nd opinion / re-scan
· If GS <25mm + no foetus à PUV (Pregnancy of Unknown Viability) à TVUSS in 7 days
- RMC – cytogenic analysis of products of conception, pelvic USS (structural abnormalities), anti-phospholipid antibodies, anticardiolipin antibodies, screen for BV à explain that the cause is often never found
- N.B. if a woman is having a miscarriage and the products of conception are coming through the cervix, the cervical excitation can cause a parasympathetic stimulation and a BRADYCARDIA, even if there is a blood loss
Management
– patient enters with PV bleeding in pregnancy…
- If signs of ectopic or severe bleeding symptoms à admission à surgical management…
- > 6w pregnant à GDR/EPAU referral (here they will do USS and tests):
Viable pregnancy -> go home and follow expectant management*
- Complete missed miscarriage -> council and go home:
· Psychological awareness of patient’s state of mind
· Advice: menstruation will begin in 4-8 weeks, try for another when mentally ready
- Miscarriage with retained products:
· 1st line: Expectant management for 7-14 days…
- If bleeding/pain settle à pregnancy test after 3 weeks à return if +ve
- If bleeding/pain persist/increasing à follow-up clinic in 4 weeks
- Not appropriate if… (patient can decline 1st line as well):
- Infection
- Coagulopathy
- Late 1st trimester
- Previous traumatic experience
· 2nd line: Medical management
1. Misoprostol (PO or PV) Indicated: expectant failed, pt. choice
2. Advise: bleeding, pain, nausea
2nd line: Surgical management
1. Manual vacuum aspiration (LA) Indicated: medical failed, pt. choice
2. Surgical ERPC (GA)
<6w pregnant à expectant management * (no USS, just send them on their way)
- Do a pregnancy test in 1 week
- If positive result or symptoms persist à follow-up in clinic in 2 weeks
- If RPC, proceed as per medical/surgical management
Administer anti-RhD (n.b. NICE and BCSH guidelines differ on this…):
- BCSH guidelines à administer if mother rhesus -ve and >12w GA (any method of management)
· For therapeutic termination, anti-D is given regardless of method and gestational age
§ NICE guidelines à administer if mother rhesus -ve and not solely managed medically (i.e. there has to be a surgical intervention to warrant a chance of PSE and the need to give anti-D)
o RMC – low-dose aspirin and LMWH if thrombophilia identified (Anti-phospholipid syndrome / APLS)
o Anti-phospholipid Syndrome / APLS:
- S/S: VTE, arterial thrombosis, thrombocytopenia, RMC, pre-eclampsia
- Assess for features of SLE
Ix: lupus anticoagulant AB ± anti-cardioliptin AB
§ Mx:
- Acute -> warfarin + LMWH
- Chronic -> DOAC
- Pregnancy -> low-dose aspirin + LMWH
Complications
Haemorrhage/bleeding Infection
o Cervical trauma Uterine perforation
o Retained products of conception Repeat ERPC
o Psychological sequelae
· Prognosis à most patients go on to have successful pregnancies:
- 1 miscarriage à 85% chance next will be successful
- 2 miscarriages à 75% chance next will be successful
- 3 miscarriages (RMC) à 60% chance next will be successful
