Module 13 - Miscarriage Flashcards
Miscarriage and Recurrent Miscarriage, NICE, GTG, TOG
What proportions of all pregnancies end in miscarriage?
20%
What is the recommended management plan for a women who presents with:
<6/40
PVB
No abdominal pain
Safety net advice
Discharge
USS in 7-10 days.
When doing an US to assess for viability, what should be looked for first? If this cannot be found, what should be measured?
First look for FH
If not seen, measure CRL.
When should the gestational sac be measures?
If foetal pole cannot be seen.
If carrying out a TA US, and the FH cannot be seen, what should happen?
The CRL (or gestational sac if no foetal pole) should be measured and documented.
Re-scan in 14 days.
Can LMP be used to determine if FH should be visible?
No.
Variation in menstrual cycle.
When carrying out a TVUS, What should happen if the CRL <7mm?
Rescan in 7 days.
When carrying out a TVUS, What should happen if the CRL >7mm?
And no FH - this is a miscarriage.
Get another person to confirm or rescan in 7 days if noone is available).
What cut off is used if carrying out a TVUS and there is no foetal pole, but CRL is measured?
If CRL <25mm and no pole, then rescan in 7 days.
If CRL>25mm and no pole, then this is a miscarriage and should be confirmed with another person or another scan in 7 days.
What is HCG a reflection of?
Trophoblastic proliferation
How should bHCG normally increase?
> 63% every 48 hours.
How often does bHCG take to double?
Doubles every 1.5 days until 35 days
then every 2-2.5 days until 42 days.
If a patient presents with positive UPT and bHCG is found to be >1500 with >63% rise between 48 hour bHCG’s. What is the likely diagnosis?
Likely IUP.
Offer re-scan in 7 days.
Can Progesterone measurements be used to determine chance of miscarriage?
No.
If pregnancy cannot be seen on US and 48 hour bHCG is between <50% decrease and <63% increase, what should be done?
This is a PUL.
Urgent EPAU referral.
May need serial bHCG measurements.
If no pregnancy can be seen on USS and bHCG falls by >50%, what is the likely diagnosis and what should the management plan be?
Likely miscarriage.
UPT in 14 days.
What is the chance of a successful ongoing pregnancy in a women who presents with symptoms of a threatened miscarriage?
83% chance of successful miscarriage.
When should women with symptoms of threatened miscarriage be re-reviewed?
If PVB worsens or continues to more than 14 days
If PVB stops in a patient with threatened miscarriage, what does NCIE recommend their management plan to be?
To return to normal antenatal care.
What can be given to women who present with PVB who have a history of previous miscarriage and are >6/40?
PV Micronised progesterone.
(400mg BD IF PREGNANCY CONFIRMED ON USS).
What does the evidence show regarding PV micronised progesterone in women with 1 previous miscarriage vs recurrent miscarriage?
1 previous - small increase in live births.
No difference in recurrent miscarriage
What is the first line management of miscarriage for stable women with no signs of sepsis and no history of traumatic miscarriage?
Expectant management for up to 14 days.
And do a UPT at 3 weeks.
What is the normal dose and timing of medical management of miscarriage?
Mifepristone (200mg STAT).
48 hours later.
Misoprostol 800 microg 4 hourly.
How long after the first misoprostol dose should PVB start?
within 48 hours.
When is misoprostol NOT given as part of medical management of miscariage?
If the sac has been passed after mifeprostone.
What medical management regime can be used in case of incomplete msicarriage?
Single misoprostol dose of 600micrograms (but 800 can be used to standardise within departments).
These women do not need mife.
What type of hormone is misoprostol?
PGE1
Define recurrent miscarriage
- 3+ miscarriages (NICE = consecutive, - GTG is not necessarily consecutive).
Does not have to be with the same man. - 1+ Morphologically normal miscarriage >10/40.
-1+ PTL <34/40 due to placental disease.
Can women be referred after 2 miscarraiges?
Yes, if a pathological/non sporadic cause is suspected.
Eg is acquired thrombophilia suspected.
Are inherited or acquired thrombophilias associated with recurrent miscarriage?
Acquired thrombophilias are associated with recurrent miscarriage.
(inherited are weakly associated)
Who should be referred to recurrent miscarriage clinic?
- 3+ miscarriages <10/40 that are morphologically normal.
- Any second trimester miscarriage
When should cytogenetics be carried out on POC?
3rd miscarriage and each subsequent miscarriage.
Any 2nd trimester miscarriage.
If there is no POC available for cytogenetics after 3rd miscarriage, what test can be carried out instead?
Parental peripheral blood karyotyping (to look for unbalanced structural abnormalities).
What imaging should be carried out for women with recurrent miscarriage?
3D US
(CUA)
What blood tests should be carried out for women with recurrent miscarriage?
TFTs including TPO-antibodies.
lupus antibodies
anti-cardiolopin antibodies
anti-beta-2-glycoprotein 1 antibody
What antibodies are present in APLS? How often should this test be carried out?
Lupus antibodies or anti-cardiolopin or anti-beta-2-glycoprotine-1-antibody.
This should be done twice at least 6 weeks apart.
What should be offered if a uterine septum is identified?
Hysteroscopic resection
What defines a sporadic miscarriage?
Usually 1st trimester.
Random chromosomal abnormalities.
Proportional to age.
What is the rate of sporadic miscarriage based on age?
12 - 19 years = 13%
20 - 29 years = 11%
30 - 34 years = 15%
35 - 39 years = 25%
40 - 44 years = 50%
45+ = 93%
What proportion of women are affected by recurrent miscarriage?
1% (if 3+ definition used)
(2% if 2+ definition used)
What male factor increases the risk of miscarriage (but is not necessarily testes for)?
Increased sperm DNA fragmentation
Does consanguinity increase risk of miscarriage?
NO
Is APLS acquired or inheritied?
ACQUIRED
Which antibody is most strongly associated with APLS?
Lupus anticoagulant.
(then anti-cardiolipin)
What are the types of inherited thrombophilias?
- Factor v Leiden
2.Protein C Deficiency - Protein S Deficiency
- Anti-thrombin deficiency
- Prothrombin gene mutation.
Which 2 inherited thrombophilias are associated with 2nd trimester miscarriage?
- Factor V Leiden
- Protein S Deficiency
What proportion of parents are found to have a chromosomal translocation if they are suffering from recurrent miscarriage?
2% if 1 miscarriage
5% if 2 miscarriages
6% if 3 miscarraiges
What is the most common type of chromosomal imbalance found in women with recurrent miscarriage?
Balanced < Unbalanced.
(55% reciprocal,
50% inversion,
35% Robertosnian
27% Other).
When cytogenetics are inspected, what is the most common cause of sporadic miscarriage?
60% trisomy.
20% polyploidy.
15% monosomy.
6% structural.
When inspected, what proportion of fetuses with normal chromosomes are found to have abnormal morphology?
20%
What CUA increase the risk of 2nd trimester miscariages?
Septum
Arcuate
Bicornuate
Do fibroids increase the risk of miscarriage?
Yes - only if sub-serosal or intramural.
Define sub-clinical hypothroid
TSH > 2.5 but asymptomatic
Does PCOS increase risk of miscarriage?
Yes.
But progesterone and LH are not predictive.
Does DM increase risk of miscarriage?
Yes if raised HbA1c.
But not if well controlled.
Risk of miscarriage is increased with which HLAs?
HLA-DRBI14/15
HLA-E01:01
(but not statistically significant)
What HLAs are associated with reduced risk of miscarriage?
HLA-DRBI*13 or 14.
Why is it not possible to use peripheral NK cell number to predict risk of miscarriage?
Because although a raised number of PNKs, the are not reflective of endometrial NK cell numbers.
Cytogenetics give a diagnosis in what proportion of miscarriages?
> 90%
What treatment is offered to women with APLS?
Aspirin and LMWH from +UPT until 34/40
Is endometrial scratch recommended for unexplained recurrent miscarriage?
No.
Neither is LMWH or Aspirin.
Define metroplasty
Hysteroscopic resection of uterine septum.
How long after miscarriage can metroplasty be carried out?
at least 6 weeks (septum resection).
What is the rate of live-birth following metroplasty?
50%
What is the risk during metroplasty of:
1. uterine perforation
2. excessive bleeding
3. cervical laceration
4. uterine synechiae (adhesions)
- uterine perforation - 1%
- excessive bleeding - 1%
- cervical laceration - 1%
- uterine synechiae (adhesions) - 2%
What proportion of early pregnancy miscarriages are due to a chromosomal anomoly?
70%
What is the rate of CUA in women with recurrent miscarriage?
13%
(5% BG risk)
What is the rate of APLS in women with recurrent miscarriage?
5-20%
(BG 2%)
What is the overall risk of serious complications during SMM?
6%
(increased if obese, pre-existing medical condition, previous surgery)
What is the risk of perforation during SMM?
Where do the majority occur?
1/1,000
40% anterior wall.
Highest risk if ERPC for PPH.
More likely in TOP than SMM.
Increased risk if junior trainee.
Does Mife cervical prep reduce risk of uterine perforation during SMM?
No
What is the risk of cervical trauma during SMM?
1 / 1,000
(increased if nullip)
(leads to 1-3% increased risk of PTL in future).
What are the frequent risks of SMM?
- Bleeding for up to 2 weeks.
- (0.3% need for blood transfusion).
- Infection (up to 4%).
- RPOC 3-18 / 1,000 (up to 4% after cons/mmm).
- Adhesions
Which women require Anti D after SMM and what dose?
All Rh Negative women.
250IU
Miscarriage affects what proportion of pregnancies?
20%
What cervical preparation is given pre - MVA?
400microg misoprostol
What can be used to carry out a para-cervical block?
Prilocain 30mg/ml with 0.03IU/ml felypressin.
Which women are suitable for MVA?
Stable women.
Multips or motivated primip.
CRL <25mm (or RPOC <5cm mean diameter).
NO clinical signs infection.
<10/40
Which factors would exclude a woman from being offered MVA?
Sepsis
>10/40
Panic attacks
Cervical stenosis
Fibroid uterus >12/40
Uterine malformation
Post Natal RPOC
What is the rate of incomplete uterine evacuation with MVA vs SMM
1% MVA
4% SMM
