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My MRCOG Part 2 > Module 13 - Miscarriage > Flashcards

Module 13 - Miscarriage Flashcards

Miscarriage and Recurrent Miscarriage, NICE, GTG, TOG

1
Q

What proportions of all pregnancies end in miscarriage?

A

20%

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2
Q

What is the recommended management plan for a women who presents with:
<6/40
PVB
No abdominal pain

A

Safety net advice
Discharge
USS in 7-10 days.

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3
Q

When doing an US to assess for viability, what should be looked for first? If this cannot be found, what should be measured?

A

First look for FH

If not seen, measure CRL.

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4
Q

When should the gestational sac be measures?

A

If foetal pole cannot be seen.

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5
Q

If carrying out a TA US, and the FH cannot be seen, what should happen?

A

The CRL (or gestational sac if no foetal pole) should be measured and documented.
Re-scan in 14 days.

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6
Q

Can LMP be used to determine if FH should be visible?

A

No.
Variation in menstrual cycle.

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7
Q

When carrying out a TVUS, What should happen if the CRL <7mm?

A

Rescan in 7 days.

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8
Q

When carrying out a TVUS, What should happen if the CRL >7mm?

A

And no FH - this is a miscarriage.
Get another person to confirm or rescan in 7 days if noone is available).

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9
Q

What cut off is used if carrying out a TVUS and there is no foetal pole, but CRL is measured?

A

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.

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10
Q

What is HCG a reflection of?

A

Trophoblastic proliferation

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11
Q

How should bHCG normally increase?

A

> 63% every 48 hours.

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12
Q

How often does bHCG take to double?

A

Doubles every 1.5 days until 35 days
then every 2-2.5 days until 42 days.

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13
Q

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?

A

Likely IUP.
Offer re-scan in 7 days.

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14
Q

Can Progesterone measurements be used to determine chance of miscarriage?

A

No.

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15
Q

If pregnancy cannot be seen on US and 48 hour bHCG is between <50% decrease and <63% increase, what should be done?

A

This is a PUL.
Urgent EPAU referral.
May need serial bHCG measurements.

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16
Q

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?

A

Likely miscarriage.

UPT in 14 days.

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17
Q

What is the chance of a successful ongoing pregnancy in a women who presents with symptoms of a threatened miscarriage?

A

83% chance of successful miscarriage.

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18
Q

When should women with symptoms of threatened miscarriage be re-reviewed?

A

If PVB worsens or continues to more than 14 days

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19
Q

If PVB stops in a patient with threatened miscarriage, what does NCIE recommend their management plan to be?

A

To return to normal antenatal care.

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20
Q

What can be given to women who present with PVB who have a history of previous miscarriage and are >6/40?

A

PV Micronised progesterone.

(400mg BD IF PREGNANCY CONFIRMED ON USS).

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21
Q

What does the evidence show regarding PV micronised progesterone in women with 1 previous miscarriage vs recurrent miscarriage?

A

1 previous - small increase in live births.

No difference in recurrent miscarriage

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22
Q

What is the first line management of miscarriage for stable women with no signs of sepsis and no history of traumatic miscarriage?

A

Expectant management for up to 14 days.
And do a UPT at 3 weeks.

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23
Q

What is the normal dose and timing of medical management of miscarriage?

A

Mifepristone (200mg STAT).

48 hours later.
Misoprostol 800 microg 4 hourly.

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24
Q

How long after the first misoprostol dose should PVB start?

A

within 48 hours.

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25
Q

When is misoprostol NOT given as part of medical management of miscariage?

A

If the sac has been passed after mifeprostone.

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26
Q

What medical management regime can be used in case of incomplete msicarriage?

A

Single misoprostol dose of 600micrograms (but 800 can be used to standardise within departments).

These women do not need mife.

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27
Q

What type of hormone is misoprostol?

A

PGE1

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28
Q

Define recurrent miscarriage

A
  • 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.
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29
Q

Can women be referred after 2 miscarraiges?

A

Yes, if a pathological/non sporadic cause is suspected.
Eg is acquired thrombophilia suspected.

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30
Q

Are inherited or acquired thrombophilias associated with recurrent miscarriage?

A

Acquired thrombophilias are associated with recurrent miscarriage.

(inherited are weakly associated)

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31
Q

Who should be referred to recurrent miscarriage clinic?

A
  • 3+ miscarriages <10/40 that are morphologically normal.
  • Any second trimester miscarriage
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32
Q

When should cytogenetics be carried out on POC?

A

3rd miscarriage and each subsequent miscarriage.
Any 2nd trimester miscarriage.

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33
Q

If there is no POC available for cytogenetics after 3rd miscarriage, what test can be carried out instead?

A

Parental peripheral blood karyotyping (to look for unbalanced structural abnormalities).

34
Q

What imaging should be carried out for women with recurrent miscarriage?

A

3D US
(CUA)

35
Q

What blood tests should be carried out for women with recurrent miscarriage?

A

TFTs including TPO-antibodies.
lupus antibodies
anti-cardiolopin antibodies
anti-beta-2-glycoprotein 1 antibody

36
Q

What antibodies are present in APLS? How often should this test be carried out?

A

Lupus antibodies or anti-cardiolopin or anti-beta-2-glycoprotine-1-antibody.

This should be done twice at least 6 weeks apart.

37
Q

What should be offered if a uterine septum is identified?

A

Hysteroscopic resection

38
Q

What defines a sporadic miscarriage?

A

Usually 1st trimester.
Random chromosomal abnormalities.
Proportional to age.

39
Q

What is the rate of sporadic miscarriage based on age?

A

12 - 19 years = 13%
20 - 29 years = 11%
30 - 34 years = 15%
35 - 39 years = 25%
40 - 44 years = 50%
45+ = 93%

40
Q

What proportion of women are affected by recurrent miscarriage?

A

1% (if 3+ definition used)

(2% if 2+ definition used)

41
Q

What male factor increases the risk of miscarriage (but is not necessarily testes for)?

A

Increased sperm DNA fragmentation

42
Q

Does consanguinity increase risk of miscarriage?

A

NO

43
Q

Is APLS acquired or inheritied?

A

ACQUIRED

44
Q

Which antibody is most strongly associated with APLS?

A

Lupus anticoagulant.

(then anti-cardiolipin)

45
Q

What are the types of inherited thrombophilias?

A
  1. Factor v Leiden
    2.Protein C Deficiency
  2. Protein S Deficiency
  3. Anti-thrombin deficiency
  4. Prothrombin gene mutation.
46
Q

Which 2 inherited thrombophilias are associated with 2nd trimester miscarriage?

A
  1. Factor V Leiden
  2. Protein S Deficiency
47
Q

What proportion of parents are found to have a chromosomal translocation if they are suffering from recurrent miscarriage?

A

2% if 1 miscarriage
5% if 2 miscarriages
6% if 3 miscarraiges

48
Q

What is the most common type of chromosomal imbalance found in women with recurrent miscarriage?

A

Balanced < Unbalanced.
(55% reciprocal,
50% inversion,
35% Robertosnian
27% Other).

49
Q

When cytogenetics are inspected, what is the most common cause of sporadic miscarriage?

A

60% trisomy.
20% polyploidy.
15% monosomy.
6% structural.

50
Q

When inspected, what proportion of fetuses with normal chromosomes are found to have abnormal morphology?

A

20%

51
Q

What CUA increase the risk of 2nd trimester miscariages?

A

Septum
Arcuate
Bicornuate

52
Q

Do fibroids increase the risk of miscarriage?

A

Yes - only if sub-serosal or intramural.

53
Q

Define sub-clinical hypothroid

A

TSH > 2.5 but asymptomatic

54
Q

Does PCOS increase risk of miscarriage?

A

Yes.
But progesterone and LH are not predictive.

55
Q

Does DM increase risk of miscarriage?

A

Yes if raised HbA1c.
But not if well controlled.

56
Q

Risk of miscarriage is increased with which HLAs?

A

HLA-DRBI14/15
HLA-E01:01
(but not statistically significant)

57
Q

What HLAs are associated with reduced risk of miscarriage?

A

HLA-DRBI*13 or 14.

58
Q

Why is it not possible to use peripheral NK cell number to predict risk of miscarriage?

A

Because although a raised number of PNKs, the are not reflective of endometrial NK cell numbers.

59
Q

Cytogenetics give a diagnosis in what proportion of miscarriages?

A

> 90%

60
Q

What treatment is offered to women with APLS?

A

Aspirin and LMWH from +UPT until 34/40

61
Q

Is endometrial scratch recommended for unexplained recurrent miscarriage?

A

No.
Neither is LMWH or Aspirin.

62
Q

Define metroplasty

A

Hysteroscopic resection of uterine septum.

63
Q

How long after miscarriage can metroplasty be carried out?

A

at least 6 weeks (septum resection).

64
Q

What is the rate of live-birth following metroplasty?

A

50%

65
Q

What is the risk during metroplasty of:
1. uterine perforation
2. excessive bleeding
3. cervical laceration
4. uterine synechiae (adhesions)

A
  1. uterine perforation - 1%
  2. excessive bleeding - 1%
  3. cervical laceration - 1%
  4. uterine synechiae (adhesions) - 2%
66
Q

What proportion of early pregnancy miscarriages are due to a chromosomal anomoly?

A

70%

67
Q

What is the rate of CUA in women with recurrent miscarriage?

A

13%
(5% BG risk)

68
Q

What is the rate of APLS in women with recurrent miscarriage?

A

5-20%
(BG 2%)

69
Q

What is the overall risk of serious complications during SMM?

A

6%
(increased if obese, pre-existing medical condition, previous surgery)

70
Q

What is the risk of perforation during SMM?
Where do the majority occur?

A

1/1,000

40% anterior wall.
Highest risk if ERPC for PPH.
More likely in TOP than SMM.
Increased risk if junior trainee.

71
Q

Does Mife cervical prep reduce risk of uterine perforation during SMM?

A

No

72
Q

What is the risk of cervical trauma during SMM?

A

1 / 1,000
(increased if nullip)
(leads to 1-3% increased risk of PTL in future).

73
Q

What are the frequent risks of SMM?

A
  • 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
74
Q

Which women require Anti D after SMM and what dose?

A

All Rh Negative women.
250IU

75
Q

Miscarriage affects what proportion of pregnancies?

A

20%

76
Q

What cervical preparation is given pre - MVA?

A

400microg misoprostol

77
Q

What can be used to carry out a para-cervical block?

A

Prilocain 30mg/ml with 0.03IU/ml felypressin.

78
Q

Which women are suitable for MVA?

A

Stable women.
Multips or motivated primip.
CRL <25mm (or RPOC <5cm mean diameter).
NO clinical signs infection.
<10/40

79
Q

Which factors would exclude a woman from being offered MVA?

A

Sepsis
>10/40
Panic attacks
Cervical stenosis
Fibroid uterus >12/40
Uterine malformation
Post Natal RPOC

80
Q

What is the rate of incomplete uterine evacuation with MVA vs SMM

A

1% MVA
4% SMM

My MRCOG Part 2 (37 decks)

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