Pregnancy complications - Miscarriage Flashcards
What is the definition of a miscarriage?
Termination/loss of pregnancy before 24 weeks gestation with no evidence of life
What are features of a threatened miscarriage?
- Viable pregnancy
- Vaginal bleeding +/- pain
- Closed cervical Os
Is the cervical Os open or closed in a threatened miscarriage?
Closed
What are features of an inevitable miscarriage?
- Viable pregnancy
- Open cervix
- PV bleeding
Is the cervical Os open or closed in an inevitable miscarriage?
Open
What are features of an incomplete miscarriage?
- Most of pregnancy contents expelled out - some remaining in uterus
- Open cervix
- Vaginal bleeding - may be heavy
Is the cervical Os open or closed in an incomplete miscarriage?
Open
What are features of a complete miscarriage?
- Passed all products of conception
- Cervix closed
- No bleeding
What are causes of septic miscarriage?
- Incomplete misarriage
- Therapeutic abortion
What is the defintion of recurrent miscarriage?
Three or more consecutive miscarriages
What are features of a missed miscarriage?
- Getational sac seen
- No clear foetus
What can cause miscarriage?
- Abnormal conceptus - Chromosomal, genetic, structural
- Uterine abnormality - Congenital, fibroids
- Cervical incompetence- Primary, secondary
- Maternal - Increasing age, diabetes
- Unknown
What are possible endocrine causes of recurrent miscarriage?
- Diabetes mellitus
- Thyroid disorders
- PCOS
What are infectious causes of recurrent miscarriage?
- BV
- CMV
- Rubella
- Malaria
- Trypanosomiasis
- Listeria
- Mycoplasma
What autimmune disorders can cause recurrent miscarriage?
- Antiphospholipid syndrome
- SLE
What haematological disorders can cause recurrent miscarriage?
Inherited thrombophilias - Factor V leiden, prothrombin gene mutations, protein C and S deficiency
How would a mother having a miscarriage potentially present?
May be asymptomatic
-
PV bleeding +/- lower abdominal pain
- Signs of shock if severe
How would you investigate someone with suspected miscarriage?
- Bloods - FBC, Crossmatch/group and save, coag screen, quantitative BHCG, RhD status
- Imaging - transvaginal USS
What are USS findings in threatened miscarriage?
- Intrauterine gestation sac
- Foetal Heart activity
- Foetal pole
What are USS features of complete miscarriage?
- Empty uterus
- Endometrial thickness <15mm
What are USS findings of an incomplete miscarriage?
- Heterogenous tissue +/- gestation sac
- Any endometrial thickness
What are USS features of inevitable miscarriage?
Intrauterine gestation sac +/- foetal heart activity +/- foetal pole
How would you manage a woman with a threatened miscarriage?
Conservative
- Anti-D - if > 12 weeks or heavy bleeding/pain
How would you manage inevitable miscarriage?
Expectant/medical/surgical management
- Expectant - allow miscarriage to play out
- Medical - mifepristone, then misoprostol; consider Anti-D if >12 weeks
- Surgical management of miscarriage - suction curettage
How would you manage a missed miscarriage?
- Medical - mifepristone, then misoprostol
- Consider Surgical management of miscarriage
- Anti-D - if > 12 weeks of medical/surgical management
How would you manage a complete miscarriage?
- Anti-D if >12 weeks
- Serum bHCG tro exclude ectopic
- Review if bleeding persists - endometritis, retained products
What are complications of surgical management of miscarriage?
- Infection
- Haemorrhage
- Uterine perforation
- Retained products
- Intrauterine adhesions
- Cervical tears
- Intra-abdominal trauma
What are the main things you would want to establish about in someone with suspected miscarriage?
- Are they shocked?
- Pain - worse than period?
- Products of conception seen?
- Uterine size appropriate for date?
- Is bleeding from outside or inside uterus?
What is cervical shock?
Vasovagal syncope produced by stimulation of the cervical canal during dilatation may occur. Rapid recovery usually follows
How would you manage cervical shock?
Remove contents in the cervical Os - resuscitation will not help
What are causes of first trimester miscarriage?
Chormosomal abnormality is most common cause
- Autosomal trisomy
- Single chromosomal anomaly is 45X karyotype
What are the stages of miscarriage?
- Threatened miscarriage
- Inevitable miscarriage
- Incomplete miscarriage
- Complete miscarriage
If a woman presented with early pregnancy bleeding, what would your differential diagnosis be?
- Miscarriage
- Ectopic pregnancy
- Molar pregnancy
- Implantation bleed
- Genital tract trauma
- Cervical pathology: - ectropion / polyp / malignancy
How would you manage someone who was having a miscarriage who was haemodynamically unstable?
- ABCDE
- Urgent O&G specialist input
- Urgent speculum examination - remove POC as clinically indicated - This may stop the bleeding and restore blood pressure (cervical shock)
- Urgent ultrasound scan: exclude ectopic pregnancy
- Anti-D - if the patient is rhesus negative.
What investigations would you do in someone with recurrent miscarriage?
- Imaging - Pelvic USS and MRI, sonohysterography, hysteroscopy
- Bloods - Thrombophilia screen, Antiphospholipid antibody screen, anticardiolipin antibodies and lupus anticoagulant, TFTs
