Pregnancy Loss Flashcards
Definition of recurrent miscarriage?
3 or more miscarriages in succession with same partner
Causes of recurrent miscarriage?
Antiphospholipid Antibodies – thrombosis in uteroplacental circulation.
Chromosomal defects – in 4%
Anatomical Features – uterine abnormalities
Infection – implicated in preterm labour and late (>16 week) miscarriage
Others = obesity, smoking, PCOS, higher maternal age
How is antiphospholipid syndrome managed?
Low dose aspirin and LWMH
How are chromosomal defects diagnosed? (in relation to recurrent miscarriage)
Parental karyotyping and translocations may be found leading to chromosomally imbalanced sperm/oocytes
How are uterine anatomical features diagnosed?
Diagnosed with pelvic ultrasound or hysterosalpingogram
Management of infection-related recurrent miscarriage?
Treatment of BV reduces incidence of foetal loss
Investigating recurrent miscarriage?
Antiphospholipid antibody screen (repeat at 6 weeks if positive)
Karyotyping of both parents
Pelvic ultrasound
Definition of a miscarriage?
Loss of pregnancy before 24 weeks (12% of recognised pregnancies)
Causes of miscarriage?
Most = foetal abnormality
• Sporadic chromosomal abnormalities (most common)
• Structural malformations (neural tube defects) - 1/3 of Down’s syndrome pregnancies miscarry – 100% of triploidies
• Acute pyrexial illness
• Uterine malformations
• Chronic maternal disease (chronic renal failure etc)
Miscarriage history?
Vaginal bleeding - amount and type of loss varies with type of miscarriage and gestation
• Abdominal pain
• Regression of pregnancy symptoms incidental finding at routine antenatal visit
What are the types of miscarriage?
Threatened Inevitable Complete Incomplete Missed/delayed
What is threatened miscarriage?
Symptoms of bleeding +/- pain suggest miscarriage but the pregnancy continues. On examination the cervical os is closed and uterine size correct for dates. The cause is unknown and there is no long-term harm to the baby or implications for the remainder of the pregnancy.
What is inevitable miscarriage?
Presents in the process of miscarriage and nothing can be done to save the pregnancy. There is vaginal bleeding and the cervical os is open.
What is complete miscarriage?
The process has completed without intervention. Presents with bleeding which has now lessened. The uterus has returned to a near normal size and the cervix has closed. The history of bleeding, pain and the findings of an empty uterus on scan are suggestive of the diagnosis but care is needed to ensure ectopic pregnancy has been excluded.
What is incomplete miscarriage?
Not all the products of conception have been expelled from the uterus by the miscarriage process. There is continued bleeding, the cervical os remains open and a scan shows mixed debris in the uterus. Medical or surgical treatment may be offered to complete the miscarriage.
What is missed/delayed miscarriage?
The entire gestation sac, which can include the embryo, is retained within the uterus. The pregnancy has stopped growing or developing and the fetal heart has stopped. The bleeding is usually minimal, the cervical os closed but the uterus smaller than the gestational age. May be found incidentally on routine scan.
First thing you do to diagnose miscarriage?
bHCG test
-ve - never pregnant or have had complete miscarriage
+ve –> Transvaginal scan
Possibilities if you find empty uterus on transvaginal scan? What comes next?
Complete miscarriage
Pregnancy of unknown location (ectopic), normal pregnancy but too early to see
Do bHCG, repeat in 48 hours - if increases by <60%, ectopic.
If increases by >60% = viable pregnancy
If falling = miscarriage.
Possibilities if there is intrauterine pregnancy on transvaginal scan?
Heartbeat present (after 6 weeks) - threatened miscarriage
Too early - come back 7-10 days
Heartbeat not present (non-viable) - incomplete/missed/ inevitable miscarriage - manage
Conservative management of miscarriage? Success rate?
Involves allowing the body to complete the miscarriage “naturally”. Chosen by few women as course unpredictable and can take weeks to complete but avoids hospital admission and use of all drugs. Risk of need for evac
Success rate = >80% within 2-6 weeks in incomplete, 30-70% in missed
Surgical management of miscarriage? Complications? Success rate?
Most common procedure. Minor surgical procedure called evacuation of the uterus, usually under general anaesthetic.
Complications include intrauterine infection (3%), damage to the cervix/trauma, haemorrhage and retained products (5%). Risk of need for evac.
Success rate >95% for all
Medical management of miscarriage? Complications? Success rate?
Involves use of prostaglandins +/- antiprogesterones to induce uterine contractions to expel remaining POC. Can take place in hospital or at home.
Complications = heavy bleeding and moderate abdominal pain. 5% incidence of retained products/failure of treatment.
Success rate = >80% with incomplete, 40-90% in missed.
Counselling in miscarriage?
- Miscarriage not the result of anything they did and could not have been prevented
- Reassure that there is high chance of further pregnancies – Inform about benefits of pre-conceptual folic acid and other general health measures for a successful pregnancy e.g. smoking advice.
- Referral to support group – Miscarriage Association
What is stillbirth?
Delivery of a dead foetus after 24 weeks gestation (beyond age of viability)
Risk factors for stillbirth?
More prevalent in high risk pregnancy
Diagnosis of stillbirth?
- Absent or reduced foetal movements described by the woman
- Antepartum haemorrhage
Diagnosis made by USS
Management of stillbirth?
Must deliver the foetus in the safest, most acceptable way for the woman
Counselling is essential:
- Support groups
- Explanation by obstetrician when cause is known from test results
- Encouraged to hold, photograph and name the baby to help with grieving process
Any subsequent pregnancy is considered high risk
Delivery of stillbirth?
80% deliver spontaneously within 2 weeks
Labour usually induced according to mother’s wishes
Prostaglandins used rather than amnihook to reduce risk of infection
Investigations after stillbirth?
Post mortem foetal chromosome culture, histological examination and culture of the placenta.
Viral screen, glucose, lupus anticoagulant testing from the mother
