Pregnancy loss symposium

Question 1

FIRST TRIMESTER MISCARRIAGE

i) what % of pregnancy loss does this account for?
ii) what will 50% of this miscarriages be due to?

Answer 1

i) accounts for 85% of pregnancy loss
ii) 50% are due to chromosomal abnormalities

Question 2

MISCARRIAGE TERMINOLOGY

define the following types of miscarriage

i) threatened
ii) inevitable
iii) incomplete
iv) complete
v) missed - what is this aka?
vi) molar pregnancy

b) what is a complete mole? what is a partial mole?

Answer 2

i) threatened - symptoms of bleeding/pain but IU pregnancy is still present (cervix closed)
ii) inevitable - symptoms of bleeding/pain but cerivcal os is open
iii) incomplete - symptoms of bleeding, cervical os open but some tissue remains
iv) complete - no tissue remaining

v) missed - diagnosed on a scan with no symptoms
- aka early fetal demise and anembryonic pregnancy

vi) molar - foetus doesnt form properly in the womb and abnormal cells develop instead of a normal foetus
- hydatifiform mole

b) complete - mass of abnormal cells in the womb and no foetus develops
partial - abnormal foetus starts to form but cant survive or develop into a baby

Question 3

FACTORS AFFECTING RISK OF MISCARRIAGE

i) give five factors increasing risk of miscarriage
ii) between what ages does the risk double?

Answer 3

i) age, obesity, antiphospholipid syndrome, parental chromo translocation, poorly controlled diabetes, alcohol/smoking, uterine anomaly, high levels of NK cells
ii) between 30 and 40 the risk doubles

Question 4

PRESENTATION AND MX OF MISCARRIAGE

i) name five presentations
ii) where can medical management take place? what is this dependent on? (2)
iii) name four risks of surgical management

Answer 4

i) bleeding, pain, found on scan, collapse, sepsis

ii) medical can take place at home or on ward
- depends on CRL and patient preference

iii) infection, bleeding, uterine perforation, cervical damage, retained tissue

Question 5

RECURRENT MISCARRIAGE

i) how is it defined? (how many pregnancies, how many weeks)
ii) what % of couples does it affect
iii) name three investigations that should be done
iv) name three blood tests to be done
v) which treatment can improve outcomes if there is a blood disorder?
vi) is there eviddence for treatment for unexplained recurrent miscarriage

Answer 5

i) 3 consecutive pregnancy losses less than 24 weeks
ii) affects 1% of couples
iii) karyotyping, recurrent miscarriage clinic, blood tests, uterine abnormalities
iv) thrombophillia screen, anti cardio-lipin, lupus co-agulant
v) aspirin/ LMW heparin
v) no evidence

Question 6

ECTOPIC PREGNANCY

i) how is it defined?
ii) where does it most commonly happen? name one other side
iii) name five risk factors? what % of women are risk factors present in that have an ectopic?
iv) give three aspects of a classical presentation? give three aspects of a modern presentation
v) how would an emergency presentation be managed?

Answer 6

i) pregnancy developing outside the uterine cavity
ii) fallopian tube or intersitial area

iii) tubal damage, previous ectopic pregnancy, IVF, IUD, progesterone only contraception, cystic fibrosis
- 25-50% of women have these RFs

iv) classical - pain/bleeding at 6-8wks, positive preg test, empty uterus on scan
modern - minor symptoms in early preg, monitor over 48hrs, expectant management

v) with emergency surgery

Question 7

DX AND TX OF ECTOPIC TREATMENT

i) which two factors + a positive pregnancy test should ectopic pregnancy always be considered in?
ii) what imaging modality can aid diagnosis?
iii) what are the three tx options?
iv) how can bHCG levels be investigated in ectopic pregnancy?

Answer 7

i) pelvic pain +/- bleeding
ii) USS
iii) conervative, medical (methotrexate injections), surgical (salphinoectomy)

iv) bHCG should double in conc every 48hrs in IU pregnancy
- in pregnancy of unknown location there is sub optimal rise in bHCG - provokes suspicion of ectopic

Question 8

SECOND TRIMESTER MISCARRIAGE

i) when does it occur?
ii) name three causes of inter uterine death

iiI) name three causes of very pre term labour

iv) name three things in the history that may be relevant
v) give three indications for cervical sutures? when are they usually inserted? name two risks

Answer 8

i) occurs 12-24 weeks
ii) fetal abnormality, infection, placental dysfunction
iii) cervical weakness, uterine abnorm, infection, ruptured membranes, bleeding
iv) bleeding, invasive procedures, screening for fetal anomalies, previous cervical surgery

v) past history of mid trimester pregnancu loss, cervical surgert, noted cervical dilation
- inserted post 12 weeks but can be inserted prepreg
- risk of prolonged pregnancy and infection

Question 9

STILLBIRTH/NEONATE DEATH

i) what is defined as a stillbirth?
ii) name four causes of stillbirth
iii) what is defined at early and late neonatal death?
iv) name four causes of neonate death
v) what is first line treatment after stillbirth?

Answer 9

i) baby delivered with no signs of life after 24 weeks
ii) bleeding, intrauterine growth restriction, fetal abnormality, placental factors, infection, poorly controlled diabetes

iii) early - baby dies within 7 days of delivery
late - baby dies within 7-28 days of delivery

iv) prematuraty, congenital abnormalities, infection, intrapartum asyphixia
v) anti-progesterone eg mifepristone