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#Phase 2.2: Obs n Gynae > Recurrent Miscarriage > Flashcards

Recurrent Miscarriage Flashcards

1
Q

What is a Recurrent miscarriage according to RCOG?

A

3+ consecutive pregnancies that end in miscarriage of fetus before 24 weeks gestation

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2
Q

What is the epidemiology of Recurrent Miscarriages?

A

1-2% women

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3
Q

What are the RF for Recurrent Miscarriages? (3 things)

A
  1. Age
  2. No. of previous miscarriages
  3. Lifestyle (smoking / alcohol / caffeine)
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4
Q

The risk of miscarriage increases after each miscarriage… what is the risk of a 4th miscarriage after the 3rd one?

A

40%

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5
Q

What are the causes of Recurrent Miscarriages? (7 things)

A
  1. Antiphospholipid syndrome
  2. Genetic factors (parental / embyronic chromosomal abn)
  3. Endocrine factors (DM / Thyroid / PCOS)
  4. Anatomical factors (uterine abn / cervical weakness)
  5. Infection (any severe infection / bacterial vaginosis)
  6. Inherited thrombophilia
  7. Idiopathic (esp older women)
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6
Q

What happens in Antiphospholipid syndrome?

A

Blood clots more

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7
Q

How can you get Antiphospholipid syndrome? (2 things)

A
  1. Randomly
  2. Secondary to SLE
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8
Q

What percentage of Recurrent Miscarriage women have Antiphospholipid syndrome?

A

15%

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9
Q

What is the live birth rate for women with Antiphospholipid syndrome with no pharma intervention?

A

10% :( , but dw is treatable

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10
Q

What percentage of Recurrent Miscarriage couples have a Parental chromosomal abn being carried by one of the parents?

A

2-5%

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11
Q

What Parental chromosomal abn can be carried that cause Recurrent Miscarriages? (2 things)

A
  1. Balanced reciprocal
  2. Robertsonian translocation
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12
Q

If DM and Thyroid disease are WELL controlled @ conception / during pregnancy is that calm?

A

Yh

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13
Q

What Uterine abn can cause Recurrent Miscarriages? (6 things)

A
  1. Asherman’s syndrome (adhesions of uterus)
  2. Fibroids
  3. Septate uterus (partition thru uterus)
  4. Unicornuate uterus (single horned uterus)
  5. Bicornuate uterus (heart shaped uterus)
  6. Didelphic uterus (double uterus)
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14
Q

How can Cervical weakness cause Recurrent Miscarriages?

A

Cervix effaces and dilates before term

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15
Q

When does Cervical weakness cause Miscarriage?

A

2nd trimester

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16
Q

How can Bacterial vaginosis cause Recurrent Miscarriages?

A

Infection in 1st trimester –> 2nd trimester miscarriage

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17
Q

How is the Bacterial vaginosis cause of Recurrent Miscarriages prevented against?

A

Screening in 1st trimester + Tx if appropriate

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18
Q

What are the Inherited Thrombophilias that cause Recurrent Miscarriages? (4 things)

A
  1. Factor V Leiden
  2. Prothrombin gene mutation
  3. Protein C/S deficiencies
  4. Antithrombin 3 deficiency
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19
Q

When do Inherited Thrombophilias cause Miscarriages?

A

2nd trimester

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20
Q

How do Inherited Thrombophilias cause Miscarriages?

A

Thrombosis of uteroplacental circulation

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21
Q

When should investigations be started for Recurrent Miscarriages? (2 things)

A
  1. After 3+ 1st trimester miscarriages
  2. After 1+ 2nd trimester miscarriages
22
Q

What different types of investigations can be done for Recurrent Miscarriages? (3 things)

A
  1. Blood tests
  2. Genetic tests
  3. Imaging
23
Q

What blood tests can be done for Recurrent Miscarriages? (2 things)

A
  1. Antiphospholipid antibodies
  2. Inherited thrombophilia screen
24
Q

How is a diagnosis of Antiphospholipid syndrome confirmed with blood tests? (3 things)

A

2 positive tests at least 12 weeks apart for either:

  1. Lupus Anticoagulant
  2. Anticardiolipin Antibodies
  3. Anti-B2-Glycoprotein Antibodies
25
Q

What is checked for in an Inherited Thrombophilia Screen for Recurrent Miscarriages? (4 things)

A
  1. Factor V Leiden
  2. Prothrombin gene mutation
  3. Protein C/S deficiencies
  4. Antithrombin 3 deficiency
26
Q

What genetic tests can be done for Recurrent Miscarriages? (2 things)

A
  1. Cytogenic analysis
  2. Parental peripheral blood karyotyping
27
Q

What does Cytogenic analysis check for in Recurrent Miscarriages?

A

Chromosomal abn

28
Q

What tissue is Cytogenic analysis done on in Recurrent Miscarriages?

A

Products of conception

29
Q

When is Cytogenic analysis done for Recurrent Miscarriages?

A

After 3rd miscarriage + all ones after that

30
Q

When should you do Parental peripheral blood karyotyping for Recurrent Miscarriages?

A

When Products of conception testing shows unbalanced structural chromosomal abn

31
Q

Who is Parental peripheral blood karyotyping done on?

A

Both partners

32
Q

What imaging can be done for Recurrent Miscarriages?

33
Q

What is a Pelvic US checking for in Recurrent Miscarriages?

A

Uterine anatomy

34
Q

If you sus uterine abn in Pelvic US, what further investigations should you do to confirm Dx? (3 things)

A
  1. Hysteroscopy
  2. Laparoscopy
  3. 3D Pelvic US
35
Q

What do Uterine Fibroids look like on Laparoscopy?

36
Q

What do Uterine Adhesions look like on Hysteroscopy?

37
Q

What does Uterine Septum look like on Hysteroscopy?

38
Q

What does a Unicornuate Uterus look like on Laparoscopy?

39
Q

What does a Bicornuate Uterus look like on Laparoscopy?

40
Q

What does a Didelphic Uterus look like on Laparoscopy?
normal as above

41
Q

What should patients with Recurrent Miscarriages be referred for?

A

Specialist treatment

42
Q

How should you manage a couple with abn Parental karyotypes?

A

Refer to clinical geneticist (genetic counselling)

43
Q

Will surgical correction of Uterine abn (like septated uterus) change the pregnancy outcome?

A

No (no evidence on this so far)

44
Q

Will surgical correction of Cervical weakness change pregnancy outcome?

45
Q

What is the surgical treatment for Cervical weakness?

A

Cervical cerclage (suture used to close cervix)

46
Q

What are the indications for Cervical cerclage? (3 things)

A
  1. Poor obstetric Hx (3+ 2nd trimester miscarriages)
  2. Cervical shortening on US (25-mm before 24 wks + Hx of 2nd trimester miscarriage)
  3. Symptomatic + Premature Cervical dilatation + Exposed Fetal membranes in vagina
47
Q

What are the complications of Cervical Cerclage? (3 things)

A
  1. Bleeding
  2. Membrane rupture
  3. Stimulating uterine contractions

Therefore need senior involvement n counselling b4 decision

48
Q

What should you offer women with Hx of 2nd trimester miscarriages + Sus cervical weakness who have NOT had Cervical cerclage?

A

Serial Cervical Sonographic Surveillance

49
Q

What is the treatment for Recurrent Miscarriages caused by Antiphospholipid Syndrome? (2 things)

A
  1. Low dose aspirin
  2. LMWH
50
Q

What is the treatment for 2nd trimester Recurrent Miscarriages caused by Inherited Thrombophilias?

51
Q

What can you offer a woman with Unexplained Recurrent Miscarriages?

A

Preimplantation genetic screening + IVF (no evidence on this tho)

#Phase 2.2: Obs n Gynae (27 decks)

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