Recurrent miscarriage and miscarriage Flashcards
define recurrent miscarriage
3 or more consecutive miscarriages
in practice, when are investigations carried out for why a patient has miscarried?
after 3 or more first trimester miscarriages
after any miscarriages that occur after the first trimester
true or false: risk of miscarriage is highest in young mothers
alse - the risk of miscarriage increases with age
e.g. patients aged 40-45 will miscarry 50% of pregnancies
7 causes of recurrent miscarriage
anti-phospholipid syndrome
inherited thrombophilia
uterine abnormalities
chronic disease in the mother e.g. diabetes
genetic abnormalities in the parents
chronic histiocytic intervillositis
idiopathic (especially in older patients
how can the chance of live birth be increased in APLS? (2)
LMWH from foetal heartbeat until 34 weeks
and low dose aspirin from +ve pregnancy test to term
4 congenital uterine abnormalities which can lead to recurrent miscarriages
unicornuate uterus (half a uterus)
uterine septum
bicornuate uterus (almost two distinct uteri)
didelphic uterus (almost two distinct uteri)
2 acquired uterine abnormalities which can lead to recurrent miscarriage
cervical insufficiency
fibroids
how does chronic histiocytic intervillositis present? (2)
with recurrent miscarriage, especially in the second trimester
with IUGR/IU death
how is chronic histiocytic intervillositis diagnosed?
with histology of the placenta - this will show infiltration of mononuclear cells in the intervillous spaces
(NB placental cells are multinucleated)
3 hereditary thrombophilia which can cause recurrent miscarriage
factor V Leiden (most common)
prothrombin gene mutation
protein C/protein S deficiency
suggest a genetic factor in the parents which may cause recurrent miscarriage in the foetus
silent translocations in both parents can cause recurrent miscarriage
5 investigations which should be carried out on couples when there is recurrent miscarriage
genetic testing of the parents
genetic testing of the products of conception
pelvic ultrasound (for uterine abnormalities)
APLS antibodies
testing for hereditary thrombophilia
suggest a potential future preventative treatment of recurrent first trimester miscarriage presenting with bleeding
vaginal progesterone pessaries have shown promise for this (NB same as used in IVF)
Early vs late miscarriage
pre/post 12 weeks gestation
because it is around this time that the placenta takes over the production of progesterone from the corpus luteum
what is the difference between a “threatened miscarriage” and an “inevitable miscarriage”?
both have PV bleeding - however if the cervix is closed it is “threatened” and if it is open it is “inevitable”
what is an anembryonic pregnancy?
a gestational sac develops but there is no foetus
mean gestational sac diameter at which a foetal pole should be visible?
foetal crown/rump length at which a foetal heartbeat should be visible?
25mm
7mm
management of miscarriage <6 weeks gestation
expectant management (so long as there is no pain or other complications)
3 options for management of miscarriage >6 weeks gestation
expectant (first line)
medical
surgical
how long is generally given in expectant management for the miscarriage to occur naturally
when would a repeat pregnancy test generally be done?
1-2 weeks
3 weeks after bleeding and pain settles`
what can persistent or worsening bleeding may indicate in miscarriage
retained products of conception
2 situations in which expectant management is not appropriate for a miscarriage
when there is a high risk of haemorrhage or evidence of infection
what is the medical management of a miscarriage?
PV/oral misoprostol
2 MOAs of misoprostol
softens the cervix
stimulates contractions
4 AEs of misoprostol
heavier bleeding
N+V
pain
diarrhoea
2 surgical options for a miscarriage
manual vacuum evacuation (local anaesthetic)
electric vacuum evacuation (general anaesthetic)
given prior to surgery for miscarriage
misoprostol (softens the cervix)
gestational age after which manual vacuum aspiration is no longer possible
10 weeks
manual vacuum aspiration is more appropriate in patients who have…
previously given birth
true or false: electrical vacuum aspiration does not require any incisions
true - it is done through the vagina and cervix (the cervix is gradually widened using dilatators)
2 options for management of retained products of conception
misoprostol
evacuation of retained products of conception
how does evacuation of retained products of conception differ from vacuum aspiration?
curettage will also be used
key complication of evacuation of retained products of conception
endometritis
