Recurrent miscarriage and miscarriage

Question 1

define recurrent miscarriage

Answer 1

3 or more consecutive miscarriages

Question 2

in practice, when are investigations carried out for why a patient has miscarried?

Answer 2

after 3 or more first trimester miscarriages

after any miscarriages that occur after the first trimester

Question 3

true or false: risk of miscarriage is highest in young mothers

Answer 3

alse - the risk of miscarriage increases with age

e.g. patients aged 40-45 will miscarry 50% of pregnancies

Question 4

7 causes of recurrent miscarriage

Answer 4

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

Question 5

how can the chance of live birth be increased in APLS? (2)

Answer 5

LMWH from foetal heartbeat until 34 weeks

and low dose aspirin from +ve pregnancy test to term

Question 6

4 congenital uterine abnormalities which can lead to recurrent miscarriages

Answer 6

unicornuate uterus (half a uterus)

uterine septum

bicornuate uterus (almost two distinct uteri)

didelphic uterus (almost two distinct uteri)

Question 7

2 acquired uterine abnormalities which can lead to recurrent miscarriage

Answer 7

cervical insufficiency

fibroids

Question 8

how does chronic histiocytic intervillositis present? (2)

Answer 8

with recurrent miscarriage, especially in the second trimester

with IUGR/IU death

Question 9

how is chronic histiocytic intervillositis diagnosed?

Answer 9

with histology of the placenta - this will show infiltration of mononuclear cells in the intervillous spaces

(NB placental cells are multinucleated)

Question 10

3 hereditary thrombophilia which can cause recurrent miscarriage

Answer 10

factor V Leiden (most common)

prothrombin gene mutation

protein C/protein S deficiency

Question 11

suggest a genetic factor in the parents which may cause recurrent miscarriage in the foetus

Answer 11

silent translocations in both parents can cause recurrent miscarriage

Question 12

5 investigations which should be carried out on couples when there is recurrent miscarriage

Answer 12

genetic testing of the parents

genetic testing of the products of conception

pelvic ultrasound (for uterine abnormalities)

APLS antibodies

testing for hereditary thrombophilia

Question 13

suggest a potential future preventative treatment of recurrent first trimester miscarriage presenting with bleeding

Answer 13

vaginal progesterone pessaries have shown promise for this (NB same as used in IVF)

Question 14

Early vs late miscarriage

Answer 14

pre/post 12 weeks gestation

because it is around this time that the placenta takes over the production of progesterone from the corpus luteum

Question 15

what is the difference between a “threatened miscarriage” and an “inevitable miscarriage”?

Answer 15

both have PV bleeding - however if the cervix is closed it is “threatened” and if it is open it is “inevitable”

Question 16

what is an anembryonic pregnancy?

Answer 16

a gestational sac develops but there is no foetus

Question 17

mean gestational sac diameter at which a foetal pole should be visible?

foetal crown/rump length at which a foetal heartbeat should be visible?

Answer 17

25mm

7mm

Question 18

management of miscarriage <6 weeks gestation

Answer 18

expectant management (so long as there is no pain or other complications)

Question 19

3 options for management of miscarriage >6 weeks gestation

Answer 19

expectant (first line)

medical

surgical

Question 20

how long is generally given in expectant management for the miscarriage to occur naturally

when would a repeat pregnancy test generally be done?

Answer 20

1-2 weeks

3 weeks after bleeding and pain settles`

Question 21

what can persistent or worsening bleeding may indicate in miscarriage

Answer 21

retained products of conception

Question 22

2 situations in which expectant management is not appropriate for a miscarriage

Answer 22

when there is a high risk of haemorrhage or evidence of infection

Question 23

what is the medical management of a miscarriage?

Answer 23

PV/oral misoprostol

Question 24

2 MOAs of misoprostol

Answer 24

softens the cervix

stimulates contractions

Question 25

4 AEs of misoprostol

Answer 25

heavier bleeding
N+V
pain
diarrhoea

Question 26

2 surgical options for a miscarriage

Answer 26

manual vacuum evacuation (local anaesthetic)

electric vacuum evacuation (general anaesthetic)

Question 27

given prior to surgery for miscarriage

Answer 27

misoprostol (softens the cervix)

Question 28

gestational age after which manual vacuum aspiration is no longer possible

Answer 28

10 weeks

Question 29

manual vacuum aspiration is more appropriate in patients who have…

Answer 29

previously given birth

Question 30

true or false: electrical vacuum aspiration does not require any incisions

Answer 30

true - it is done through the vagina and cervix (the cervix is gradually widened using dilatators)

Question 31

2 options for management of retained products of conception

Answer 31

misoprostol

evacuation of retained products of conception

Question 32

how does evacuation of retained products of conception differ from vacuum aspiration?

Answer 32

curettage will also be used

Question 33

key complication of evacuation of retained products of conception

Answer 33

endometritis