Recurrent Miscarriage and Stillbirth Flashcards
‘Abortion’ is a spectrum of one event
- threatened
- inevitable
- complete
- missed
- septic
- recurrent
Abortion = unexpected unplanned spontaneous loss of a pregnancy
Aetiology of recurrent abortion?
35% aetiology unknown
- fetal factors (genetic = 70%; morphological)
- Maternal disease (Endocrine = diabetes, thyroid; cardiac; renal; thrombophilia; INFECTION)
- Immunological (ANTIPHOSPHOLIPID SYNDROME)
- Anatomical factors: MULLERIAN ABNORMALITIES, FIBROIDS, Asherman’s, Cervical incompetence
- Other endocrine (PROLACTIN)
Describe approach to recurrent miscarriage
- Hx
- Ex
- Ix
HX: Bleeding (volume/color/symptoms of hypovolemia); Pain (site/severity); Passage POC
EX: General/BP/Pulse/features(uterus size, cervix open/close, adnexal tenderness or mass)
IX: Blood group/ beta hCG = double every 48hrs in wks 4-8/ US (confirm loss/site of pregnancy/ see fetal heart by 7 wks/ bHCG 1500 TV, 6000 TA)
Note on US: BhCG as a predictor of fetal visibility
How many weeks gestation to see fetal heart?
bHCG 1500 = TV viewable
bHCG 6000 = TA viewable
Fetal heart seen by 7 weeks
Describe approach to recurrent miscarriage
- Management
shock (vagal shock, hypovolaemic shock)
Reassurance
medical/surgical/expectant
- Med: mifepristone/misoprostol
- Surg: suction curettage (SE: perforation/ cervical tears/ haemorrhage…Ashermann’s syndrome…screen for chlamydia trachomatis…examine evacuated tissue histopathologically - trophoblastic disease and ectopic pregnancy)
- Exp: women in 1st trimester, just wait
Anti-D if necessary (miscarriage…within 72hrs of event)
Grief: Psycho-social counseling and support
Medical abortion:
- what medications?
- how do the medications work?
mifepristone/misoprostol
MIFEPRISTONE: Mifepristone (also known as RU-486) is a synthetic steroid and progesterone antagonist that competes with progesterone and blocks progesterone receptors. It causes dilatation of the cervix and increases the sensitivity of the myometrium to the action of prostaglandins.
MISOPROSTOL: Misoprostol is a synthetic analogue of prostaglandin E1 that induces contractions of the smooth muscle fibres in the myometrium and relaxation of the uterine cervix. Mifepristone is followed 36–48 hours later with misoprostol to terminate a developing intrauterine pregnancy.
Describe approach to recurrent miscarriage
- Management (Anti D, when is it required?)
1st trimester: CVS, proven miscarriage, termination, ectopic
2nd/3rd: APH, amniocentesis, ECV, abdo trauma, prophylactically at 28-34 wks
Postnatally: within 72hrs if baby Rh +ve, use Kleihauer to quantify how much to give
Investigation of recurrent abortion?
- when do we ix
- how do we ix
Official: 3 spontaneous abortions BUT
Reality: any 2nd trimester loss, any loss w hx of complicated pregnancy (preeclampsia/IUGR)
- chromosomal anomaly (POC for chromosomal analysis/ parental chromosomes e.g. translocations or mosaicism)
- anatomical (endocrine: diabetes, thyroid, prolactin/androgens; immunity: SLE/antiDs DNA/Antiphospholipid syndrome)
Management of recurrent abortion?
- chromosomal anomaly
- anatomic factors
- endocrine factors
- immunologic factors
- maternal disease
CHROMOSOME: refer medical geneticist for individual prognosis. donor egg/sperm
ANATOMIC: division of intrauterine adhesions, hysteroscopic resection of interuterine septum, cervical cerclage, fibroid removal
ENDOCRINE: Progesterone PV
IMMUNOLOGIC: Antiphospholipid Syndrome (placental damage from thrombosis, aspirin + heparin (reduce loss by 50%)
MATERNAL DISEASE: stabilize disease, treat endocrine abnormality, APS (aspirin + heparin)
STILLBIRTH
- definition
- incidence
- aetiology
DEF: fetal demise after 20/40 but before onset of labour
INCIDENCE:
STILLBIRTH
- diagnosis
- complications
Dx:
- features of underlying conditions (severe PET, abruption = bleeding & pain, sepsis)
- absent fetal movement (normal = 10 from 7am-7pm)
- unable to locate fetal heart
- US confirms no fetal heart or perimortem feature e.g. Spalding’s sign = overiding fetal skull bones
Complications:
- coagulopathy (chronic consumptive coagulopathy OR haemorrhagic complication). Normal usually by 48hrs post delivery.
STILLBRITH
- investigation
Maternal:
- random blood glucose, HbA1c (diabetes)
- Rh Ab
- Kleihauer (fetal-maternal haemorrhage)
- ANA
- Lupus anticoagulant test/anti cardiolipin Ab/ thrombophilia screen (anti-phospholipid syndrome)
- TORCH (infection)
- Firbinogen/platelet count (Thromboembolism/clotting disorders)
Fetal:
- US (confirm FDIU, examine for fetal/placental malformation, IUGR)
- post mortem (most valuable) or swabs/chromosomal analysis or xray if denied
Placental: histology/swabs (malformation, infection, damage)
STILLBIRTH Mx
- telling parents
- labour and delivery
- bereavement
TELLING:
- setting is important (quiet, no distraction)
- warning shot and fire (be clear baby has died/ wait/ explain cause if known/ reassure ix cause of death maybe autopsy? pathologist meet family/ reassure not their fault/ discuss delivery (can go home first night usually, pain relief, No C section b/c can compromise later pregnancies)
- offer other services (pastoral care, social worker, GP involvement)
- be a nice human being (offer phone calls for family, airlines, transport)
LABOUR/DELIVERY
- 80% labour spontaneously within 2-3wks
- wait, observe coagulopathy weekly
- induction Prostaglandin (misoprostol) OR ARM&oxytocin AND analgesia
BEREAVEMENT
- care/support
- post delviery = pastoral care/suppression of lactation (dopamine agnonist: bromocriptine or cavergoline)
- early discharge
- review 2,4,6W post partum
- discussion next pregnancy
ABORTION summary
- classifications
- causes
- recurrent abortion =?
- Ix single underlying identifiable/correctable cause
- Mx
- reassure
- threatened/inevitable/ incomplete/ complete/ missed/ septic
- in 1st trimester due to random nondysjunction resulting in lethal aneuploidy
- 3 or more OR any 2nd trimester loss OR poor obstetric hx
Ix:
- chromosomal (parental)
- anatomical: hysterosalpingogram (HSG), hysteroscopy/laparoscopy
- maternal: systemic disease/ autoimmunity
Mx: subsequent pregnancy depends on underlying cause. 50% COUPLES NORMAL TEST RESULT
Reassure: risk of livebirth next time if 1 or more normal livebirths is 70%. Risk of livebirth with no previous live birth is 55-60%
STILLBIRTH summary
- incidence
- Ix and complication
- encourage parents to?
- Timing of Induction of Labour
- Post partum Mx
fetal death in utero occurs in up to 1% of pregnancies
Ix: fetal/maternal/placental causes. Exclude coagulopathy
AUTOPSY if possible. Will be more conclusive.
IOL dictated by maternal condition, parent’s wishes (aim for normal vaginal delivery)
Post partum mx: lactation suppression/ emotional suppport/ frequent review for Ix results/ subsequent pregnancy
