Spontaneous miscarriage

Question 1

Spontaneous miscarriage

Answer 1

Foetus dies/delivers dead <24w (majority <12w)

Question 2

Rate of spontaneous miscarriage increases…

Answer 2

…with maternal age

Question 3

Threatened miscarriage (viable intrauterine pregnancy)

Answer 3

Bleeding but foetus still alive, uterus expected size, cervical os closed (25% miscarry)

Question 4

Inevitable miscarriage

Answer 4

Bleeding typically heavier, foetus potentially still alive, cervical os open; miscarriage about to occur.

Question 5

Incomplete miscarriage

Answer 5

Some foetal parts passed but os usually open

Question 6

Complete miscarriage

Answer 6

All foetal tissue passed. Bleeding diminished, uterus not longer enlarged, os closed.

Question 7

Septic miscarriage

Answer 7

Uteral contents infected causing endometritis. Vaginal loss typically offensive, uterus tender but fever may be absent. If pelvic infection = abdo pain/peritonism

Question 8

Missed miscarriage

Answer 8

Foetus not developed/died in utero but this not recognised until bleeding occurs or USS performed. Uterus smaller than expected from dates and os closed.

Question 9

Main cause of one off/sporadic miscarriage

Answer 9

Isolated, non-recurring chromosomal abnormalities (>60%)

Question 10

Exercise, stress and emotional trauma…

Answer 10

…do not cause miscarriage

Question 11

Typical presentation

Answer 11

Bleeding PV (exception = missed miscarriage - may be incidental finding on USS). Pain from uterine contractions may cause confusion with ectopic pregnancy

Question 12

Investigations

Answer 12

USS - show foetus/viability, any retained foetal products. Can be repeated a week later as non-viables can be confused with very early pregnancy
Blood tests - hCG in blood increases by >63% in viable pregnancy; in failed pregnancy, hCG declines by 50%. Note hCG changes between a rise of 63% and fall of 50% may indicate ectopic. Also Rh blood type.

Question 13

Coexisitant ectopic (heteropic pregnancy) is a rare complication associated with…

Answer 13

IVF

Question 14

Pregnancy of unknown location (PUL)

Answer 14

Empty uterine cavity and no abnormal adnexal masses of fluid/blood (could be early viable, failing intrauterine, ectopic pregnancies or complete miscarriage)

Question 15

Admission may be required if…

Answer 15

…ectopic suspected, woman is symptomatic, miscarriage is septic or if there is very heavy bleeding

Question 16

If bleeding is profuse (and pregnancy non-viable)…

Answer 16

…consider ergometrine 0.5mg IM (induces uterine contraction)

Question 17

If there is unacceptable pain/bleeding, or USS still showing significant amounts of retained products…

Answer 17

…consider surgical management of miscarriage (SMM), previously called emergency removal of products of conception (ERPC)

Question 18

Bed rest/hormone treatment with progesterone/hCG…

Answer 18

…do not prevent miscarriage

Question 19

Management can be…

Answer 19

Expectant
Medical
Surgical

Question 20

Expectant management

Answer 20

Woman must be willing + not signs of infection
Successful in most women within 2-6 weeks
First line approach

Question 21

Medical management

Answer 21

Missed miscarriage - 800micrograms misoprostol (oral/vaginal)
Incomplete miscarriage - 600/800micrograms misoprostol (oral/vaginal)
Repeat urine pregnancy test at 3w to rule out ectopics/molar
Mifipristone may also be used (600)

Question 22

Surgical management

Answer 22

SMM/ERPC - evacuation of uterus (many be manual in clinic or under GA in theatre)
Products sent to histology to exclude molar pregnancy

Question 23

Complications

Answer 23

Expectant and medical management may require surgical management to complete
Infection (all management))
Long term conception rates unaffected by management option.
In <1% surgically managed cases, risk of Asherman’s syndrome (partial removal of endometrium) or uterine perforation

Question 24

For follow up

Answer 24

Offer counselling

Question 25

Further investigation only recommended in women who…

Answer 25

Have had three+ miscarriages

Had miscarriage >12w

Question 26

Causes of miscarriage

Answer 26

Genetic abnormalities (most common)
Maternal illness (diabetes, ?thyroid)
Phospholipid/lupus (esp recurrent miscarriage)
Uterine abnormalities
Cervical incompetence

Question 27

Hx questions?

Answer 27

LMP
When
Amount
Pain
Timing (of pain)

Question 28

Examination findings

Answer 28

ABC vital signs
Abdominal
Vaginal speculum (cervical state, amount of bleeding)

Question 29

Key Ix in EPC/EPAU

Answer 29

USS (most important)
Serum hCG
Blood and Rh group
FBC, G&S, admit if bleed significant
Psychological support

Question 30

USS findings

Answer 30

Expect to see viable foetus from 6.5w transabdominally, 5.5w transvaginally
Diagnosis made by TVS only
Crown-rump length >7mm
Empty GS with mean diameter >25mm

Question 31

b-hCG

Answer 31

Should double (inc by 66%) within 1-2 days if foetus viable
Halve (decrease 50%) in 1-2 days in complete miscarriage
Should see foetal pose with hCG of 1500-2000

Question 32

Second trimester miscarriage associated with

Answer 32

Infection (e.g. CMV)

Bacterial vaginosis

Question 33

Mid trimester miscarriage

Answer 33

Assoc with mechanical abnormalities (cervical weakness), uterine abnormalities, chronic maternal disease, infection or no identified cause.