Stillbirth, miscarriage and infant mortality Flashcards
what are the leading causes of stillbirth?
fetal growth restriction
structural e.g. neural tube defects/genetic defects
fetal infection in utero
maternal disease e.g. diabetes, HT etc
what perinatal infections can cause stillbirths?
GBS, E coli, Listeria, Parvovirus, CMV, HSV, rubella, H1N1, toxoplasmosis, influenza
define fetal death in utero?
fetal demise after 20 weeks but before the onset of labour
what are the prenatal/maternal causes of stillbirth
• Congenital abnormality (e.g. structural/chromosomal/genetic)
• Perinatal infection (GBS, E coli, Listeria, Parvovirus, CMV, HSV, rubella, H1N1, toxoplasmosis)
• Hypertension (chronic HT, gestational HT, pre-eclampsia)
• Antepartum haemorrhage
• Maternal medical conditions e.g. diabetes, SLE, heart disease
• Increased maternal age
• Maternal obesity
• Increasing assisted reproduction
• Fetal growth restriction
• Fetal anaemia
Twin to twin transfusion syndrome
how might we confirm fetal death in utero and what do we need to do?
- Reduced or no fetal movements
- Unable to locate fetal heart sounds
- Diagnosed by ultrasound
Search for maternal coagulopathies. RISK of HAEMORRHAGE
what medications do we use for induction of stillborn baby and which do we use and why?
prostaglandins are used for induction
misoprostol for early gestational period
PGE2 for near term babies
what are some general things we need to consider when managing/breaking bad news to parents who have lost a baby in utero?
- Breaking bad news- SPIKEs
- At some point, you will need to ask for consent for post-mortem autopsy/further investigations for cause
- No rush for delivery if completely well
- Talk about methods of induction or spontaneous labour
- Talk about pain relief
- Pastoral care, bereavement services, contact the GP
- Monitor for maternal coagulopathy
- Suppression of lactation
- Review frequently postpartum
If required, have discussion about another pregnancy
what exactly IS fetal hydrops and what can cause it?
fetal hydrops refers to a fetus with fluid accumulation in two or more body cavities (pleural fluid, pericardial fluid, ascites or skin oedema
it can be caused by CAUSTIC C- cardiac cause A- anaemia U- unexplained S-structural abnormalities T- twins I- infections C- chromosomal abnormalities
what does missed miscarriage mean?
Non-viable intrauterine pregnancy that has not had any vaginal bleeding as yet
what does a threatened miscarriage mean?
early trimester 1 bleeding but still viable intrauterine pregnancy
Bleeding in early pregnancy should be considered…… or otherwise? fill in the gap
ectopic pregnancy
what are the options of managing miscarriage during the first trimester?
expectant management especially if confirmed inevitable miscarriage
medical management using misoprostol
surgical management- definitive; dilation and curettage or dilation and suction
what are the risks of surgically managing a miscarriage?
anaesthetic risk
risk of uterine perforation
usual surgical risks including infection etc
what are some risk factors for ectopic pregnancies?
previous STIs/PID causing adhesions previous ectopics use of emergency contraceptive pill use of intrauterine device IVF
what are the management options for ectopic pregnancy?
- conservative (if bHCG levels falling) and woman is otherwise medically stable
- medical management using methotrexate
- surgical management- type depending on where the ectopic pregnancy is located and haemodynamic status of the woman
what are some key practice points of using methotrexate for medical management of ectopic pregnancy?
There is still a risk of ectopic rupture during medical management. Hence follow up appointment is ESSENTIAL
Women who choose this method require WEEKLY bHCG serum measurements to ensure the ectopic pregnancy has resolved
Methotrexate can either be given single dose IM or as a multi-dose regimen
A quantitative bHCG drop of >15% day 4-7 of methotrexate is consistent with treatment success
Contraindications or patient refusal to methotrexate warrants surgical management of ectopic pregnancy
tell me about the surgical management of ectopic pregnancies?
Type of surgery depends on location of ectopic pregnancy and state of maternal haemodynamic status.
Since tubal ectopic pregnancies are most common; generally laparoscopic salpingectomy is performed.
A salpingostomy which removes the products of conception but retains the fallopian tube can be performed in those who have contralateral disease.
what are some contraindications of using methotrexate in ectopic pregnancies?
- poor patient compliance/inability to follow up
- hypersensitivity/liver dysfunction etc direct contraindications to methotrexate
- presence of fetal heart beat
- bHCG > 5000 IU
- patient refusal of using methotrexate
what drug is RU486?
mifepristone
what is the role of RU486 in medical termination of pregnancy?
Primes the uterus and cervix for the actions of the prostaglandin, and reverses the acceptance of the fetal allograft
what drugs do we use in medical termination of pregnancy?
misoprostol and mifepristone
what are some complications of termination of pregnancy (medical/surgical)?
Complications include endometritis, negative psychological impact, Asherman syndrome and retained products of conception
describe dilation and suction method of surgical termination of pregnancy?
Misoprostol is used prior to surgery. This is a day procedure.
Cervix is grasped and gently dilated from 6 to 10 mm depending on gestation. Suction curettage is performed using a plastic catheter.
when do most miscarriages occur?
less than 12 weeks (first trimester)
what is the most common cause of > 12 weeks gestation miscarriages?
Miscarriages > 12 weeks are often due to cervical insufficiency–> silent miscarriage (often presents silently)
both ectopic pregnancies and miscarriages present with pelvic pain and bleeding. how might we differentiate between the two on history?
Central pain= miscarriage; unilateral pain= ectopic pregnancy
Ectopic pregnancy–> bleeding is due to sloughing of the endometrium; bHCG is less in ectopic pregnancy and hence progesterone levels is less–> endometrium sloughs–> vaginal bleeding (vaginal blood loss is relatively less than a miscarriage)
Larger blood loss from vagina–> think miscarriage; women often say it’s more painful and heavier than normal period
which type of miscarriage is associated with cervical shock, and what IS cervical shock?
incomplete miscarriage
Cervical shock may occur if products become trapped within the cervix. This presents as bleeding, significant pain and often vagal/parasympathetic symptoms (bradycardia, hypotension, sweatiness and nausea/vomiting).
what is the key clinical difference between cervical shock due to miscarriage and ectopic pregnancy?
cervical shock- BRADYCARDIA
ectopic pregnancy-rupture=> tachycardia
how does septic miscarriage come about?
infection due to retained products of conception, often after incomplete miscarriage
what ix should we do if there is a history of recurrent miscarriages?
Investigations that can be undertaken include imaging of the uterus, endocrine profiling (especially thyroid), thrombophilia screening and parental karyotyping
what is the maternal risk associated with fetal death in utero?
DIC
how might we manage a woman with confirmed fetal death in utero > 20 weeks gestation?
- watch and wait as she may spontaneously go into labour
2. induce her for a vaginal delivery
what are the clinical features and risk of cholestasis in pregnancy?
pruritus on palms and soles
deranged LFTs
dark urine
pale stools
increased risk of stillbirth and preterm labour
how might we manage cholestasis in pregnancy?
ursodeoxycholic acid
induction of labour at 37-38 weeks
what is the u/s criteria for a non-viable intrauterine pregnancy?
CRL > 7mm
or gestational sac of > 25mm
WITH
no fetal heart beat
= missed miscarriage
how might we administer misoprostol?
buccal
PR
PV
oral
describe the clinical examination characteristics of a complete miscarriage?
closed cervix
small for dates uterus
large amount of vaginal blood loss
abdominal pain +++ now passed
describe the clinical examination characteristics of an inevitable miscarriage?
open cervix
appropriate for dates sized uterus
some vaginal bleeding
some abdominal pain
describe the clinical examination characteristics of a threatened miscarriage?
closed cervix
appropriate for dates sized uterus
little vaginal bleeding
little abdominal pain
describe the clinical examination characteristics of an incomplete miscarriage?
open cervix
small for dates sized uterus
large amount of vaginal blood loss
acute abdominal pain +++ ongoing
describe the clinical examination characteristics of a missed miscarriage?
closed cervix
asymptomatic otherwise, minimal vaginal bleeding
small for dates sized uterus
why do we call a missed miscarriage a ‘missed miscarriage’?
patient is otherwise asymptomatic
usually picked up incidentally on u/s
when would we do dilation and evacuation rather than dilation and suction curettage for miscarriages?
miscarriages > 14 weeks require dilation and curettage because fetus + placenta is larger
in a pregnant lady who has had a known miscarriage, what is something you need to check?
check her blood group status and if she is Rh-ve, administer 250IU of anti-D immunoglobulin IM
what are some side effects of misoprostol?
side effects may include nausea, vomiting, diarrhoea, flushing and abdominal cramps.
what ix might we consider for a woman with recurrent miscarriages?
thrombophillia screen
imaging for uterine abnormalities
endocrine profile –> TFTs
maternal karyotyping
karyotyping of products of conception
how might we inhibit lactation in a lady who has had a stillbirth?
bromocriptine
dopamine antagonist
what is your management of a pregnant woman who has just found out her baby has died in utero around 28 weeks?
- Aim for induced or spontaneous vaginal delivery when emotionally appropriate and when maternal haemodynamics is stable
- Active management of 3rd stage of labour and close monitoring for PPH
- Allow parents time with their baby before asking if an autopsy can be performed.
- Send placenta for histological analysis and karyotyping.
- Provide counselling and bereavement services to the parents.
- Inhibit lactation with bromocriptine.
For future pregnancies can consider maternal screening for thrombophilias etc
