Subfertility Flashcards
Define miscarriage
In the UK, miscarriage is defined as the loss of an intrauterine pregnancy before 24 weeks of gestation.
It is defined by the World Health Organization (WHO) as the expulsion of a fetus or embryo weighing 500 g or less, and the gestational limit is less than 22 ‘completed’ weeks of pregnancy.
What are the ultrasound transvaginal scan definitions of miscarriage? ( must be confined by second operator)
Ultrasound diagnosis of miscarriage should only be considered with a mean gestation sac diameter >/= 25mm (with no obvious yolk sac),
or
with a fetal pole with crown rump length >/=7mm (the latter without
evidence of fetal heart activity)
A transvaginal ultrasound scan should be performed in all cases
If the crown–rump length is 7.0 mm or more with a transvaginal ultrasound scan and there is no visible heartbeat: Seek a second opinion on the viability of the pregnancy and/or
perform a second scan a minimum of 7 days after the first before making a diagnosis.
If the mean gestational sac diameter is less than 25.0 mm with a transvaginal ultrasound scan and there is no visible fetal pole, perform a second scan a minimum of 7 days after the first before making a diagnosis.
Further scans may be needed before a diagnosis can be made.
What is the incidence of miscarriage?
Recurrent miscarriage 1–2% of fertile women.
The majority of miscarriages are classified as early (before 12 weeks of gestation) and account for 50000 inpatient admissions.
Second-trimester pregnancy loss is more rare (less than 4% of miscarriages occur at this stage).
Less than 5% of miscarriages occur after identification of fetal heart activity
What are the cases of miscarriage?
Chromosomal abnormalities – this is the single largest cause of sporadic miscarriage, accounting for 60% of all cases
Exercise, intercourse and emotional trauma does not cause miscarriage
what should you advise a woman with vaginal bleeding and a confirmed intrauterine pregnancy with a fetal heartbeat and bleeding (threatened miscarriage)?
if her bleeding gets worse, or persists beyond 14 days, she should return for further assessment
if the bleeding stops, she should start or continue routine antenatal care.
Three Management options for miscarriage
- expectant conservative management
- Medical Management
- Surgical management
Describe conservative management of miscarriage
Use expectant management for 7–14 days as the first-line management strategy for women with a confirmed diagnosis of miscarriage. Explore management options other than expectant management if:
Discuss other options
• if the woman is at increased risk of haemorrhage (for example, she is in the late first trimester) or
• she has previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) or
• she is at increased risk from the effects of haemorrhage (for example, if she has coagulopathies or is unable to have a blood transfusion) or
• there is evidence of infection.
Conservative management may be continued as long as the woman is willing,
no signs of infection such as: vaginal discharge, excessive bleeding, pyrexia or abdominal pain
Give the woman a contact number to ring if there are any problems
The duration may be as long as 6–8 weeks
Reassurance that the infection rate is low at approximately 3% (MIST Trial 2004).
Go through the information leaflet and explain what to expect and how to deal with it.
Describe the medical management of miscarriage
Offer all women receiving medical management of miscarriage pain relief and anti-emetics as needed.
Inform women undergoing medical management of miscarriage about what to expect throughout the process, including the length and extent of bleeding and the potential side effects of treatment including pain, diarrhea and vomiting.
Advise women to take a urine pregnancy test 3 weeks after medical management of miscarriage unless they experience worsening symptoms, in which case advise them to return to the healthcare professional responsible for providing their medical management.
Advise women with a positive urine pregnancy test after 3 weeks to return for a review by a healthcare professional to ensure that there is no molar or ectopic pregnancy
Do not offer mifepristone as a treatment for missed or incomplete miscarriage. Offer vaginal /oral misoprostol
For women with a missed miscarriage, use a single dose of 800 micrograms of misoprostol
Advise the woman that if bleeding has not started 24 hours after treatment, she should contact EPAU
incomplete miscarriage, use a single dose of 800 micrograms of misoprostol Offer pain relief and anti-emetics
Describe surgical management of miscarriage
Where clinically appropriate, offer women undergoing a miscarriage a choice of: Manual vacuum aspiration under local anesthetic in an outpatient or clinic setting or Surgical management in a theatre under general anesthetic.
Provide oral and written information to all women undergoing surgical management of miscarriage about the treatment options available and what to expect during and after the procedure
Describe SMOM
Day-case Leaflet
Surgical Management (SMOM )
Written consent
FBC, G&S
Anti D
Chlamydia screening to at risk women (usually under 25)
or offer prophylactic doxycycline 100 mg twice daily for 10 days and metronidazole 1 g PR. Send products histology
to exclude molar pregnancy
To exclude ectopic
Give RCOG patient information on “What you may need to know after a miscarriage”
Send products histology
to exclude molar pregnancy To exclude ectopic
Discuss resus prophylaxis in miscarriage
Confirmed miscarriage
RH prophylaxis
Anti-D immunoglobulin should be given to all nonsensitised Rh-negative women who miscarry after 12 weeks of gestation, whether the miscarriage is complete or incomplete,
and to those who miscarry below 12 weeks of gestation when the uterus is evacuated (either surgically or medically). The dose should be 250 IU for <20 weeks and 500 IU for >20 weeks.
Threatened miscarriage
Anti-D should be given to all nonsensitised Rh-negative women with threatened miscarriage after 12 weeks of gestation.
Anti D to be given with repeated bleeding or pain
Ectopic pregnancy
All Rh negative women with ectopic pregnancies, whether managed surgically or medically, should be given anti-D. The recommended dose before 20 weeks of pregnancy is 250 IU.
Definition of sub fertility
• A couple are sub fertile if conception has not occurred after
1 year of unprotected sexual intercourse and can be referred for investigations.
• 15% couples are affected
• Primary- never conceived
• Secondary-she has conceived previously
Chance of conception
- 80% of couples within 1 year
- 90% second year
- Inform people who are concerned about their fertility that female fertility and (to a lesser extent) male fertility decline with age
Factors associated with sub fertility
Age • Increasing maternal age, decline in fertility due to reduced ovarian reserve BMI >30 • Longer to conceive • Increased miscarriage • Pregnancy complications Smoking Alcohol
What Detailed history of female partner should be taken in sub fertility?
• Age/LMP/Details of menstrual cycle-regular/irregular
• History of dysmenorrhea
• Coital frequency /problems
• History of dyspareunia
• Previous pregnancies-how they were conceived/any problems/delivery details
• Previous surgeries/PID
• Medical history/medication-to optimise the medical condition before
conception
• Family history –genetic diseases/DVT
• Smoking/alcohol/illicit drugs/occupation
• Smear history
• BMI/ rubella immunity status
What Detailed history of male partner should be taken in sub fertility?
- Age/fathered any other children • Occupation
- Smoking/alcohol/drugs
- Previous operations
- History of mumps/trauma
- Medical disorders/medication • Coital problems
Aetiology of sub fertility
- unexplained infertility (no identified male or female cause) (30%)
- ovulatory disorders (30%)
- tubal damage (25%)
- male factors (25%)
- Cervical problems (<5%)
- Coital problems (5%)
- Uterine or endometrial factors, gamete or embryo defects, and pelvic conditions such as endometriosis may also play a role
what Frequency of intercourse should be recommended?
- Vaginal sexual intercourse every 2 to 3 days optimises the chance of pregnancy
- Artificial insemination should be timed around ovulation
World Health Organization reference values- semen analysis
- semen volume: 1.5 ml or more
- pH: 7.2 or more
- sperm concentration: 15 million spermatozoa per ml or more
- total sperm number: 39 million spermatozoa per ejaculate or more
- total motility (percentage of progressive motility and non- progressive motility): 40% or more motile or 32% or more with progressive motility
- vitality: 58% or more live spermatozoa
- sperm morphology (percentage of normal forms): 4% or
Common causes of abnormal semen analysis
- Unknown
- Smoking/alcohol/drugs/chemicals/tight under wear • Genetic factors
- Antisperm antibodies
Common causes of abnormal/absent sperm release
• Idiopathic oligospermia/asthenozoospermia
• Drug exposure :Alcohol/smoking/drugs (sulfasalazine or
anabolic steroids)
• Exposure to industrial chemicals , solvents
• Varicocele:varicosities of pampiniform venous plexus , usually left side. 25% of infertile men. Surgical treatment don’t improve outcome .
• Antisperm antibodies:5% of men
• Common after vasectomy reversal
• Poor motility and clumping are seen on semen analysi
• Infections-Epididymitis, mumps architis
• Testicular abnormalities- Klinefelter syndrome( XXY)
(karyotyping)
• Obstruction: congenital absence of the vas associated with cystic fibrosis
• Hypothalamic problems
• Kallmann’s syndrome( hypogonadotrophic hypogonadism) (Low
FSH/LH and testosterone)
• Hyperprolactemia
• Retrograde ejaculation ( ejaculation into bladder due to diabetes/ transurethral resection of prostate gland)
Pathophysiological classification of male infertility
Hypothalamic pituitary disease (secondary hypogonadism) (1–2%)
Testicular disease (primary hypogonadism) (30–40%)
Sperm transport problems (10–20%)
Unexplained (40–50%)
