The Loss of a Baby Flashcards
1
Q
Why is Pregnancy loss important?
- It is common - 1 in … pregnancies end in miscarriage (UK)
- It is a major cause of … in women worldwide
- …-…. emotional and mental health impact
- Affects …
- … subject - hidden misery
- Some causes can be …
A
- It is common - 1 in 4 pregnancies end in miscarriage (UK)
- It is a major cause of death in women worldwide
- Long-lasting emotional and mental health impact
- Affects most women and their families at some point in their life
- Taboo subject - hidden misery
- Some causes can be prevented
2
Q
What does this table show?
A
Causes of death in omen <24 weeks (UK and Ireland 2009-2014)
3
Q
Percentage of women who died <24 weeks due to early pregnancy-related causes
A
6%
4
Q
First Trimeter Miscarriage
- 1st trimester - up to … weeks
- ..-..% of clinically recognised pregnancies
- Accounts for …% of pregnancy loss
- Approx …% of first trimester miscarriages will have chromosomal abnormality
- ..-..% of couple suffer recurrent miscarriage
A
- 1st trimester - up to 12 weeks
- 10-20% of clinically recognised pregnancies
- Accounts for 85% of pregnancy loss
- Approx 50% of first trimester miscarriages will have chromosomal abnormality
- 1-2% of couple suffer recurrent miscarriage
5
Q
Define Threatened miscarriage
A
symptoms of bleeding / pain but intra-uterine pregnancy still present
6
Q
Define Inevitable miscarriage
A
symptoms of bleeding / pain, cervical os is open
7
Q
Define Incomplete miscarriage
A
symptoms of bleeding, os open, some tissue remaining
8
Q
Define Complete miscarriage
A
no tissue remaining
9
Q
Define Missed miscarriage
A
(early fetal demise/ anembryonic pregnancy) – diagnosed at scan with no symptoms
10
Q
Define Molar pregnancy
A
fetus doesn’t form properly in the womb and abnormal cells develop instead of a normal fetus. Known as hydatidiform mole
- complete mole, where there’s a mass of abnormal cells in the womb and no foetus develops
- partial mole, where an abnormal fetus starts to form, but it can’t survive or develop into a baby
11
Q
What is ‘complete mole’ (pregnancy)
A
where there’s a mass of abnormal cells in the womb and no foetus develops
12
Q
What is ‘partial mole’ (pregnancy)
A
where an abnormal fetus starts to form, but it can’t survive or develop into a baby
13
Q
Factors Affecting Risk of Miscarriage
- A…
- O…
- …% increase risk with BMI > … compared with normal BMI
- A… syndrome / SLE
- Parental chromosomal …
- Poorly controlled …
- Alcohol, smoking, recreational drug use
- … anomaly
- (High levels of natural … cells)
A
- Age
- Obesity
- 25% increase risk with BMI > 30 compared with normal BMI
- Antiphospholipid syndrome / SLE
- Parental chromosomal translocation
- Poorly controlled diabetes
- Alcohol, smoking, recreational drug use
- Uterine anomaly
- (High levels of natural killer cells)
14
Q
Risk of Miscarriage
- Age 20
- Age 30
- Age 40
- Age 45
A
- Age 20 - 15%
- Age 30 - 18%
- Age 40 - 38%
- Age 45 - 70%
15
Q
Presentation of Miscarriage
- B…
- P…
- Found at time of routine scan (i.e. … miscarriage)
- (Loss of … symptoms)
- Acute …
- Cervical …, hypotension, t.., bleeding
- Sepsis
- P.., hyp…tension, ..cardia, raised … rate, c…
A
- Bleeding
- Pain
- Found at time of routine scan (i.e. missed miscarriage)
- (Loss of pregnancy symptoms)
-
Acute collapse
- Cervical shock, hypotension, tachycardia, bleeding
-
Sepsis
- Pyrexia, hypotension, tachycardia, raised resp rate, confusion
16
Q
Management of miscarriage
- Conservative / expectant (…-…% success)
- Medical management – can be managed at home or on the ward dependent on … of pregnancy (CRL length) / patient …
- Patients must be … re: expectations for bleeding and discomfort, potential risk of retained tissue
- … management (SMM)
- Risks include infection, bleeding, uterine perforation, cervical damage, retained tissue and need for repeat procedure.
- Follow up - support/…
A
- Conservative / expectant (40-80% success)
- Medical management – can be managed at home or on the ward dependent on size of pregnancy (CRL length) / patient preference
- Patients must be counselled re: expectations for bleeding and discomfort, potential risk of retained tissue
- Surgical management (SMM)
- Surgical risks include infection, bleeding, uterine perforation, cervical damage, retained tissue and need for repeat procedure.
- Follow up - support/counselling,
17
Q
Recurrent miscarriage
- … consecutive pregnancy losses less than … weeks
- Affects …% of couples
- Investigations / Management:
- On … (or later) miscarriage offer … of the tissue (Chromosomal abnormalities- …-…% of couples. Most common: balanced translocation)
- Recurrent miscarriage clinic
- Blood tests - thrombophilia screen, anti-cardiolipin antibodies, lupus anticoagulant
- Anti Phospholipid syndrome- …% of patients with recurrent miscarriage.
- Treatment (Aspirin and LMWH) improves outcome
- Uterine anomalies: Ultrasound scan (3D scan) or hysteroscopy/laparoscopy
- No evidence at present for any effective treatment for unexplained recurrent miscarriage
A
- 3 consecutive pregnancy losses less than 24 weeks
- Affects 1% of couples
- Investigations / Management:
- On third (or later) miscarriage offer karyotyping of the tissue (Chromosomal abnormalities- 2-5% of couples. Most common: balanced translocation)
- Recurrent miscarriage clinic
- Blood tests - thrombophilia screen, anti-cardiolipin antibodies, lupus anticoagulant
- Anti Phospholipid syndrome- 15% of patients with recurrent miscarriage.
- Treatment (Aspirin and LMWH) improves outcome
- Uterine anomalies: Ultrasound scan (3D scan) or hysteroscopy/laparoscopy
- No evidence at present for any effective treatment for unexplained recurrent miscarriage
18
Q
Ectopic pregnancy
- Pregnancy developing … the … cavity
- …% in fallopian tube
- …% interstitial
- Affects … per 1000 pregnancies (12000 in UK each year)
- Heterotopic pregnancy 1 in … (much higher with IVF)
- Mortality … per 1000 ectopic pregnancies
- Risk factors for ectopic pregnancy are only present in …-…% of women with an ectopic pregnancy
A
- Pregnancy developing outside the uterine cavity
- 97% in fallopian tube
- 2% interstitial
- Affects 11 per 1000 pregnancies (12000 in UK each year)
- Heterotopic pregnancy 1 in 30000 (much higher with IVF)
- Mortality 0.2 per 1000 ectopic pregnancies
- Risk factors for ectopic pregnancy are only present in 25-50% of women with an ectopic pregnancy
19
Q
Risk Factors for Ectopic Pregnancy
- Previous ectopic pregnancy (…% risk after one)
- … damage
- Previous … surgery
- History of … infection / PID
- History of endo…
- History of s…/ IVF
- Presence of …
- Use of … … contraception
- C… F…
A
- Previous ectopic pregnancy (15% risk after one)
- Tubal damage
- Previous tubal surgery
- History of pelvic infection / PID
- History of endometriosis
- History of subfertility/ IVF
- Presence of IUCD
- Use of progesterone only contraception
- Cystic fibrosis
20
Q
Clinical presentation of ectopic pregnancy - ‘Classic’ presentation
- Pain and bleeding ..-… weeks gestation
- … … test
- … uterus on TV ultrasound scan
- Given options for conservative / expectant , medical (m…), or surgical management
A
- Pain and bleeding 6-8 weeks gestation
- Positive pregnancy test
- Empty uterus on TV ultrasound scan
- Given options for conservative / expectant , medical (methotrexate), or surgical management
21
Q
Clinical presentation of ectopic pregnancy - ‘Modern’ presentation
- Seen with EPAU … symptoms in early pregnancy
- May be monitored over … hours to confirm diagnosis (using scans and … levels)
- Expectant management / medical / elective surgical
A
- Seen with EPAU minor symptoms in early pregnancy
- May be monitored over 48 hours to confirm diagnosis (using scans and hcg levels)
- Expectant management / medical / elective surgical
23
Q
Diagnosis and Treatment of Ectopic Pregnancy
- ALWAYS be suspicious of ectopic for any patient who presents with … … +/- … + positive … test and ALWAYS perform more investigations to rule out ectopic
- Diagnosis may be
- From a visualised ectopic on …
- At … (eg. following previous suspicious investigations)
- After the patient has …
- Treatment
- C…
- Medical – … injections
- Surgical (salping.., salping..)
A
- ALWAYS be suspicious of ectopic for any patient who presents with pelvic pain +/- bleeding + positive pregnancy test and ALWAYS perform more investigations to rule out ectopic
- Diagnosis may be
- From a visualised ectopic on USS
- At laparoscopy (eg. following previous suspicious investigations)
- After the patient has collapsed
- Treatment
- Conservative
- Medical – methotrexate injections
- Surgical (salpingectomy, salpingotomy)
34
Q
Cervical Sutures - Indications
- Past history of …-trimester pregnancy loss
- Past history of … surgery
- Known … anomaly
- Cervical … noted - on speculum examination or TV scan
A
- Past history of mid-trimester pregnancy loss
- Past history of cervical surgery
- Known uterine anomaly
- Cervical dilatation noted - on speculum examination or TV scan
36
Q
Cervical Sutures - Emergency
- Usually ..-.. weeks but occasionally later
- RCOG evidence that can … pregnancy (upto 6-weeks)
- Risk of …
A
- Usually 12-24 weeks but occasionally later
- RCOG evidence that can prolong pregnancy (upto 6-weeks)
- Risk of infection
43
Q
What is this figure showing?
A
Still birth rate and maternal age
45
Q
After a Stillbirth
- Offer investigations – … to rule in / out potential causes if not known, full … screen
- …-… – complete or incomplete, vs. genetics from placenta
- Creating memories
- … options
- On going …
- Follow up with consultant to go through investigations and plan for the …
- Next pregnancy – make a plan
- … teardrop stickers
A
- Offer investigations – bloods to rule in / out potential causes if not known, full infection screen
- Post-mortem – complete or incomplete, vs. genetics from placenta
- Creating memories
- Funeral options
- On going support
- Follow up with consultant to go through investigations and plan for the future
- Next pregnancy – make a plan
- SANDS teardrop stickers
50
Q
Perinatal Mortality Review Tool
A
54
Q
Women who died <24 weeks (Early-pregnancy-related causes) - out of 6
- 1 death from a self inflicted …
- 5 deaths as a result of … pregnancies
- 3 women were from black or other minority ethnic groups
- 3 women were over the age of …
- All women died within … hours of presentation
A
- 1 death from a self inflicted TOP
- 5 deaths as a result of ectopic pregnancies
- 3 women were from black or other minority ethnic groups
- 3 women were over the age of 35
- All women died within 48 hours of presentation
