miscarriage and abortion Flashcards
what is miscarriage?
Miscarriage is the involuntary loss of pregnancy before 24 weeks of gestation. It can be classified as either early (≤12 weeks) or late (13-24 weeks
which factors are most responsible for first trimester miscarriages?
Embryonic factors
- Chromosomal abnormality: up to 80% of first-trimester miscarriages are associated with a chromosomal abnormality, such as trisomy, monosomy, and triploidy [
- Embryonic malformation: such as a CNS defect
what factors can cause miscarriage in the second and third trimester?
Second and third-trimester miscarriages are commonly caused by maternal factors:
- Infection: ascending infection from the lower genital tract is the most prominent infectious cause of early pregnancy loss
- Maternal anatomical anomalies: fibroids, septa, adhesions or polyps may impede the natural development of a foetus
- Exposure to teratogens
- Thrombophilia: antiphospholipid syndrome usually causes recurrent early miscarriages (first or second trimester)
- Endocrine: poorly controlled diabetes mellitus or thyroid disease
what are the features of a threatened miscarriage ?
- 6-9 weeks
- mild vaginal bleeding and abdominal pain
- but cervical os is closed
- pregnancy may continue
this occurs in 25% of pregnancy
what are features of inevitable miscarriage?
- open os
- heavy bleeding with pain and clots
- pregnancy will not continue
what are features of an incomplete miscarriage?
- Os is open
- pain and vaginal bleeding
- products of conception are only partially expelled
what are features of complete miscarriage?
- os is close
- foetal tissue is completely expelled
what is a silent miscarriage?
- closed os
- gestational sac with dead foetus
- asymptomatic or with transient bleeding
- non viable pregnancy is seen on USS
when would someone have recurrent miscarriages?
≥ 3 consecutive miscarriages before 24 weeks of gestation
which investigations should you do if you suspect a miscarriage?
Urine hCG: confirms pregnancy
Transvaginal ultrasound (TVUS): diagnostic, with visualisation of the foetal pole, heartbeat and size of the gestational sac. TVUS allows assessment of the viability of the pregnancy
Serum β-hCG: a falling hCG suggests a failing pregnancy
FBC: if significant anaemia is present, the patient may need a transfusion
Rhesus status: will guide the need for anti-D immunoglobulin
what is the management of a first trimester incomplete or missed miscarriage?
- expectant management
- advice and analgesia for 7-14 days
- if sxs improve do urine pregnancy test in 3 weeks
- if no improvement repeat TVUS and consider medical management - medical management
- vaginal misoloprost and repeat pregnancy test in 3 weeks
- it is a prostaglandin analogue that causes myometrial contractions - surgical management
- manual evacuation- under LA
- surgical management under general
Anti-D should be given to rhesus negative women
what are complications of miscarriage??
- Depression: although grief is a normal response to loss, psychological support may be required if symptoms persist
- Sepsis: endometritis and sepsis characterised by fever and abdominal pain
- Recurrent miscarriage: affects 1% of women and requires further investigation
- Asherman’s syndrome: a consequence of curettage resulting in uterine adhesions leading to potential amenorrhoea
in what case would medical or surgical management of miscarriage be considered first line?
- Increased bleeding risk (e.g. late first trimester pregnancy or coagulopathy)
- Previous traumatic experience in pregnancy (e.g. stillbirth, miscarriage)
- Evidence of infection
what are the different options for abortion?
- less than 9 weeks: mifepristone followed 48 hours later by prostaglandins to stimulate uterine contractions
- less than 13 weeks: surgical dilation and suction of uterine contents
- more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
what is a risk of surgical abortion?
future premature labour
