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Women's Health > Foetal Death (Recurrent Miscarriage, Stillbirth) > Flashcards

Foetal Death (Recurrent Miscarriage, Stillbirth) Flashcards

1
Q

What is abortion?

A

Expulsion of the foetus prior to 20 weeks gestation

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2
Q

What is the incidence of spontaneous abortion?

A

15-25% (>80% in the first 12 weeks)

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3
Q

What causes many early spontaneous abortions?

A

50% due to chromosomal abnormalities, most of which are trisomy

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4
Q

What are the causes of second trimester abortions?

A

Not usually chromosomal:

  • maternal systemic disease
  • abnormal placentation or other anatomic considerations
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5
Q

Why is the distinction between early and second trimester abortions clinically significant?

A

Second trimester conditions can often be treated and therefore recurrent abortion can be prevented

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6
Q

What are the infectious aetiologies of spontaneous abortion?

A

Uncommon cause of early spontaneous abortion.

  • Chlamydia trachomatis
  • Listeria monocytogenes
  • Mycoplasma hominis
  • Ureaplasma urealyticum
  • Syphilis
  • HIV(1)
  • GBS vaginal colonisation
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7
Q

What are the endocrine aetiologies of spontaneous abortion?

A
  • Thyroid autoantibodies (even in absence of clinical hypothyroidism)
  • TIDM (degree of metabolic control important)
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8
Q

What are the environmental aetiologies of spontaneous abortion?

A
  • Smoking (linear with #/day)
  • Alcohol (abortion + foetal abnormalities)
  • Radiation (such as RT therapeutic dose)
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9
Q

What are the immunologic aetiologies of spontaneous abortion?

A

Genetic disorders of blood coagulation (increase risk of arterial and venous thrombosis); a/w recurrent miscarriage

  • Factor V Leiden mutations
  • Prothrombin G20210A
  • Antithrombin 3
  • Proteins C and S
  • Hyperhomocysteinemia
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10
Q

What are the uterine factor aetiologies of spontaneous abortion?

A
  • Large and multiple uterine leiomyomas (location usually more important than size)
  • Intrauterine synechiae (Asherman syndrome)
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11
Q

What is the type of uterine leiomyoma more frequently implicated in miscarriage?

A

Submucous leiomyomata (?due to role on implantation)

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12
Q

What is Asherman syndrome?

A

Intrauterine synechiae - condition caused after curettage has denuded endometrium past layer of baseless so webs of scar tissue develop across the uterine cavity (the synechiae)

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13
Q

What is a threatened abortion?

A

Pregnancy complicated by vaginal bleeding prior to 20th week (incidence 25%)

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14
Q

How many women with threatened abortion progress to spontaneous abortion?

A

~50%

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15
Q

What are the risks when a threatened abortion is carried to viability?

A

-Low birth weight
-Preterm birth
No higher incidence of congenital malformations in these newborns

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16
Q

What is inevitable miscarriage?

A

Gross rupture of membranes in presence of cervical dilation (open os).
-uterine contractions usually commence promptly –> expulsion of products of conception

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17
Q

What is the risk of conservatively managing patients with inevitable abortion?

A

Significantly increases risk of maternal infection

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18
Q

What is an incomplete miscarriage?

A
  • Pain and bleeding

- Internal cervical os opens and allows passage of blood. -Products of conception may extrude through dilated os.

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19
Q

What is a complete abortion?

A

Documented pregnancy that spontaneously passes all products of conception. Before 10 weeks foetus and placenta are expelled in toto.
-Pain, bleeding and passage of all products of conception; then reduction in bleeding, closure of cervix, empty uterus on scan

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20
Q

What is a missed miscarriage?

A

Retention of failed intrauterine pregnancy for an extended period (usually defined as more than 2 menstrual cycles). Usually no pain or bleeding.

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21
Q

What is recurrent pregnancy loss

A

More than three consecutive pregnancy losses

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22
Q

What is recommended when recurrent early abortion occurs?

A

karyotyping for both parents (early pregnancy loss usually genetic; 3% chance once parent is a symptomless carrier of a genetically balanced chromosomal translocation)

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23
Q

What is Asherman syndrome associated with clinically?

A
  • amenorrhoea or irregular periods
  • infertility
  • recurrent pregnancy loss
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24
Q

Diagnosis of Asherman syndrome?

A

Hysterogram showing webbed pattern; or hysteroscopy

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25
Q

How is Asherman syndrome treated?

A
  • Lysis of synechiae

- Post op oestrogen to encourage endometrial proliferation to re establish normal endometrial layer

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26
Q

What are anti phospholipid antibodies?

A

Family of autoantibodies that bind negatively charged phospholipids (e.g. Lupus anticoagulant, anti cardiolipin)

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27
Q

Treatment anti phospholipid antibodies in recurrent preganancy wastage?

A
  • Low dose aspirin

- Unfractionated heparin

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28
Q

Treatment threatened abortion?

A 
No intervention (even if bleeding + cramps)
-if no evidence of abnormality of US 
-Pregnancy intact on US
then reassure and allowed to continue normal activities
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29
Q

Treatment incomplete abortion?

A

Expectant, medical and surgical options.

  • surgical invasive but decisive
  • Expectant and medical a/w unpredictable bleeding, may progress to surgery
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30
Q

What are the immediate considerations in management of abortion?

A
  • Control of bleeding
  • Prevention of infection
  • Pain relief (panadeine forte, NSAIDs)
  • Rh imune globulin if Rh -ve
  • Emotional support
  • commence Ix
31
Q

What are the signs of complete abortion?

A
  • Uterus small and firm
  • Cervix closed
  • US shows empty uterus
32
Q

What measures decrease risk of infection?

A
  • Removal of products of conception

- Vaginal rest (no tampons, douches or intercourse)

33
Q

what should be discussed at follow up appointment following abortion?

A
  • Evaluate uterine involution
  • Assess return of menses
  • Discuss rep`roductive plans
  • Causes (or lack of) discussed (one loss does not increase risk of future losses, multiple carries increased risk of future losses).
34
Q

What are anatomical aetiologies of abortion?

A
  • Mullerian abnormalities
  • Fibroids
  • Asherman’s syndrome
  • Cervical incompetence
35
Q

What are the Hx features to elicit in abortion evaluation?

A
  • Bleeding (volume, colour, Sx of hypovolemia)
  • Pain (site, severity)
  • Passage POC
  • Dating pregnancy
36
Q

PEx features of abortion evaluation?

A
  • General exam, vitals

- Features relevant to miscarriage: uterus size, open or closed cervix, adnexal tenderness or mass.

37
Q

Ix miscarriage evaluation?

A
  • Blood group and Abs (Rhesus)
  • bHCG (doubling every 48h, more than 3000 seen on TVUS)
  • US
  • FBE (Hb)
  • Histopath of PoC
38
Q

HOW are recurrent miscarriages investigated?

A
  • Chromosomal:
  • Submit POC for chromosomal analysis if possible
  • Parental karyotyping
  • Anatomical: saline hysterosonography, MRI
  • Maternal disease:
  • Endocrine (DM, thyroid)
  • Autoimmunity
39
Q

what are the investigation for maternal autoimmune disease causing recurrent abortion?

A
  • SLE: FBE, ANA, anti dsDNA

- Antiphospholipid syndrome: anti phospholipid antibodies (lupus anticoagulant), anticardiolipin antibody

40
Q

How are chromosomal anomalies managed?

A
  • Refer medical geneticist for individual prognosis on subsequent miscarriage and risk of foetal anomaly
  • May consider donor egg / sperm
41
Q

What is the most common chromosomal cause of abortion?

A

Random non dysjunction resulting in lethal aneuploidy

42
Q

What is foetal death in utero?

A

Fetal demise after 20 weeks gestation but before onset of labour

43
Q

What are the maternal aetiologies of foetal death in utero?

A
  • Diabetes
  • HTN (inc PIH, PET)
  • SLE, CT disorders, anti phospholipid syndrome, thrombophilia
44
Q

What are the foetal aetiologies of foetal death in utero?

A
  • Malformation (structural, chromosomal)
  • Infection
  • Immune haemolytic disease
  • Non immune foetal hydrops
  • Metabolic disease
45
Q

What are the placental aetiologies of foetal death?

A
  • Abruption
  • Placental insufficiency (IUGR, post term pregnancy)
  • Twin Twin Tx
  • Foeta-maternal transfusion
46
Q

What are the cord aetiologies of foetal death?

A

Cord accident

47
Q

What are the clinical features of foetal death in utero?

A
  • Features of underlying condition
  • Reduced or absent FM
  • Unable to locate FH
  • US confirms no FH movement, PM features e.g. Spalding’s sign
48
Q

What are the complications of foetal death in utero?

A

Coagulopathy: 25% with FDIU >20w for over 4 weeks will develop chronic consumptive coagulopathy (decreased fibrinogen, plasminogen, aTIII, platelets)
-Spontaneously resolves within 48/24 of delivery

49
Q

Maternal investigation of FDIU?

A
  • RBG, HbA1C
  • Rh antibodies
  • Kleihauer
  • ANA
  • LAC, ACLA, thrombophilia screen
  • TORCH
  • fibrinogen, platelet count
50
Q

Foetal investigation of FDIU?

A
  • US to confirm FDIU (also examine for foetal/placental malformation / IUGR)
  • post mortem most valuable (consider limited post mortem, swabs, chromosomal analysis if parents don’t agree)
51
Q

Placental investigation of FDIU?

A

Histology, swabs

52
Q

Mx FDIU wrt telling parents?

A
  • Together, private room
  • Be clear baby has died
  • Explain cause if apparent
  • Explain investigations generally
  • Discuss delivery (no rush, methods of delivery, pain relief, post partum care)
  • Pastoral care, SW, GP
53
Q

What are the methods of labour and delivery in FDIU?

A
  • Induction with PGs
  • Induction with ARM and oxytocin
  • Quiet, secluded room in labour ward
  • Analgesia (epidural if no coagulopathy)
54
Q

Post delivery management of FDIU?

A
  • Pastoral care support (burial, funeral etc)
  • Suppression of lactation
  • Early discharge if well but good post natal support
  • Review frequently post partum (2, 4, 6w)
  • Discussion of next pregnancy
55
Q

What is a septic miscarriage?

A

Serious uterine infection during or shortly after a miscarriage

56
Q

What are the methods of dating a pregnancy?

A
  • Gestation wheel / apps
  • LNMP (1st day LN period; regular? cycle length?)
  • Date of conception in known
  • Date of embryo transfer for IVF
  • USS CRL in T1, biometry if >T1 (use USS dates if
57
Q

How may miscarriage present?

A
  • Routine US
  • Pain / bleeding
  • Haemodynamic shock
  • Cervical shock
  • genital tract sepsis
58
Q

What is cervical shock?

A

Bradycardia + hypotension

59
Q

What are the Ddx of miscarriage presentations?

A

-Ectopic pregnancy until proven otherwise

60
Q

When is miscarriage diagnosed on TV US scan?

A
  • Gestational sac >25mm with no foetal pole
  • Foetal pole >7mm with no FH
  • Absence of embryo >2w after scan showed empty gestational sac (i.e. no yolk sac or embryo)
  • Adnexae: corpus luteum, ectopic pregnancy, free fluid)
61
Q

What are the principles of miscarriage management?

A 
BIO:
-stabilise pt
-Evacuation of uterus: expectant, medical, surgical
-Anti D if Rh-
PSYCHOSOCIAL:
-counselling: cause, guilt / grief, future risk, reversible RFx
-partner
-supports
-LMO
-What to expect, signs to return
62
Q

When is Anti D given in T1? Dose?

A

T1 = 250IU:

  • CVS
  • miscarriage
  • termination
  • ectopic
63
Q

When is Anti D given in T2? Dose?

A

T2 = 625IU

  • APH
  • Amniocentesis
  • ECV
  • Abdo trauma
  • Prophylactically at 28 and 34 weeks
64
Q

What are the management options for miscarriage?

A
  • Conservative/ expectant
  • Medical
  • Surgical
65
Q

What is conservative / expectant management of miscarriage?

A
  • Wait for spontaneous expulsion of PoC
  • Can take weeks - months (esp missed miscarriage)
  • Follow up to check complete
66
Q

What is medical management of miscarriage?

A
  • 600 - 800mcg misoprostol STAT and 24h later
  • Case selection
  • 80% success, 20% further intervention
  • Follow up to check complete
67
Q

what is surgical management of miscarriage?

A
  • Dilation and curettage +/-PV misoprostol to aid cervical dilation
  • Risks: incomplete, perforation, bleeding, cervical trauma, adhesions, infection
  • Benefit of being controlled and timed with predictable recovery
68
Q

Aetiology recurrent pregnancy loss?

A
  • Unexplained 40%
  • Immunological (SLE, APLS, thyroid antibodies) 25%
  • Endocrine 20% (PCOS, DM, thyroid)
  • Uterine anomalies 20% (septate or bicornuate uterus, submucous fibroids, adhesions, cervical insufficiency)
  • Genetic 3%
  • Infection 6% (syphilis, malaria
69
Q

Hx recurrent miscarriage?

A
  • Timing
  • Medical disorders
  • Hx of uterine instrumentation
  • FHx
70
Q

What is the aetiology of mid trimester pregnancy loss?

A
  • Cervical incompetence
  • Genetic (aneuploidy etc)
  • Other: IUGR, immunological, infection, placental
71
Q

CFx cervical insufficiency?

A

-Relatively fast, painless premature labour (esp T2)

May be preceded by prolapsed or ruptured membranes

72
Q

How is cervical insufficiency investigated?

A

TVUS. Empty bladder, fundal pressure.

Cervix

73
Q

Mx cervical insufficiency?

A
  • Conservative with serial measurements 16-28w
  • Progesterone
  • Cerclage: consider if previous PTB and short Cx (inserted T1 screening, clear swabs, GA, McDonalds versus Shirodkar, removal approx 36 weeks or at time of CS)

Women's Health (39 decks)

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