Miscarriage

Question 1

Bleeding in early pregnancy

Answer 1

Bleeding in early pregnancy associated with Miscarriage, Ectopic, Gestational Trophoblastic Disease or rarely, Gynaecological Lower Tract Pathology (E.g. Chlamydia, Ca Cervix, Polyp)

Question 2

How common is miscarraige

Answer 2

Miscarriage is common; 15 – 20% of Pregnancies; Possibly 40% of Conceptions
o Most women who miscarry will have non-elevated risk after; Rare few recurrent

Question 3

What is definition of miscarriage

Answer 3

=Expulsion of Pregnancy, Embryo or Foetus at a stage where it is incapable of independent survival; Includes losses before 24 weeks (Majority before 12 weeks)

Question 4

What are early pregnancy assessment units for?

Answer 4

Readily available Transvaginal Ultrasound and Serum hCG measurement; Definitive diagnosis of Pregnancy and Miscarriage

Question 5

How does hCG change in miscarriage?

Answer 5

hCG might be positive for up to 3 weeks after as renal excretion occurs

Question 6

Risk factors for miscarriage

Answer 6

Chromosomal Problems, Placental Disorders, Maternal Age, Obesity, Smoking,
Drug Abuse, Caffeine intake (>2 cups coffee), ETOH, Diabetes, HTN, SLE, Thyroid issues, Infections (TORCHES), Food Poisoning (E.g. Listeriosis, Salmonella) Teratogenic Drugs,
Fibroids, Cervical Incompetence

Question 7

Threatened Miscarriage

Answer 7

Bleeding and Abdo Pain; Cervix Undilated
o Anti-D prophylaxis should be given if >12wks or heavy bleeding/pain
o Gestation sac, Foetal Poles and Heart Activity on Ultrasound

Question 8

Complete Miscarriage

Answer 8

Bleeding and Pain ceased; Cervix Undilated
o Anti-D prophylaxis if >12 wks; Serum hCG to exclude ectopic if any doubt
o Empty Uterus, Thinning Endometrium on Ultrasound

Question 9

Incomplete Miscarriage

Answer 9

Bleeding and Pain; Cervix possibly dilated

Question 10

Management of Expectant Management

Answer 10

If not heavily bleeding; Repeat TVUSS at 2 weeks to ensure complete; Offered surgical management if unsuccessful

Question 11

Management of Medical Management

Answer 11

Prostaglandin Analogues (Misoprostol) usually with Antiprogesterone priming (Mifepristone); Bleeding might continue up to 3/52 after Uterine Evacuation; Might be associated with Pain and Heavy Bleeding in some; Admission might be required\

Question 12

Management of Surgical Management

Answer 12

ERPC if excessive or persistent bleeding, or Request surgical management; Suction Curettage
Prostaglandins (E.g. Misoprostol, Gemeprost) minimises Trauma

Question 13

Complications of surgical management

Answer 13

Infection, Haemorrhage, Uterine Perforation, RPOC, Intrauterine Adhesions (Asherman’s Syndrome), Cervical Tears, Intra-abdominal tears

Question 14

Other support for miscarriage

Answer 14

Miscarriage is very distressing; Appropriate support, counselling and written information

Question 15

Define recurrent miscarriage

Answer 15

≥3 Consecutive, Spontaneous miscarriages in First Trimester with same biological father
o Incidence 1 – 2%; Half unexplained

Question 16

Antiphospholipid syndrome

Answer 16

Antiphospholipid Syndrome – 15% of women with Recurrent Miscarriages
o Anticardiolipin Antibodies or Lupus Anticoagulant Antibodies on two separate
occasions, with miscarriages/<34weeks prem with severe Pre-eclampsia

Question 17

Genetic Disorders

Answer 17

Robertsonian Translocation of parent; Carrier phenotypically normal but
50 – 75% of gametes will be unbalanced; or Foetal Chromosomal Abnormalities

Question 18

Reproductive Anatomical Risk factors for recurrent miscarriage

Answer 18

Uterine Abnormalities (Septae, Bicornate), Fibroids (Little data to support assertion)

Question 19

Thrombophilia

Answer 19

Factor V Leiden and Factor II PT G20210A; Protein C, Protein S deficiency
have weak association

Question 20

Infections

Answer 20

Bacterial Vaginosis; More likely to cause recurrent second trimester losses

Question 21

Management of Recurrent Miscarriage

Answer 21

• Parental Karyotyping, Cytogenetic Analysis of POC (Post-miscarriage)
• Pelvic Ultrasound for structural abnormalities
• Thrombophilia Screening, Lupus Anticoagulant testing (dRVVT/aPTT), Anticardiolipin
Antibodies (aCL IgG and IgM)
• Insufficient evidence to screen if asymptomatic for Thyroid, Diabetes, Hyperprolactinaemia;
TORCH screening not helpful
• For Antiphospholipid Syndrome – Aspirin and Heparin commenced as soon as Foetal Viability
confirmed in first Trimester
• Proven Bacterial Vaginosis – Regular swabs and Rotating Prophylactic Abx (e.g. Clinda, Amox)