Clinical: Pregnancy Loss Flashcards Preview

Block I: Reproduction & Sexuality > Clinical: Pregnancy Loss > Flashcards

Flashcards in Clinical: Pregnancy Loss Deck (44):
1

Define miscarriage

  • Loss of intra-uterine pregnancy before 24 completed weeks
  • Loss of fetus/mbryo <500 g and less than 22 completed gestational weeks

2

Typical presentation of spontaneous abortion

Vaginal bleeding and uterine cramps or back pain

3

5 potential ultrasound findings for spontaneous abortion

  • Anembryonic pregnancy
  • Abortion in progress
  • Missed abortion
  • Retained products of conception
  • Abnormally shaped gestational sac

4

US for anembryonic pregnancy

Large (>18 mm) gestational sac without embryo

5

US for abortion in progress

Low-lying gestational sac (thick arrow), decidual reactoi nand hemorrhage (mixed hyper- and hypo-echoic material between arrowheads)

6

7 causes of sporadic miscarriage

  • Chromosomal abnormalities
  • Fetal malformations
  • Placental abnormalities
  • Infection
  • Fetal sex
  • Mulitple pregnancy
  • Maternal health

7

4 chromosomal abnormalities associated with multiple fetal abnormalities (risk for sporadic miscarriage)

  • Trisomies
  • Monosomy X (45X0)
  • Polyploidy (69XXY, 69XXX)

8

8 infections that may cause sporadic miscarriage

  • Listeria
  • Toxoplasmosis
  • Malaria
  • Rubella
  • CMV
  • HIV
  • B19 parvo (late)
  • Syphilis (late)

9

7 steps of the pathophysiology of sporadic miscarriage

  1. Fetal demise or abnormal placental invasion
  2. Reduced trophoblastic invasion
  3. Blood flow enters the intervillous space and dislodges the conceptus
  4. Further intrauterine bleeding
  5. Local prostagladin release
  6. Pain
  7. Uterine contraction/expulsion of the conceptus

10

3 presentations of miscarriage

  • Bleeding (threatened miscarriage)
  • Complete miscarriage
  • Arrested pregnancy

11

Define complete miscarriage

Cervix opens and conceptus/products expelled

12

3 conditions associated with incomplete miscarriage

  • Massive hemorrhage
  • Cervical shock syndrome
  • Urgent evacuation of the uterus

13

3 treatments for sporadic miscarriage

  • Expectant management
  • Cytotec (misoprostol)
  • Suction curettage

14

2 risks of suction curettage

  • Infection
  • Uterine damage

15

Define recurrent miscarriage

Three (or more) consecutive miscarriage

16

Define primary recurrent miscarriage

No previous llive births

17

Define secondary recurrent miscarriage

At least one successful pregnancy

18

6 reproductive problems that recurrent miscarriage is associated with

  • Infertility
  • Late miscarriage
  • Stillbirth/NND
  • Ectopic pregnancy
  • Fetal abnormality TOP
  • Prematurity/IUGR

19

7 etiologies of recurrent miscarriage

  • Genetic
  • Anatomical
  • Infective
  • Endocrine
  • Immune
  • Thrombophilic
  • Unexplained

20

5 examples of genetic causes of recurrent miscarriage

  • Prental chromosomal abnormalities (peripheral blood karyotype of both parents)
  • Recurrent fetal aneuploidy (fetal cytogenetic analysis)
  • Balanced or reciprocal translocations
  • Robertsonian translocation
  • Pericentric inversions

21

2 anatomical causes of recurrent miscarriage

  • Uterine anomalies
  • Fibroids

22

8 uterine anomalies

  • Arcuate
  • Subseptate
  • Septate
  • Unicollis bicornuate
  • Bicolis bicornuate
  • Didelphus
  • Unicornuate
  • Hypoplastic

23

Treatment for arcuate and didelphys uterine anomalies

None

24

Treatment for septate and subseptate uterine anomalies

Resect septum

25

Treatment for bicornuate uterus

Consider metroplasty usually as last resort

26

Treatment for fibroids causing recurrent miscarriage

Myomectomy (only if no other cause identified)

27

3 infective causes of recurrent miscarriage

  • Syphilis
  • Malaria
  • Bacterial vaginosis (trichomonas vaginalis)

28

4 endocrine causes of recurrent miscarriage

  • Systemic endocrine disease
    • Diabetes (esp NIDDM)
    • Thyroid disease
  • Luteal phase deficiency
  • PCOS (hypersecretion of LH, hyperinsulinemia)

29

3 immune causes of recurrent miscarriage

  • Autoimmune disease
  • Antiphospholipid syndrome (PAPS, aPL, APS, APAs)
  • Allo-immune factors

30

3 auto-immune diseases associated with recurrent miscarriage

  • SLE
  • Antithyroid antibodies (anti-thyroglobulin and anti-thyroid peroxidase)
  • Anti-nuclear antibodies

31

2 antiphospholipid antibodies

LA and aCL

32

Diagnosis of antiphospholipid syndrome

dRVVT (for LA) and ELISA (for aCL). Need at least two tests at least 6 weeks apart

33

3 treatments of antiphospholipid syndrome

SC heparin and LDA until 34 weeks

Potential IVIG for thrombocytopenia

34

7 thrombophilic causes of recurrent miscarriage

  • APS (acquired thrombophilic state)
  • Hyperhomocysteinemia (dietary or MTHFR mutation)
  • Activated protein C resistane (factor V leiden)
  • Protein S deficiency
  • Protein C deficiency
  • AT III deficiency
  • Prothrombin G20210A mutation

35

Effect of hyperhomocystenemia

Impairs endothelial function and promotes thrombosis

36

Cause of acquired hyperhomocystenemia

Deficiencies of Vit B6, (B9) and B12

37

Cause of inherited hyperhomocystenemia

MTHFR mutation

NOTE: individuals homozygoud for MTHFR mutation are NOT at increased risk of RM by most recent meta-analysis

38

Treatment for acquired hyperhomocysteinemia

Folate and B12 supplementatoin

39

Effect of activated Protein C resistance

Factor V resistant to cleavage by activated Protein C

40

Cause of inherited activated Protein C resistance

Factor V Leiden mutation (hetero- or homo-)

41

Test for activated protein C resistance

Test for APCR and FVL

42

Treatment for activated protein C resistance

LDA and heparin?

43

Effect of prothrombin G20210A mutation

Increased factor II (prothrombin)

44

3 thrombophilic causes that are not directly related to recurrent miscarriage, but which should be treated due to risk of thrombosis anyway

  • Inherited hyperhomocystenemia
  • Protein C deficiency
  • Anti-thrombin III deficiency