Miscarriage

Question 1

What is a miscarriage?

Answer 1

The loss of a pregnancy <24weeks gestation

Question 2

What is an early miscarriage?

Answer 2

1st trimester (<12 weeks)

Question 3

What is a late miscarriage?

Answer 3

2nd trimester (13-24 weeks)

Question 4

What percentage of pregnancies result in miscarriage?

Answer 4

20-25%

Question 5

List the risk factors for miscarriage

Answer 5

Maternal age >30-35 (increase in chromosomal abnormalities) 
Previous miscarriage
Obesity 
Chromosomal abnormalities
Smoking
Uterine anomalies (fibroids and adhesions) 
Previous uterine surgery 
Anti-phospholipid syndrome
Coagulopathies

Question 6

List the clinical features of misccariage

Answer 6

Vaginal bleeding - clots/products of conception

If heavy bleeding then haemodynamic instability - pallor, SOB, dizziness

Suprapubic cramping pain

Question 7

List the signs of miscarriage on examination

Answer 7

Haemodynamic instability - pallor, tachycardia, tachypnoea, hypotension

Abdominal examination - Abdomen may be distended with localised areas of tenderness

Speculum examination - assess the diameter of the cervical os and observe for any products of conception in cervical canal or local areas of bleeding

Bimanual examination - assess any uterine tenderness and any adnexal masses or collections

Question 8

List the differentials for miscarriage

Answer 8

Ectopic pregnancy
Hydatiform mole
Cervical/uterine malignancy

Question 9

What is the main diagnostic investigation of miscarriage?

Answer 9

Transvaginal ultrasound

Question 10

What can gestation be estimated by?

Answer 10

Foetal crown rump length

Question 11

What is required if foetal crown rump length is <7mm and no foetal heart can be identified?

Answer 11

Repeat scan in 7 days

Question 12

If a foetal pole is not visible but intrauterine pregnancy is confirmed with gestational sac and yolk sac, what does management depend on?

Answer 12

The mean sac diameter
>25mm - failed pregnancy
<25mm - repeat scan 1-14days later

Question 13

What other investigations can be done for someone with suspected miscarriage?

Answer 13

Serum b-HCG - rule out ectopic
FBC
Blood group and rhesus status
Triple swabs and CRP if pyrexial

Question 14

What is given regardless of treatment type to a woman experiencing a miscarriage?

Answer 14

Anti-D immunoglobulin if Rh-ve mother and >12weeks gestation or managed surgically regardless of gestation

Question 15

What are the 3 definitive management options for miscarriage?

Answer 15

Conservative (expectant)
Medical
Surgical

Question 16

Describe conservative (expectant) management

Answer 16

Allows the products of conception to pass naturally

Question 17

What are the advantages of conservative management?

Answer 17

Can remain at home
No medication SE
No anaesthetic risk
No surgical risk

Question 18

What are the disadvantages of conservative management?

Answer 18

Unpredictable timing
Heavy bleeding
Pain
Chance of being unsuccessful requiring further investigation and need for transfusion

Question 19

What follow up is required for conservative management of miscarriage?

Answer 19

Depends on the unit

Some offer US in two weeks and others do a pregnancy test in 3 weeks

Question 20

List the contraindications to conservative management of miscarriage

Answer 20

Infection

High risk of haemorrhage

Question 21

Describe medical management of miscarriage

Answer 21

Mifepristone 24-48hours prior to administration of vaginal misoprostol

Question 22

What class of drugs is misoprostol

Answer 22

Prostaglandin analogue

Question 23

Describe what happens after vaginal misoprostol is given

Answer 23

Cervical ripening and myometrial contractions

Question 24

What are the advantages of medical management of miscarriage?

Answer 24

Can be at home if patient desires with 24/7 access to gynae services, avoid anaesthetic and surgical risk

Question 25

What are the disadvantages of medical management of miscarriage?

Answer 25

``` Vomiting Diarrhoea Heavy bledding Pain during passage or POC Chance of requiring emergency surgical intervention ```

Question 26

What follow up is required in the medical management of miscarriage?

Answer 26

Pregnancy test 3 weeks after

Question 27

Describe the surgical management of miscarriage

Answer 27

Manual vacuum aspiration with local anaesthetic if <12 weeks or evacuation of retained products of conception (ERPC)

Question 28

Describe evacuation of retained products of conception

Answer 28

Patient under general anaesthetic Speculum passed to visualise the cervix Dilated allowing suction tube to be passed and remove the products of conception Patients attend hospital as a day case

Question 29

What are the definite indications for evacuation of retained products of conception?

Answer 29

Haemodynamically unstable Infected tissue Gestational trophoblastic disease

Question 30

What are the advantages of evacuation of retained products of conception

Answer 30

Planned procedure | Unaware during process

Question 31

What are the disadvantages of evacuation of retained products of conception

Answer 31

``` Anaesthetic risk Infection (endometritis) Uterine perforation Haemorrhage Ashermans syndrome Bladder/bowel damage Retained products of conception ```

Question 32

Name the types of miscarriage

Answer 32

Threatened Missed Complete Incomplete

Question 33

Describe threatened miscarriage

Answer 33

Mild bleeding, pain, cervix closed | Viable pregnancy seen on TV USS

Question 34

What is the management for threatened miscarriage?

Answer 34

If heavy bleeding - admit/observe, if not reassure and back to midwife If >12 weeks and Rh-ve then AntiD

Question 35

Describe missed miscarriage

Answer 35

Asymptomatic or Hx threatened miscarriage, ongoing discharge, small for dates uterus No foetal heart pulsation in a foetus where crown rump length >7mm

Question 36

How is missed miscarriage managed?

Answer 36

Rescan and second person to confirm Manage conservatively, medially or surgically If Rh-ve and >12 weeks then anti-D

Question 37

Describe incomplete miscarriage

Answer 37

POC partially expelled Symptoms of missed miscarriage or bleeding/clots Retained POC with A/P endometrial diameter >15mm and prrof there was an intrauterine pregnancy previously present

Question 38

Describe complete miscarriage

Answer 38

Hx of bleeding, passing clots and POC, pain, symptoms now settling No POC seen in uterus with endometrium that is <15mm diameter and previous proof of intrauterine pregnancy