Miscarriage

Question 1

What is miscarriage?

Answer 1

The spontaneous loss of a pregnancy at less than 24 weeks gestation

Question 2

When does early miscarriage occur?

Answer 2

Before 12 weeks gestation

Question 3

When does late miscarriage occur?

Answer 3

Between 12 and 24 weeks gestation

Question 4

What are the . risk factors of miscarriage?

Answer 4

Age > 35 years old

Underweight

Overweight

Previous miscarriages > 2 occasions

Chronic conditions, such as uncontrolled diabetes

Uterine abnormalities

Invasive prenatal tests

Smoking

Alcohol

Illicit Drugs

Question 5

What is a missed miscarriage?

Answer 5

They occur when the fetus is no longer alive, however the patient is asymptomatic

Question 6

How is a missed miscarriage identified on a transvaginal US scan?

Answer 6

There is a gestational sac present with no fetus present or a gestational sac with a fetal pole but no fetal heartrate

Question 7

What is a threatened miscarriage?

Answer 7

They occur when the pregnancy is still viable, however there is a threat of miscarriage

Question 8

What are the clinical features of a threatened miscarriage?

Answer 8

Mild vaginal bleeding

Pain from a non-dilated, closed cervix

Question 9

What is an inevitable miscarriage?

Answer 9

This occurs when the pregnancy is still viable, however miscarriage is inevitable

Question 10

What are the clinical features of an inevitable miscarriage?

Answer 10

Heavy bleeding

Clots

Pain from a dilated, open cervix

Question 11

What is an incomplete miscarriage?

Answer 11

They occur when the products of conception remain in the uterus after miscarriage

Question 12

What are the clinical features of an incomplete miscarriage?

Answer 12

Heavy vaginal bleeding from a dilated, open cervix

Question 13

How is an incomplete miscarriage identified on a transvaginal US scan?

Answer 13

The retained products of conception can be visualised

The endometrial diameter is usually greater than 15mm

Question 14

How do we manage incomplete miscarriages?

Answer 14

We usually treat patients surgically

Question 15

What is a complete miscarriage?

Answer 15

They occur when there are no products of conception left in the uterus after miscarriage

Question 16

What are the clinical features of a complete miscarriage?

Answer 16

They will have experienced vaginal bleeding and clots, however this is now settling

Question 17

How is a complete miscarriage identified on a transvaginal US scan?

Answer 17

No retained products of conception can be visualised

The endometrial diameter is usually less than 15mm

Question 18

How do we manage complete miscarriages?

Answer 18

There are no management options required for this type of miscarriage

Question 19

What is a septic miscarriage?

Answer 19

They occur when an incomplete miscarriage results in the development of an infection within the uterus

Question 20

What are the four clinical features of a septic miscarriage?

Answer 20

Fever

Rigors

Bleeding

Pain

Question 21

How do we manage septic miscarriages?

Answer 21

We prescribe patients IV antibiotics followed by pharmacological or surgical management

Question 22

What are the six risk factors of a miscarriage?

Answer 22

Maternal Age > 35

Miscarriage History

Foetal Chromosomal Abnormalities

Uterine & Cervical Abnormalities

Obesity

Maternal Diabetes

Question 23

What are the two investigations used to diagnose miscarriages?

Answer 23

Transvaginal Ultrasound Scan

Blood Tests

Question 24

What is the investigation of choice for diagnosing a miscarriage?

Answer 24

Transvaginal ultrasound scan

Question 25

What are the three key features that the sonographer looks for in an early pregnancy?

Answer 25

Mean Gestational Sac Diameter Fetal Pole & Crown Rump Length (CRL) Fetal Heartbeat

Question 26

What ultrasound feature indicates a viable pregnancy?

Answer 26

Fetal heartbeat

Question 27

When do we expect a fetal heartbeat on an US scan?

Answer 27

When the crown rump length is 7mm or more

Question 28

What do we do when the the crown rump length is less than 7mm and no fetal heartbeat is present?

Answer 28

The scan is repeated after at least one week to ensure the heartbeat develops

Question 29

What do we do when the the crown rump length is more than 7mm and no fetal heartbeat is present?

Answer 29

The scan is repeated after one week before confirming a non-viable pregnancy

Question 30

What do we do when the the crown rump length is more than 7mm and no fetal heartbeat is present - however there is evidence of infection or increased haemorrhage risk?

Answer 30

Dilation and curettage

Question 31

What ultrasound feature should be present with a gestational sac and yolk sac?

Answer 31

Fetal pole

Question 32

What do we do when the mean sac diameter is greater than 25mm and no fetal pole is present?

Answer 32

A diagnosis of failed pregnancy can be made

Question 33

What do we do when the mean sac diameter is less than 25mm and no fetal pole is present?

Answer 33

A repeat scan needs to be arranged in 10-14 days

Question 34

How are blood tests used to diagnose a miscarriage?

Answer 34

Serum b-HCG This should not be used to diagnose a viable or non-viable pregnancy, however used to assess the possibility of an ectopic pregnancy

Question 35

How do we conservatively manage a miscarriage?

Answer 35

It involves awaiting the miscarriage without investigations or treatment We allow one to two weeks for the miscarriage to occur spontaneously A repeat urine pregnancy test should be performed after 7-10 days to confirm the miscarriage is complete

Question 36

When do we select conservative management for a miscarriage?

Answer 36

It is offered to women with a pregnancy less than six weeks gestation provided they have no pain, complications or risk factors

Question 37

How do we pharmacologically manage a miscarriage?

Answer 37

It involves the prescription of vaginal misoprostol A repeat urine pregnancy test should be performed after three weeks to confirm the miscarriage is complete

Question 38

What is the action of misoprostol?

Answer 38

It is a prostaglandin analogue used to stimulate cervical ripening and myometrial contractions This expedites the process of miscarriage

Question 39

What are the two surgical procedures for a miscarriage?

Answer 39

Manual Vacuum Aspiration Electric Vacuum Aspiration

Question 40

What is manual vacuum aspiration?

Answer 40

It involves the insertion of a tube through the cervix into the uterus This tube aspirates the contents of the uterus This procedure is conducted under local anaesthetic

Question 41

When do we use manual vacuum aspiration to treat a miscarriage?

Answer 41

It is offered to women below 12 weeks’ gestation and those who believe the procedure is ethically acceptable

Question 42

What is electric vacuum aspiration?

Answer 42

It involves the cervix being gradually widened using dilators and the products of conception being removed using an electric powered vacuum

Question 43

When do we prescribe anti-D prophylaxis to miscarriage patients?

Answer 43

If the patient is Rhesus negative and is greater than 12 weeks’ gestation If the patient is Rhesus negative and receiving surgical treatment the gestation doesn't matter