Miscarriage

Question 1

Define miscarriage.

Answer 1

spontaneous loss of a pregnancy before 24w of gestation.
Early: before 13w of gestation.
Late: 13 - 24w of gestation.

Question 2

What is a threatened miscarriage?

Answer 2

Painless PV bleeding in the presence of a viable pregnancy in first 24w
Bleeding often less than menstruation
Os closed

Question 3

What is a recurrent miscarriage?

Answer 3

spontaneous consecutive loss of 3 pregnancies before 24w of gestation.

Question 4

What is complete miscarriage?

Answer 4

all POC have been expelled from the uterus + bleeding has stopped.

Question 5

What is incomplete miscarriage?

Answer 5

non-viable pregnancy in which bleeding has begun but POC remains in the uterus.
Pain + PV bleeding
Os open

Question 6

What is inevitable miscarriage?

Answer 6

non-viable pregnancy in which bleeding has begun + os is open, but POC remains in the uterus.

Heavy bleeding with clots + pain

Leads to incomplete or complete miscarriage.

Question 7

What is missed miscarriage?

Answer 7

Non viable pregnancy identified on USS
No pain or bleeding

AKA delayed or silent miscarriage

Question 8

What advice should be given if the woman is <6 weeks pregnant and is bleeding but not in pain?

Answer 8

Expectant Mx
Repeat pregnancy test after 7–10d

Return if test is +ve or if her Sx continue or worsen

-ve test means the pregnancy has miscarried.

Question 9

What is the diagnostic tool of choice to assess the location and viability of the pregnancy?

Answer 9

TVUSS

Question 10

What is the aetiology of miscarriage? What are risk factors for miscarriage?

Answer 10

Majority occur in 1st trimester

Most common cause: chromosome abnormality.
No cause of recurrence can be determined in ~50% of couples

Question 11

What are signs and symptoms of miscarriage?

Answer 11

Pain

PV bleeding

Clotting

Open cervical os

Question 12

What investigations should be carried out to confirm miscarriage?

Answer 12

Transvaginal USS: Empty fetal sac measuring >45mm OR fetal pole measuring >7mm without fetal heartbeat

Blood hCG - hCG should double every day - if it is not it is a miscarriage, if it is rising every day but not double it is ectopic

Question 13

What symptoms of ectopic should be screened for in women with PV bleeding that are/ could be <15w pregnant?

Answer 13

Abdo or pelvic pain.
Gastro Sx: N+V
Dizziness, fainting or syncope.
Shoulder tip pain.
Urinary Sx
Passage of tissue.
Rectal pressure or pain on defecation

Question 14

What signs of ectopic should be screened for in women with PV bleeding?

Answer 14

Abdominal tenderness
Pelvic tenderness
Adnexal tenderness.

Question 15

Give 2 pregnancy-related conditions that can cause bleeding in the 1st +2nd trimesters

Answer 15

Ectopic

Molar pregnancy

Question 16

Give 3 features that may indicate a molar pregnancy

Answer 16

Bleeding heavy + prolonged
Sx of pregnancy exaggerated
Uterus large for dates

Question 17

Give 3 pregnancy-related conditions that can cause abdominal pain in the 1st + 2nd trimesters

Answer 17

Ruptured ovarian corpus luteal cyst.
Adnexal torsion.
Pregnancy-related degeneration of a fibroid “red degeneration”

Question 18

List 6 non-pregnancy-related conditions that can cause bleeding in early pregnancy

Answer 18

Cervicitis, cervical ectropion, or cervical polyps.
Haemorrhoids
TRAUMA of cervix, vagina, or vulva.
Urethral bleeding.
Vaginitis.
CANCER of cervix, vagina, or vulva.

Question 19

Give 6 non-pregnancy-related conditions that can cause abdominal pain in early pregnancy

Answer 19

MSK pain
Gastro: IBS, constipation
UTI/ Renal colic
PID
Ovarian cyst
Torsion of a fibroid

Question 20

Which symptoms in combination with a positive pregnancy test require immediate admission to early pregnancy unit?

Answer 20

Abdominal pain + tenderness, or

Pelvic tenderness, or

Cervical motion tenderness.

Question 21

If there is no abdominal pain and tenderness, pelvic/ cervical motion tenderness and the woman is >,6w pregnant or of uncertain gestation how should they be managed?

Answer 21

Refer to early pregnancy assessment unit
(urgency of referral depends on clinical presentation)

Question 22

When should you arrange immediate ambulance transfer to hospital for a woman presenting with bleeding or any other Sx suggestive of an early pregnancy complication ?

Answer 22

If haemodynamic instability: pallor, tachycardia, hypotension, shock, + collapse.

If significant concern about the degree of bleeding or pain.

Question 23

What happens if viability of an IU pregnancy can’t be established because the fetus is of insufficient size for a heartbeat to be visualized?

Answer 23

Repeat after min. 7d

Question 24

How should women with threatened miscarriage be managed?

Answer 24

If bleeding worsens, or persists beyond 14d, she should have a further clinical assessment.

If bleeding stops, she should start or continue routine antenatal care.

Question 25

What is conservative management for miscarriage?

Answer 25

If bleeding + pain settle (suggesting complete miscarriage), take a pregnancy test after 3w Return to the hospital if it is positive. Offer medical/ surgical Mx if >14d persistent Sx

Question 26

In which 4 scenarios is conservative management inappropriate?

Answer 26

Increased risk of haemorrhage (e.g. pregnancy is in late 1st trimester) Previous adverse +/or traumatic experience a/w pregnancy: stillbirth, miscarriage, or APH Increased risk from effects of haemorrhage: coagulopathy or is unable to have a blood transfusion Evidence of infection.

Question 27

What is the medical management for miscarriage?

Answer 27

Misoprostol: oral or PV Pregnancy test after 3w + return if positive.

Question 28

What is the mechanism of action of misoprostol in the management of miscarriage?

Answer 28

Prostaglandin analogue, binds to myometrial cells Causes strong myometrial contractions leading to the expulsion of tissue

Question 29

When may surgical management of miscarriage be more appropriate?

Answer 29

If RPOC despite medical Tx or if ongoing Sx after 14 days of expectant Mx

Question 30

What are the options for surgical management of miscarriage?

Answer 30

Vacuum aspiration: LA as OP. "Suction curettage" Surgical Mx in Theatre: GA "evacuation of RPOC"

Question 31

When should anti D be given? (10)

Answer 31

Invasive prenatal dx: amniocentesis, CVS APH ECV of fetus (inc. attempted). Ectopic (regardless of Mx) Evacuation of molar pregnancy. Intrauterine death + stillbirth. Intrauterine procedures (eg, insertion of shunts, embryo reduction). Miscarriage or threatened miscarriage >12w gestation. Therapeutic TOP (regardless of gestation, inc. Miscarriage <12w with med/ surgical Mx) Delivery: normal, instrumental or caesarean section.

Question 32

What are complications of a miscarriage?

Answer 32

Incomplete evacuation of the uterus can result in placenta accreta in subsequent pregnancies Post-evacuation uterine bleeding Recurrent miscarriage Asherman's syndrome Psychological dysfunction

Question 33

When can women try again for a baby?

Answer 33

After the first negative pregnancy test, wait one cycle.

Question 34

What are risk factors for miscarriage?

Answer 34

Maternal age Previous miscarriage Paternal age

Question 35

What is an ectopic pregnancy?

Answer 35

fertilised ovum implanting + maturing outside the uterine cavity.

Question 36

Where do most ectopics implant?

Answer 36

Ampulla of fallopian tube

Question 37

Where are ectopic pregnancies more dangerous?

Answer 37

Isthmus

Question 38

Give 7 RFs for ectopic pregnancy

Answer 38

Tubal damage: PID, surgery Previous ectopic Endometriosis IUCD POP Maternal age >35y Smoking No identifiable cause in 1/3

Question 39

Give 3 complications of ectopic pregnancy

Answer 39

Tubal rupture (potentially fatal if Tx is delayed). Recurrent ectopic pregnancy. Grief, anxiety, or depression.

Question 40

Give 6 symptoms of ectopic pregnancy

Answer 40

6-8w amenorrhoea Lower abdo pain (constant +/- unilateral) PV bleeding (less than normal period) Shoulder tip pain/ pain on defecation/ urination (peritoneal bleeding) Dizziness, fainting, syncope Sx of pregnancy- breast tenderness

Question 41

Give 2 signs of ectopic pregnancy

Answer 41

Pelvic + abdominal tenderness. Cervical excitation

Question 42

What should be avoided when examining a patient with suspected ectopic?

Answer 42

DONT palpate for an adnexal or pelvic mass as this may increase the risk of rupture of an ectopic pregnancy if present.

Question 43

Where are women with a suspected ectopic pregnancy managed?

Answer 43

Stable: Investigated + managed in EPAU Unstable: refer to ED

Question 44

What is the investigation of choice for an ectopic pregnancy?

Answer 44

TVUSS (Pregnancy test: +ve)

Question 45

Which criteria must be fulfilled for an ectopic pregnancy to be managed expectantly?

Answer 45

<35mm Unruptured Asymptomatic No fetal heartbeat hCG <1000 IU/L

Question 46

Which criteria must be fulfilled for an ectopic pregnancy to be managed medically?

Answer 46

<35mm Unruptured No significant pain No fetal heartbeat hCG <1500 IU/L

Question 47

Which criteria must be fulfilled for an ectopic pregnancy to be managed surgically?

Answer 47

>35mm Can be ruptured Pain Visible fetal heartbeat hCG >5000 IU/L

Question 48

Which forms of management are compatible with another intrauterine pregnancy?

Answer 48

Expectant Surgical

Question 49

What does expectant management of ectopic involve?

Answer 49

close monitoring over 48h If B-hCG levels rise again or Sx manifest intervention is performed.

Question 50

What is medical management of ectopic?

Answer 50

Methotrexate (parenteral) Patient must attend f/u

Question 51

What is surgical management of ectopic?

Answer 51

Salpingectomy: 1st line if no other RF for infertility Salpingotomy: consider if RFs for infertility e.g. contralateral tube damage

Question 52

What is salpingectomy and salpingotomy?

Answer 52

Salpingectomy: Fallopian tube removal Salpingotomy: incision. Preservation of tube.

Question 53

What is termination of pregnancy?

Answer 53

Medical/ surgical way of ending a pregnancy

Question 54

What are the requirements for TOP to be legal?

Answer 54

Before 24w 2 registered medical practitioners must sign a legal document (in an emergency only 1 is needed) Only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise

Question 55

How quickly should TOP be performed?

Answer 55

Should not have to wait >2w from 1st referral to time of abortion.

Question 56

Give 5 contraindications to medical TOP

Answer 56

Known/ suspected ectopic pregnancy Previous allergic reaction to mifepristone or misoprostol Severe uncontrolled asthma Chronic adrenal failure Inherited porphyria

Question 57

What is medical TOP?

Answer 57

Mifepristone followed 48h later by misoprostal

Question 58

What is the MOA of Mifepristone and Misoprostal?

Answer 58

Mifepristone: anti-progesterone- cervical ripening + sensitisation to prostaglandin induced contractions Misoprostal: Prostaglandin analogue- stimulates uterine contraction

Question 59

Where is medical TOP performed?

Answer 59

<12w: At home >12w: medical facility preferred

Question 60

What is the most effective regimen for medical TOP?

Answer 60

Mifepristone 200mg orally, followed 24–48h later by Misoprostol 800 micrograms taken by the vaginal, buccal or sublingual route.

Question 61

In medical TOP, if expulsion of the pregnancy has not occurred within 4h, what should be done?

Answer 61

A further 400 micrograms of misoprostol should be taken by the vaginal, buccal or sublingual route.

Question 62

What is surgical TOP?

Answer 62

<14w: vacuum aspiration >14w: dilation + evacuation

Question 63

What is vacuum aspiration for TOP?

Answer 63

Cervical preparation If <14w can be done with LA if chosen (or sedation/ GA)

Question 64

What is dilation + evacuation for TOP?

Answer 64

Cervical preparation GA Forceps + vacuum aspiration Safest + most effective method >14w

Question 65

What preparation is required before surgical TOP?

Answer 65

<12w: Mifepristone or Misoprostal >12w: Mifepristone + Misoprostal + Osmotic dilators

Question 66

What dose of anti-D should be given if <20w gestation?

Answer 66

250 IU No need to screen for FMH

Question 67

What dose of anti-D should be given if >20w gestation?

Answer 67

500 IU Kleihauer test required