Miscarriage

Question 1

What is this?
→ How is it classified?
→ When do most (>95%) occur?

What are most due to?

How does it present?
→ How does this differ from an Ectopic?

Answer 1

➊ Involuntary loss of a pregnancy before the point of viability (<24 wks)
→ Early is <12 wks. Late is 12-24 wks.
→ < 12 wks

➋ Idiopathic or chromosomal abnormalities

➌ • PV Bleeding – usually light, but can be heavy
• +/- Pain – usually mild cramp, but can be severe
• Can be asymptomatic
→ Bleeding comes before the pain!

Question 2

Types:
What is a Threatened m/c?
→ What does TVUS show?

What is an Inevitable m/c?
→ What does TVUS show?

What is a Complete m/c?
→ What does TVUS show?

What is an Incomplete m/c?
→ What does TVUS show?
→ Why does this need to be managed quickly?

What are the other rarer types?

Answer 2

➊ PV bleeding w/viable pregnancy – Actually NOT a m/c, but there is a threat to miscarry
→ Intrauterine pregnancy

➋ Heavy bleeding and pain and open cervix – As cervix is open, the m/c is inevitably going to happen
→ Intrauterine pregnancy

➌ PV bleeding and pain, which settles down as tissue is spontaneously passed
→ Endometrial thickness <15mm and homogenous with no irregular echogenicity. No retained products of conception.

➍ PV bleeding and pain, which doesn’t settle down as tissue doesn’t spontaneously pass
→ Endometrial remains inhomogeneous with increased echogenicity
→ Retained products increases the risk of infection (commonly endometritis, which present as 2º PPH)

➎ * Delayed miscarriage – Asymptomatic, or may have mild bleeding +/or cramp
‣ Presence of foetus crown-to-rump length (CRL) >7mm w/no cardiac activity
‣ Pregnancy is no longer viable but there’s a delay to it happening
* Anembryonic miscarriage - Asymptomatic, or may have mild bleeding +/or cramp
‣ Presence of gestational sac w/o a visible foetus
* Septic miscarriage – m/c in presence of clinical signs of intrauterine infection

N.B. Closed os = consonants (threatened, complete, missed). Open os = vowels (inevitable, incomplete)

Question 3

Management:
What is the 1st line option?
→ What are its pros and cons?
→ When is it not an appropriate option?

What is the Medical option?
→ How does this work?
→ What are its pros and cons?

What are the surgical option?
→ What needs to be given with this?
→ What are its pros and cons?
→ What is done to reduce the risk of complications?

Answer 3

➊ Conservative - Letting m/c occur naturally
→ • Pros – Natural, No harm from drugs/anaesthesia/surgery, Most prefer it
• Cons – Can take longer, Uncertainty and anxiety, Some prefer active Rx, Psychologically worse
→ When heavy ongoing bleeding, signs of infection, or mother’s choice of active Rx

➋ Misoprostol (Prostaglandin E1) 800mcg PV/PO
‣ Mifepristone (anti-progesterone) is another option
→ Induces uterine action and contractions to induce m/c, and ripens cervix
→ • Pros – Mimics “natural” m/c, No harm from anaesthesia/surgery, Most prefer it
• Cons – SE (Diarrhoea, N+V), Might need a repeat dose, May not work (10%)

➌ • Manual vacuum aspiration (MVA) under LA
• Surgical evacuation under GA
→ Anti-RhD prophylaxis to Rh -ve women
→ • Pros – Quick, Usually easy and safe, MVA avoids GA risks, Control over timing
• Cons – GA risk, risk of infection/uterine perforation/incomplete procedure
→ • Misoprostol 400mcg 2 hrs before – cervical ripening (softens and opens)
• TVUS pre and post procedure – check uterus is empty
• Prophylactic Abx

Question 4

Recurrent Miscarriage:
What is this defined as?

What are its risk factors?

What is the main cause in older women?

What is an important cause to look out for?
→ What occurs here?
→ How is it diagnosed?
→ How is it managed?

What are other less common causes?

Answer 4

➊ 3+ consecutive m/c’s

➋ • Maternal age
• Paternal age >40
• Previous miscarriage
• Smoking/Caffeine
• Raised BMI
• Heavy alcohol

➌ Idiopathic

➍ Antiphospholipid Syndrome (15%)
→ Inhibits trophoblastic function → Local inflammation → Thrombosis of uteroplacental vasculature
→ Lupus anticoagulant or Anticardiolipin antibody (2 +ve’s of 12 wks apart)
→ Aspirin 75mg + LMWH (Reduces miscarriage rate by 54%)

➎ • Chromosomal Rearrangements (2-5%)
• Uterine Abnormalities (2-3%)
• Cervical Incompetence
• Hereditary Thrombophilia – Factor V Leiden, Protein S deficiency, Prothrombin (FII) gene mutation
• Other - DM (Poor control), Untreated thyroid disease, PCOS, SLE