Miscarriage Flashcards
(27 cards)
Define miscarriage (+early and late)
spontaneous termination <24 weeks gestation
Early <12 weeks
Late >12 weeks
What are the causes of miscarriages
Chromosome abnormalities (first trimester) e.g. foetal abnormalities/placental abnormalities
Genetic abnormalities /defects in embryo/placenta development
Cervical incompetence e.g. from cone biopsy/LLETZ
Thrombophillic disorders e.g. APS, thrombophilia, factor V leiden
Medical endocrine disorders e.g. uncontrolled diabetes, PCOS, hyperprolactinaemia, thyroid disorder
Infections
Assisted reproduction
Lifestyle: Drugs/chemicals, smoking, alcohol
What are the risk factors for miscarriage
Advanced maternal age (Risk increases with age)
Previous miscarriages
Extremes of weight
Uterine abnormalities e.g. bicornuate, unicornuate, septate, didelphys
Bacterial vaginosis
Advanced paternal age
What are the types of miscarriage
Incomplete
Complete
Missed
Inevitable
Threatened
Describe incomplete miscarriage
RPOC remains in the uterus
Vaginal bleeding and cramps
Dilated cervical os
No foetus/FH on scan with visible POC
Describe complete miscarriage
All POC has been evacuated from the uterus
Vaginal bleeding and cramping
Cervical os closed
POC completely expelled, no FH, empty sac
Describe missed miscarriage
The pregnancy has terminated but the mother had no symptoms
No vaginal bleeding or cramps
Cervical os closed
POC completely expelled, no FH, empty sac
Describe inevitable miscarriage
Miscarriage will occur, POC may be seen or felt at or above the cervical os.
Vaginal bleeding and cramps
Cervical os dilated
POC may be present
Describe threatened miscarriage
May become/remain a viable pregnancy or not
Vaginal bleeding and cramps
Cervical os closed and soft
FH activity can be seen
Wha proportion of pregnancies are results in miscarriage
10-20% of pregnancies
What are the symptoms of miscarriage
Asymptomatic
Vaginal bleeding: Scanty, brown discharge or bright red bleeding
Lower cramping abdominal pain
Lower back ache
Abdominal/pelvic/suprapubic pain
GI: N&V
Dizziness, fainting, syncope
Shoulder tip pain (referred)
Urinary symptoms
Passage of tissue
What are the differentials for miscarriage
Ectopic pregnancy
Molar pregnancy
Vaginal trauma
Cervical ectropion
Cervical cancer
What investigations should be done for miscarriage
A-E approach
Bedside: urine dip, pregnancy test
Bloods: FBC, G&S, Rhesus status, U&Es, Beta-hCG
Other:
- TVUSS: must always have a second opinion
Describe the process in which a miscarriage is diagnosed on USS
Is there a FH
Yes → re-assure, follow up
No→ measure CRL
CRL >7mm → call second sonographer to confirm → re-scan in 1 week
CRL <7mm → may be pre-viable → repeat in 7-14 days
No foetal pole → measure MSD
MSD >25mm → call second sonographer to confirm → re-scan in 1 week
MSD <25mm → may be pre-viable → repeat in 7-14 days
What are the outcomes of an USS
Viable intrauterine pregnancy (VIUP)
Miscarriage
Pregnancy of unknown viability (PUV) - gestational sac, no foetus seen
Pregnancy of unknown location (PUL)
How do you decide which management is needed for miscarriage
Expectant: first line, bleeding with no pain
Medical:
- Evidence of infection
- Increased risk of haemorrhage (late first trimester, coagulopathy)
- Previous adverse experience
Surgical
- Persistent excessive bleeding
- Haemodynamic instability
- Evidence of infection
- Preferred option
Describe expectant management (process, follow up)
Wait 7-14 days for events
Safety netting advice (continued bleeding, other symptoms)
Expect bleeding, pain, diarrhoea, vomiting
Repeat pregnancy test in 3 weeks to check the miscarriage it has passed. If the test is till positive, the woman should return
Repeat TVUSS
What are the benefits and risks of expectant management for miscarriage
70-80% success rate
Avoids complications from surgery/medicines
No difference in pain or infection
Patient satisfaction is greater compared to the medical option
Risks
Risk of blood transfusion
Unplanned admission/surgery
Longer duration of bleeding
Describe medical management for miscarriage (procedure and follow up)
Misoprostol PV 800mcg (Missed) or 600mcg (incomplete)
Start within 24 hours of diagnosis
Accompany with analgesia + anti-emetic
Counsel women on what to expect
Safety netting (as above)
Expect bleeding, pain, diarrhoea, vomiting
Urinary pregnancy test 3 weeks after treatment
What are the benefits and risks to medical management of miscarriage
84% success rate
More predictable than expectant method
Avoids the risks of surgery
Satisfaction rates and infection the same as surgery
GI side effects (Nausea, diarrhoea)
Longer pain/PV bleeding than surgery
Risk of unplanned admission
Not always successful - around 15% failure rate
What are the options for surgical management of miscarriage
Surgical management of miscarriage (SMM) >14 weeks
- Performed under GA in theatre
- Suction and curettage of tissue, sent for histology
- No incisions
- Cervix dilated gradually using dilators, followed by vacuum aspiration and curettage
Manual vacuum aspiration (MVA) <14 weeks
- Can be done in OP setting under LA
- LA applied to the cervix. A tube attached to a specially designed syringe is inserted through the cervix into the uterus. Syringe used to aspirate contents of the uterus.
- It is more appropriate for women that have previously given birth (parous women).
What are the benefits and risks of surgical management of miscarriage
97% success rate
Most predictable method
Shorter duration of pain/bleeding
MVA has a reduced waiting time, hospital stay and avoids GA
Uterine perforation (0.5%)
Cervical trauma
Bleeding
Infection
Need for repeat procedure
Asherman’s syndrome
What extra considerations should be added to management for all women regardless of method of miscarriage management
Anti-D in non-sensitised Rh -ve women
- >12 weeks in any woman with bleeding
- <12 weeks with uterine evacuation (Surgical management) or ectopic pregnancies
It should be given within the first 72 hours following surgery
Emotional support
Time to process
Leaflets
Miscarriage association website
Support groups
Define recurrent miscarriage
Three of more consecutive, spontaneous miscarriages occurring in the first trimester with the same biological father, which may or may not follow a successful birth
