Miscarriage

Question 1

What are causes of bleeding in early pregnancy?

Answer 1

• miscarriage.
• ectopic pregnancy
• gestational trophoblastic disease.
• rarely, gynaecological lower tract pathology (e.g. Chlamydia infection, cervical cancer, or a polyp).

Question 2

How common is miscarriage in pregnancy?

Answer 2

Miscarriage is common, occurring in at least 15–20% of pregnancies.

Question 3

What percentage of conceptions miscarry (potentially)?

Answer 3

40% of all conceptions.

Question 4

What are two key investigations in the diagnosis off problems in early pregnancy?

Answer 4

transvaginal ultrasound
serum hCG estimations

Question 5

What investigation definitively diagnoses miscarriage?

Answer 5

transvaginal ultrasound (TVS)

Question 6

What is a threatened miscarriage?

Answer 6

an ongoing pregnancy with vaginal bleeding, indicating the possibility of miscarriage

Question 7

What is a complete miscarriage?

Answer 7

a loss of pregnancy where all pregnancy tissue has left the uterus

Question 8

What is an incomplete miscarriage?

Answer 8

a loss of pregnancy where some of the pregnancy tissue remains in the uterus

Question 9

What is a missed miscarriage?

Answer 9

a loss of pregnancy where the embryo or fetus has dies without bleeding or pain, and the embryo has stayed in the uterus

Question 10

What is an inevitable miscarriage?

Answer 10

when bleeding has commenced and the cervical os is open but pregnancy tissue remains in the uterus

This will proceed onto an incomplete or complete miscarriage.

Question 11

What is a recurrent miscarriage?

Answer 11

when there have been three or more consecutive miscarriages (losses of pregnancy before 24 weeks)

Question 12

When are further investigations to invesigate the cause of a miscarriage performed?

Answer 12

after three or more consecutive miscarriages.

Question 13

What clinical signs indicate a threatened miscarriage?

Answer 13

• PVB ± pain
• Closed cervix

Question 14

What are the typical ultrasound findings of a threatened miscarriage?

Answer 14

• intrauterine gestation sac
• fetal pole
• fetal heart +ve

Question 15

What are the clinical signs of a complete miscarriage?

Answer 15

• bleeding and pain
  cease
• closed cervix

Question 16

What are the ultrasound findings of a complete miscarriage?

Answer 16

• empty uterus
• endometrial thickness <15
  mm

Question 17

How would you manage a threatened miscarriage?

Answer 17

• if >12wks, heavy PVB or pain; anti-D
• if PVB persists >2wks, attend for TVS

Question 18

What clinical signs would you expect for an incomplete miscarriage?

Answer 18

• Bleeding ± pain
• possible open
  cervix

Question 19

What ultrasound signs would you expect for an incomplete miscarriage?

Answer 19

• heterogeneous tissues ±
  gestation sac
• any endometrial thickness

Question 20

What manangement would you offer all miscarriages after 12 weeks?

Answer 20

anti-D prophylaxis

Question 21

What differentials should you consider in a woman with complete miscarriage but persistent per vaginal bleeding?

Answer 21

• endometritis
• retained products of conception

Question 22

What clinical findings would you expect in a missed miscarriage?

Answer 22

• bleeding ± pain ±
  loss of pregnancy
  symptoms
• closed cervix

Question 23

What ultrasound findings would you expect in a missed miscarriage?

Answer 23

• Fetal pole >7 mm with no
  fetal heart
• Mean gestation sac diameter >25 mm with no
  fetal pole or yolk sac

Question 24

How many clinicians does it require to diagnose a missed miscarriage?

Answer 24

two | if not available, a rescan can be performed in 7 days

Question 25

What clinical findings are associated with an inevitable miscarriage?

Answer 25

* Bleeding ± pain * Open cervix

Question 26

What ultrasound findings are associated with an inevitable miscarriage?

Answer 26

intrauterine gestation sac ± fetal pole ± fetal heart activity

Question 27

What is a pregnancy of unknown location?

Answer 27

a pregnancy where a urine pregnancy test is positive but there is no evidence of intrauterine pregnancy on the scan

Question 28

What are the possible causes of a pregnancy of unknown location?

Answer 28

1. Ectopic pregnancy 2. Early pregnancy (dates wrong/too small to see yet) 3. A completed miscarriage

Question 29

What tertiary investigation is performed after a woman experiences a third consecutive miscarriage?

Answer 29

cytogenetics

Question 30

What ultrasound findings exclude a patient from having conservative management of miscarriage?

Answer 30

* a crown-rump length >25mm * a mean sac diameter > 50mm

Question 31

What clinical findings exclude a patient from having conservative management of miscarriage?

Answer 31

* pyrexia * tachycardia – suggesting infection * very heavy menstrual bleeding

Question 32

What medical conditions/past history exclude a patient from having conservative management of miscarriage?

Answer 32

* any conditions associate with immunocompromise * any associated risk of haemorrhage – coagulopathy * sickle cell disease * diabetes (a relative indication) * any previous adverse/traumatic experiences associated with pregnancy

Question 33

What ultrasound findings exclude a patient from having conservative management of miscarriage?

Answer 33

* fetal pole >22mm or gestational sac >50mm

Question 34

What should you advise a women to expect after taking tablets to medically manage miscarriage?

Answer 34

Most women experience their heaviest bleed after 4-6 hrs. It can last up to 12 hours.

Question 35

How long can bleeding persist after giving mifepristone and misoprostol to manage a miscarriage?

Answer 35

3 weeks