Miscarriage Flashcards by Kirsty Sutherland

What is a miscarriage?

Spontaneous loss of pregnancy before 24 weeks of gestation

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When do most miscarriages tend to occur?

In the first trimester

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What percentage of all women who become pregnant will have 1 or more miscarriages?

25%

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What is the major cause of first trimester miscarriages?

Chromosomal abnormalities

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What percentage of the population has recurrent miscarriages?

About 1%

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What classifies as recurrent miscarriage?

3 or more consecutive miscarriages

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What is an early miscarriage?

<13 weeks

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What is a late miscarriage?

13-24 weeks

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What types of miscarriages are there?

Threatened
Inevitable
Incomplete
Complete 
Septic 
Missed

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Describe a threatened miscarriage

Bleeding and or pain up to 24/40m but TVUSS shows a foetal heart (viable pregnancy)
Closed cervical os
75% will settle
Carry high risk of preterm delivery and preterm rupture of membranes

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Describe an inevitable miscarriage

Non viable pregnancy
Vaginal bleeding (heavy, clots, pain) 
Open internal cervical os 
Products of conception have not been passed, but they inevitably will

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Describe an incomplete miscarriage

Some products of conception passed
Some tissues and blood remain within uterus
Cervix stays open until all tissue passed

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Describe a complete miscarriage

All products of conception passed
History of bleeding, passing clots and POC and pain that have now stopped
Cervix closed
No POC seen in uterus with endometrium than is <15mm diameter and previous proof of intrauterine pregnancy ie scan

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What is a missed (delayed) miscarriage?

A gestational sac which contains a dead fetus before 20 weeks without symptoms of expulsion
Mother may have light bleeding/discharge
Cervical os closed
When the gestational sac >25mm and no fetal part can be seen - described as a blighted ovum or anembryonic pregnancy

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What causes are there?

In most cases no identifiable cause
Abnormal fetal development - chromosomal and structural abnormalities (trisomy = most common abnormality, trisomy 16 especially)
Maternal conditions:
- infections e.g BV, CMV, rubella, HSV, toxoplasmosis, parvovirus B19
- antiphospholipid syndrome
- SLE
- thrombophilia
- endocrine problems e.g PCOS, thyroid disease, DM, hyperprolactinaemia
- genetic abnormalities in the parents
Uterine conditions
Incompetent cervix - previous cervical surgery
Iatrogenic - amniocentesis, CVS
Social factors - smoking, alcohol, cocaine

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What uterine factors can cause miscarriages?

Septate, bicornuate or acute uterus can affect development of growing foetus
Cervical incompetence- not allowing normal development
Fibroids - can distort the uterus

What risk factors are there?

Advanced maternal age
Previous miscarriage (especially 2)
Lifestyle - smoking, obesity, alcohol, drug use (NSAIDS and street drugs)
Folate deficiency e.g methotrexate
Consanguinity
Paternal factors - tight (bottom) clothing, sperm abnormalities, old paternal age
Environmental- high dose radiation, heavy metal exposure

Describe the pathophysiology

Haemorrhage occurs in the decidua basalis leading to necrosis and inflammation
Ovum unable to continue development- initiates uterine contractions, cervix dilates causing loss of fetus and pregnancy tissue

Why is a complete miscarriage more likely before 12 weeks?

The placenta is unlikely to have been independently developed - thus being expelled with fetus

Why is an incomplete miscarriage more likely to occur if the miscarriage occurs between 12-24 weeks?

The gestation sac is more likely to rupture and the fetus then expelled while parts of the placenta remain in the uterus

What are the clinical features?

Vaginal bleeding - vary from brownish light spotting to heavy bright red blood with clots
Lower abdominal cramping pain
Vaginal fluid/discharge/tissue discharge
Loss of pregnancy symptoms - no more nausea, breast tenderness
Lower back pain
A missed miscarriage often does not present with any symptoms

What investigations should be done?

Urine pregnancy test
Transvaginal USS - if unable to determine status of fetus a repeat scan will be done after minimum 7 days
If the crown rump length is <7mm and no fetal heart, a conclusive diagnosis of miscarriage cannot be made - so repeat scan in at least 7 days
Serum beta-human chorionic gonadotropin (bhCG) levels
FBC, blood group and rhesus status
Triple swabs and CRP if pyrexial

If serum bhCG is > 1500 and nothing seen in uterus, what does this suggest?

Chances of ectopic high

If bhCG level is low what should be done?

Further bhCG 48 hours later - establish if pregnancy developing properly
A rise by 63% - most likely intrauterine pregnancy, but 10% of ectopics have a normally rising bhCG so should not be falsely reassured - bring patient back 1 week later for USS

If second bhCG does not rise by 63%, what is likely?

Ectopic | Could be intrauterine not developing properly

What produced bhCG?

The placenta, so bhCG levels will decrease after miscarriage

What differentials are there?

``` Ectopic pregnancy - but pain usually unilateral, more severe and before bleeding presents, bleeding darker and less heavy Molar pregnancy Ruptured ovarian corpus luteum cyst Ovarian torsion Fibroid degeneration ``` ``` Non pregnancy related: Cervicitis Cervical ectropian Cervical polyps Cancers Haemorrhoids ```

What 3 types of management options are there?

Expectant Medical Surgical

Describe the expectant approach

Waiting for spontaneous miscarriage Waiting for 7-14 days Need 24 hour access to gynae services Advantages: at home, avoid risk of surgery/medication Disadvantages: pain and bleeding unpredictable, takes longer, may be unsuccessful Follow up: repeat scan in 2 weeks or pregnancy test 3 weeks later

Describe medical management

Drugs used to encourage pregnancy to come away Vaginal misoprostol - prostaglandin analogue Stimulates cervical ripening and myometrial contractions Give with antiemetics and pain relief Advantages: avoid surgery, done as outpatient Disadvantages: pain and bleeding, side effects of drug, 5% emergency SERPC Follow up: pregnancy test 3 weeks later

How does misoprostol work?

Binds to myometrial cells for cause strong contractions leading to expulsion of tissue

What is the surgical option?

Suction curette to empty uterus 5 minutes under GA Can do via local - NVA

What are the disadvantages of surgical option?

Perforation of bowel/bladder Cervix damage Asherman’s Anaesthesia risk

What complications can occur with miscarriage?

Incomplete Haemorrhagic shock due to excessive bleeding Infection - retained tissue Psychological complications HDN - give anti-D to Rhesus neg women who have had surgical intervention Increased risk of another miscarriage

What should be done 3 weeks after medical management?

Pregnancy test | If positive return for a review to ensure there is no molar or ectopic pregnancy

How should a threatened miscarriage be managed?

If heavy bleeding, admit/observe, if not reassure and back to GP/midwife If more than 12w and rhesus negative: anti D

When can fetal cardiac activity be observed via TVUSS?

5 and 1/2 to 6 weeks gestation

Who required anti d prophylaxis?

Rhesus neg women, fetus greater than 12w gestation or managed surgically

When may you be advised to have surgery immediately?

Heavy bleeding Signs of infection Coagulopathy or unable to have blood transfusion