Miscarriage (Complete)

Question 1

Define miscarriage

Answer 1

Intrauterine loss of pregnancy prior to 24 weeks gestation

Question 2

What percentage of pregnancies lead to miscarriage?

Answer 2

10%-20%

(1 in 5)

Question 3

What are the main causes of miscarriage?

Answer 3

Maternal factors:

Old age

Infections (e.g. bacterial vaginosis)

Uterine abnormalities

• Septate uterus
• Uterine fibroids
• Intrauterine adhesions

Cervical incompetence

PCOS

Poorly controlled diabetes

Anti-phospholipid syndrome

Poorly controlled thyroid disease

Foetal factors:

Genetic disorders

Abnormal development (e.g. neural tube defecs, anencephaly)

Placental failure

Often cases are IDIOPATHIC

Question 4

What are the most common causes of first-trimester pregnancy?

Answer 4

Chromosomal abnormalities

Question 5

What is a common cause of late miscarriages?

Answer 5

Bacterial vaginosis

Question 6

What are the 5 main types of miscarriage?

Answer 6

Missed miscarriage

Threatened miscarrage

Inevitable miscarriage

Incomplete

Complete miscarriage

Question 7

What is considered missed miscarriage?

Answer 7

Woman is assymptomatic (hence missed)

Cervical os closed

Uterus contains foetal tissue but no foetal cardiac activity

Question 8

What is considered threatened miscarriage?

Answer 8

Mild symptoms of bleeding

Foetus retained within the uterus

Cervical os closed

Ultrasound reveals that there is an intrauterine foetus present.

There is the “threat” of a miscarriage, but it is not certain

Question 9

What is considered inevitable miscarriage?

Answer 9

Cervical os open

Heavy bleeding and pain

Foetus felt/seen on US

Question 10

What is considered incomplete miscarriage?

Answer 10

Cervical os open

Heavy bleeding and pain

Presence of some foetal products

Question 11

What is considered complete miscarriage?

Answer 11

All products of conception expelled (empty uterus)

Cervical os closed

Patient may have been alerted to the miscarriage by pain and bleeding.

Question 12

What are the main clinical features of miscarriage?

Answer 12

Vaginal bleeding (variable)

• Brownish light spotting
• Heavy bright red with clots

Abdominal pain

• Lower
• Cramping

Vaginal fluid/tissue discharge

Lower back pain

Question 13

What investigations should be conducted in patients suspected of having a miscarriage?

Answer 13

Bedside:

Speculum examination: Check for passage of content and cervical os opening

Pregnancy test: Can consider if patient not aware of pregnancy

Bloods:

FBC: Check for anaemia

Beta-hCG: Falling titres

Serum progesterone: Assess risk of miscarrige in threatened miscarriage (low levels –> high risk)

Imaging:

Trans-vaginal ultrasound: Check for foetal content / loss of foetal hearbeat

Question 14

What US findings can confirm miscarriage?

Answer 14

Foetal absence of heartbeat and either:

Crown-rump length >7

Gestational sac >25mm with no yolk sac or foetal pole

• Somtimes known as ‘anembryonic pregnancy’ or ‘blighted ovum’

CR7

Question 15

If transvaginal US findings are uncertain (e.g. < 8 weeks), what additional investigations should be conducted?

Answer 15

Repeat US after a minimum of 7 days

Question 16

Why should transvaginal US should be performed twice (at least 7 days between eachother?)

Answer 16

Findings arent 100% reliable (especially in earlier gestational periods)

N.B. If >8 weeks (e.g. 12 weeks) then initial findings likely to be miscarriage

Question 17

When should serial beta-hCG levels be considered?

Answer 17

If pregnancy of uncertain location or ectopic suspected

In miscarriage there is downtrending levels >50% after 48 hours

Question 18

What beta-hCG levels after 48 hours is suggestive of ectopic pregnancy versus miscarriage?

Answer 18

beta-HCG fail to decrease >50% over 48 hours

OR

beta-HCG rises less than >50/63% in 48 hours

Question 19

What beta-hCG levels after 48 hours is suggestive of progressing pregnancy versus miscarriage?

Answer 19

beta-hCG levels rise >50/63% over 48 hours

Question 20

What additional investigations should be considered if patient has recurrent miscarriages (3 or more)?

Answer 20

Lupus anticoagulant/anticardiolipin antibodies : Check for Antisphopholipid syndrome

Parental karyotype

Cytogenetic analysis on products of conception

Question 21

For patients with antiphospholipid syndrome, what medication is given to reduce risk of miscarriage?

Answer 21

Low-dose aspirin and LMWH

Started pre-pregnancy and continued until 6 weeks post-partum

Question 22

What is the first-line management of miscarriage?

Answer 22

Expectant management: waiting for 7-14 days for the miscarriage to complete spontaneously

Question 23

What are the main features of expectant management?

Answer 23

Written and verbal information on expectant management

Analgesia

Monitor for 7-14 days

Offer repeat transvaginal US if incomplete pregancy suspected:

• Pain and bleeding symptoms have not started after 7-14 days
• Pain and bleeding symptoms not resolved/worsening after 7-14 days

Pregnancy test to use after 3 weeks of resolution of pain/bleeding during moinitoring period, if positive required return

Question 24

What should be advised for woman who have a positive pregnancy test >3 weeks since symptoms resolved?

Answer 24

Advised to return (suggests incomplete miscarriage)

Question 25

When should repeat transvaginal ultrasound be offered?

Answer 25

Pain and bleeding symptoms have not started after 7-14 days Pain and bleeding symptoms not resolved/worsening after 7-14 days Positive pregnancy test after 3 weeks ## Footnote Suggests incomplete miscarriage

Question 26

Medical/surgical management is given first-line in which individuals? (4)

Answer 26

Increased risk of haemorrhage (e.g. late first trimester) Increased risks of effects of haemorrhage (e.g. coagulopathy) Previous traumatic pregnancy experiences (e.g. miscarriage, stillbirth) Evidence of infection ## Footnote Woudl require medical/surgical interventions

Question 27

There is increased risk of haemorrhage from miscarriage if occuring in which stage of pregnancy?

Answer 27

Late first trimester

Question 28

When is medical management offered for miscarriage?

Answer 28

Ongoing symptoms after expectant management Expectant management clinically inappropriate

Question 29

How are woman with miscarriage medically managed?

Answer 29

**_Missed miscarriage_**: * 200 mg oral mifepristone * 800 **micrograms** misoprostol (vaginal, oral or sublingual) **48 hours later** **_Incomplete miscarriage_**: * 600-800 micrograms misoprostol (vaginal, oral or sublingual) **ONLY** Required to do pregnancy test 3 weeks later and return if positive

Question 30

When is surgical management indicated?

Answer 30

If medical management failed If symptomatic after 14 days of expectant management

Question 31

How are patients with miscarriage surgically managed?

Answer 31

Either option depending on preference: * Manual vacuum aspiration under local anaesthetic (in outpatient or clinic setting) * Surgical management under general anaesthetic (Evacuation of retained products of conception [**ERPC**])

Question 32

What are some complications of surgical management?

Answer 32

**Incomplete evacuation of the uterus**: continued vaginal bleeding and lower abdominal pain. **Post-uterine evacuation bleeding**: May occur following the procedure as tissue in this area is highly vascularised. **Asherman's Syndrome**: Adhesions that obstruct the uterine cavity and lead to recurrent miscarriage **Perforation**

Question 33

Summary of miscarriage management

Answer 33

**_Conservative_**: Expectant management (First-line) Offer all women written and verbal information about miscarriage Analagesia + anti-emetics as required Pregnancy test to be completed 3 weeks after monitoring period Psychological support: If required **_Medicine_**: (Second-line) **Missed miscarriage**: * 200 mg oral mifepristone * 800 micrograms misoprostol (vaginal, oral or sublingual) **48 hours later** **Incomplete miscarriage**: * 600-800 micrograms misoprostol (vaginal, oral or sublingual) **ONLY** **_Surgical_**: (Second-line) **Outpatient setting**: Manual vacuum aspiration under local anaesthetic **Hospital setting**: Surgical management under general anaesthetic (Evacuation or retained products of conception [**ERPC**])

Question 34

What is the effect of mifepristone in management of miscarriage

Answer 34

Inhibits effects of progesterone which is important in maintaining uterine lining in pregnancy

Question 35

What is the effect of misoprostol in management of miscarriage?

Answer 35

Mimics the effects of prostaglandins which promotes uterine contraction