Miscarriage - GM

Question 1

define miscarriage

Answer 1

spontaneous loss of intrauterine pregnancy before 24 weeks gestation

Question 2

how often does miscarriage occur

Answer 2

10-24% of all clinical pregnancies
risk decreases as gestational age increases

Question 3

common causes of miscarriage

Answer 3

chromosomal abnormality
fetal malformations (eg. neural tube defects)
chronic maternal health factors: thrombophilia, antiphospholipid syndrome, systemic lupus erythematosus, PCOS, poorly controlled diabetes mellitus, thyroid dysfunction
active maternal infection (rubella, CMV, herpes, listeria infection, toxoplasmosis, parvovirus)
iatrogenic causes: amniocentesis and chorionic villus sampling
lifestyle factors
environmental toxins
advanced maternal age

Question 4

early miscarriage

Answer 4

before 13 weeks

Question 5

late miscarriage

Answer 5

between 13 and 24 weeks

Question 6

threatened miscarriage

Answer 6

vaginal bleeding but the cervical os is closed, and ultrasound shows viable intrauterine pregnancy

Question 7

inevitable miscarriage

Answer 7

veginal bleeding with an open cervical os, with or without cramping abdominal pain
pregnancy loss will occur/is inevitable

Question 8

incomplete miscarriage

Answer 8

when there is vaginal bleeding, an open cervical os and products of conception are seen on examination

Question 9

complete miscarriage

Answer 9

when the products of conception have passed, but the cervical os is closed and US shows an empty uterine cavity

Question 10

missed miscarriage

Answer 10

the presence of a nonviable intrauterine pregnancy that has not yet resulted in symptoms or the passage of the products of conception

Question 11

recurrent miscarriage

Answer 11

the occurence of three or more miscarriages

Question 12

typical symptoms of miscarriage

Answer 12

vaginal bleedings
cramping abdominal pain
passage of any fetal tissue or clots

Question 13

other things to ask about

Answer 13

symptoms and risk factors for ectopic pregnancy
menstrual history
pregnancy history
past obstetric history
past gynae history
social history

Question 14

symptoms of ectopic pregnancy

Answer 14

unilateral abdominal pain
nausea and vomiting
pre-syncope or syncope
back pain
shoulder tip pain
rectal pressure or pain

Question 15

risk factors for ectopic pregnancy include

Answer 15

previous ectopic pregnancy
previous pelvic inflammatory disease
intrautuerine contraception
previous tubal surgery including sterilisation
fertility treatment

Question 16

clinical examination of presentation with symptoms of miscarriage

Answer 16

vital signs
abdo exmination for signs of acute abdomen which may be suggestive of ectopic
speculum exmination to asses the cervical os, rule out other sources of bleedings, quantify bleeding and assess for visible products of conception
bimanual examination if ectopic pregnancy is suspected
adnexal tenderness or a mass, and cervical motion tenderness, may be present in ectopic pregnancy

Question 17

lab investigations

Answer 17

FBC: in patients who have significant blood loss and/or evidence of hypovolaemia
beta HCG: provides an indication as to whether the pregnancy is progressing
group and save / cross match: if significant bleeding
antibody screen: rhesus negative women undergoing a surgical proceduse to manage miscarriage will require anti d rhesus prophylaxis

Question 18

imageing for vaginal bleeding presentations

Answer 18

transvaginal US - assess for an intrauterine pregnancy or evidence of an ectopic pregnancy (adnexal pathology or the presence of free fluid in the abdomen)

Question 19

if the ultrasound scan is inconclusive

Answer 19

if the Us is inconclusive for intrauterine pregnancy ie. there is pregnancy of unknown location
serial beta HCG measurements should be performed
serum beta HCG levels should increase by more than 63% in 48 hours in a progressive pregnancy - the does does exclude ectopic pregnancy but makes it unlikley

Question 20

Changes in beta HCG levels

Answer 20

serum beta HCG levels should increase by more than 63% in 48 hours in a progressive pregnancy - the does does exclude ectopic pregnancy but makes it unlikley
beta HCG levels that fall by more than 50% in 48 hours indicate a failing pregnancy (potential miscarriage)
beta HCG levels that fall by less than 50% or fail to rise by more than 63% over 48 hours require clinical review to exclude an ectopic pregnancy

Question 21

beta HCG levels that fall by less than 50% or fail to rise by more than 63% over 48 hours

Answer 21

require clinical review to exclude an ectopic pregnancy

Question 22

beta HCG levels that fall by more than 50% in 48 hours indicate

Answer 22

indicate a failing pregnancy (potential miscarriage)

Question 23

emergency managemnt of a haemodynamically unstable patient

Answer 23

patients with significant haemorrhage or haemodynamic instability
required ABCDE approach and senior input from OBGYN
speculum examination should be performed and products of conception should be removed

Question 24

products of conception in the cervical os can lead to

Answer 24

cervical shock due to vaginal stimulation

Question 25

two options for surgical management of miscarriage

Answer 25

• manual vacuum aspiration (MVA) can be performed under local anaesthetic on the ward, involves manual suction aspiration of the uterus
• surgical evacuation: usually performed in theatre under GA

Question 26

when should surgical management be conducted

Answer 26

in patients with significant bleeding who have retained products of conception
surgical management is also used and medical or expectant management is unsuccessful

Question 27

rhesus negative patients durig surgical management of miscarriage

Answer 27

require anti-D rhesus prophylaxis

Question 28

medical management

Answer 28

prostaglandin agent (misopristol) to induce uterine contractions and effacement of the cervix

Question 29

follow up after medical management

Answer 29

a pregnancy test should be performed three weeks after medical management
if positive, imaging for retained products of conception will be required

Question 30

expectant management

Answer 30

waiting for spontaneous passage of the products of conception, without any medical or surgical intervention

Question 31

follow up after expectant management

Answer 31

a pregnancy test should be performed three weeks after medical management
if positive, imaging for retained products of conception will be required
if no bleeding occurs, or worsening of pain or bleeding, women require repeat assessment and alternative management

Question 32

recurrent miscarriage is defined as

Answer 32

three or more miscarriages
these patients require specialist review for underlying cause

Question 33

causes of recurrent miscarriage

Answer 33

increased maternal age
parental genetic factors (balanced translocations, mosiacism)
thrombophilic disorders
endocrine disorders (diabetes melitus, thyroid disorders, PCOS)
structural uterine abnormalities

Question 34

relevant investiagtions for recurrent miscarriages include

Answer 34

cytogenic analysis performed on the products of conception of the third and any subsequent miscarriages
parental karyotyping and genetic counselling
blood tests: HbA1c, antiphospholipid/thrombophilia screen, thyroid funtion tests
pelvic US

Question 35

complications of miscarriage include

Answer 35

infection
retained products of conception: may still require surgical management
asherman’s syndrome (uterine adhesions): a complication of repeated surgical management
psychological impact: depression or anxiety

Question 36

risk of recurrence

Answer 36

no increased risk of second miscarriage after the first miscarriage
25% risk of subsequent miscarriage after 2
40% risk of subsequent miscarriage after 3