Miscarriages

Question 1

What is a miscarriage?

Answer 1

A Miscarriage is one of the most common gynaecological problems a medical practitioner will encounter

Question 2

What is the definition of recurrent miscarriages?

Answer 2

The consecutive miscarriages happening >3 times before 20 weeks gestational age

Question 3

What are the risk factors associated with miscarriages?

Answer 3

1. Maternal age >40% chance in above 40 years
2. Previous spontaneous miscarriage >20% increase
3. Smoking and alcohol while pregnant
   4.

Question 4

What investiagations do we need to do if we encounter a late miscarriage?

Answer 4

1. Serology for syphilis
2. Lupus anticoagulant
3. Hystersonography (u/s)
4. Antinuclear factor

If hystersonography is abnormal then do laparoscopy and hysteroscopy

Question 5

What are the miscellaneous causes of late miscarriage?

Answer 5

1. Syphillis -especially recurrent miscarriages
2. Cytomegalovirus, rubella, toxoplasmosis
3. Chlamydia and mycoplasma infections
4. Hypothyroidism and diabetes mellitus should not cause recurrent miscarriages

Question 6

What are the causes of early trimester miscarriages?

Answer 6

1. Chromosomal abnormalities (60%)-aneuploidy(abnormal number of chromosomes)
2. Environmental factors:
   - smoking, alcohol, caffeine and cocaine consumption, maternal age
3. Poor placentation
   - uterine septum placentation
   - autimmune (SLE, antiphospholipid syndrome)
   - HLA status(human lymphocytic antigen)

Question 7

What are the causes of late trimester miscarriage?

Answer 7

1. Inability of the uterus to hold the pregnancy
   - cervical incvompetence
   - uterine didelphys
   - leimyomas
2. Poor placentation
   - pre-eclampsia
   - infections
   - inadequate trophoblastic invasaion of the uterine spiral arteries
   - SLE

Question 8

What are the causes of recurrent miscarriages?

Answer 8

1. Genetic abnormalities
2. Structural abnormalities
3. Infection
4. Thromobophilic infections
5. Anti-phospholipid syndrome

Question 9

What is the genetic abnormality seen in recurrent miscarriages?

Answer 9

A balanced reciprocal translocation or robertsonian translocation

Question 10

What are the structural abnormalities seen in recurrent miscarriages?

Answer 10

1. Uterine structural abnormalities (uterine septal or bicornuate uterus)
2. Cervical incompetence

Question 11

What infections tend to cause recurrent miscarriages?

Answer 11

Bacterial vaginosis and syphillis because they remain asymptomatic most of the time

Question 12

What is anti-phospholipid syndrome?

Answer 12

It is one of the causes of recurrent miscarriages

• (directed at phospholipid binding plasma proteins)
• we treat antiphospholipid syndrome with heparin and low dose aspirin

Question 13

What thromobolititc disorders are associated with recurrent miscarriage?

Answer 13

1. Factor V Leiden, prothrombin G20210A, and activated protein C resistance

Question 14

What are the 5 clinical presentations of a miscarriage?

Answer 14

1. Threatened miscarriage
2. Inevitable miscarriage
3. Complete miscarriage
4. Incomplete miscarriage
5. Missed miscarriage

Question 15

What is a threatened miscarriage?

Answer 15

A threatened miscarriage is when

• there is light vaginal bleeding with or without backache or abdominal pain
• the cervix is closed and the foetus is alive

Question 16

What is the differential diagnosis of a threatened miscarriage?

Answer 16

1. Blighted ovum
2. Implantation bleeding
3. Ectopic pregnancy

Question 17

What should a patient do for the next couple of days to prevent worse prognosis for a threatened miscarriage?

Answer 17

Avoid exertional activities for a few days

Question 18

When can we expect foetal heart sounds ?

Answer 18

By 5 to 6 weeks or at a BHCG level of 10 000IU

Question 19

What percentage of threatened miscarriages do not end up aborting?

Answer 19

60%

Question 20

What is should we worry about in the second trimester if a threatened miscarriage occurs?

Answer 20

Preterm labour and pregnancy and we should observe the patient and mom accordingly

Question 21

What is an inevitable miscarriage?

Answer 21

It is a miscarriage that presents with vaginal bleeding , increasing pain and the uterus may be tender and there might be cervical dilation

Question 22

What is the management of a shocked patient with inevitable miscarriage?

Answer 22

Start resus with crystalloids fluids and blood transfusion if needed
Oxytocin to allow for uterine contraction
1st trimester: suction curettage or vacuum aspiration
2nd trimester: oxytocin, analgesia, abort spontaneously followed by vacuum aspiration or curettage

Question 23

What is an incomplete miscarriage?

Answer 23

It is a miscarriage where there are products of conception that are passed
-the cervical os is open and the uterus is smaller than the expected gestational age

Question 24

How do we manage patients with incomplete miscarriages?

Answer 24

1. We manage them by removing remaining products with an ovum forceps
   Then we can use a vacuum aspiration if not bigger than 12 weeks then a curretage

Question 25

What is a complete miscarriage?

Answer 25

This is diagnosed when the clinician has seem the foetal parts him/herself No evacuation is necessary but we must still watch out for post-abortion haemorrhage

Question 26

What should we investigate if it is a fresh miscarriage?

Answer 26

Congenital abnormalities | -blood from the foetal Heart must be aspirated

Question 27

What should we suspect if the it is a macerated miscarriage?

Answer 27

Infection or poor placentation and investigate the tissue biopsy for possible chorioamnionitis

Question 28

What is a missed miscarriage?

Answer 28

It is a miscarriage where the foetus is still in the uterus but has no cardiac activity There is no bleeding and the cervical os is closed and there’s no pain <12 weeks dilatation and curettage or manual vacuum aspiration of the uterus is performed >14 weeks misoprostol needs to be used before and then dilation

Question 29

What special investigations do we need to always do in patients with miscarriages?

Answer 29

1. Syphilis 2. Rhesus status and if mom is Rhesus negative give anti-D immunoglobulin in second trimester 3. Cervical intra-epithelial neoplasia

Question 30

What are the advantages of suction curettage over sharp curettage?

Answer 30

``` Less pain Less bleeding Less operation time Less long term endometrial damage Less uterine perforation ```

Question 31

What analgesia do we give to women who are going to have a suction curettage?

Answer 31

1. Fentanyl, midazolam and intracervical block using bupivicaine of about 0,5%