O&G miscarriage

Question 1

Miscarriage risk factors

Answer 1

• Age: >35 is increased risk, continues to increase with age
• Previous miscarriage: >2 consecutive miscarriage= higher risk
• Chronic conditions: higher risk of miscarriage (e.g. uncontrolled diabetes
• Uterine or cervical problems: certain uterine abnormalities (Mullerian duct anomalies, large cervical cone biopsies)= increased risk
• Smoking, alcohol, illicit drug use: all increase risk
• Weight: extremes of weight= increased risk
• Invasive prenatal tests: e.g. chorionic villus sampling and amniocentesis carry slight risk

An abortion is the expulsion of the products of conception before 24 weeks. The term miscarriage is used often to avoid any misunderstandings

Question 2

Epidemiology of miscarriage

Answer 2

• 15-20% of diagnosed pregnancies will miscarry in early pregnancies
• non-development of the blastocyst within 14 days occurs in up to 50% of conceptions
• recurrent spontaneous miscarriage affects 1% of women

Question 3

Threatened miscarriage

Answer 3

• painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
• the bleeding is often less than menstruation
• cervical os is closed
• complicates up to 25% of all pregnancies

Question 4

Missed (delayed) miscarriage

Answer 4

• a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
• mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
• cervical os is closed
• when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’

Question 5

Inevitable miscarriage

Answer 5

• heavy bleeding with clots and pain

- cervical os is open

Question 6

Incomplete miscarriage

Answer 6

• not all products of conception have been expelled
• pain and vaginal bleeding
• cervical os is open

Question 7

Management: expectant

Answer 7

• ‘Waiting for a spontaneous miscarriage’
• First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously
• If expectant management is unsuccessful then medical or surgical management may be offered

Question 8

Management: medical

Answer 8

• ‘Using tablets to expedite the miscarriage’
• Vaginal misoprostol: prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
• The addition of oral mifepristone is not currently recommended by NICE in contrast to US guidelines
• Advise them to contact the doctor if the bleeding hasn’t started in 24 hours.
• Should be given with antiemetics and pain relief

Some situations are better managed with medically or surgically. NICE list the following:

• increased risk of haemorrhage (in the late first trimester, if she has coagulopathies or is unable to have a blood transfusion)
• previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
• evidence of infection

Question 9

Management: surgical

Answer 9

• ‘Undergoing a surgical procedure under local or general anaesthetic’
• The two main options are vacuum aspiration (suction curettage) or surgical management in theatre
• Vacuum aspiration is done under local anaesthetic as an outpatient
• Surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’

Some situations are better managed with medically or surgically. NICE list the following:

• increased risk of haemorrhage (in the late first trimester, if she has coagulopathies or is unable to have a blood transfusion)
• previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
• evidence of infection