Obstetrics and Gynaecology - QuesMed

Question 1

When would you use surgical management for an ectopic pregnancy?

Answer 1

Surgical management is recommended if the patient would be unable to attend follow-up or if the ectopic is advanced. An advanced ectopic is indicated if any of the following are present:

• The patient is in a significant amount of pain
• There is an adnexal mass of size ≥35mm
• B-hCG levels are ≥5000IU/L
• Ultrasound identifies a foetal heartbeat

Surgical management is often in the form of a salpingectomy where the Fallopian tube containing the ectopic is removed. In cases where the ectopic is in a woman with only one functioning Fallopian tube, and they wish to remain fertile, a salpingotomy may be done where only the ectopic is removed.
Salpingotomy carries the risk that not all the tissue may have been removed and so serial serum B-hCG measurements are done to exclude any trophoblastic tissue still within the Fallopian tube.

Make sure to give anti-D immunoglobulin if the mother is rhesus D negative.

Question 2

What is hyperemesis gravidarum?

Answer 2

Intractable vomiting before 20 weeks leading to weight loss, dehydration and electrolyte disturbance. Early signs include ketonuria (from starvation due to vomiting) and/or weight loss of up to 5% of overall pre-pregnancy weight. It is a diagnosis of exclusion.

Question 3

What is the treatment for hyperemesis?

Answer 3

Electrolyte rehydration therapy and anti-emetics. IV fluids may be necessary as well (requiring admission).

• Fluid replacement therapy with normal saline
• Potassium chloride as excessive vomiting usually causes hypokalaemia
• Anti-emetic medications such as cyclizine (first line), metoclopramide or prochlorperazine. Ondansetron or domperidone may be used in severe cases.
• Thiamine and folic acid to prevent development of Wernicke’s encephalopathy
• Antacids to relieve epigastric pain
• Thromboembolic (TED) stockings and low molecular weight heparin as there is increased risk of venous thromboembolism. This is due to the combination of pregnancy, immobility and dehydration.

Question 4

What are the complications of hyperemesis?

Answer 4

• Gastrointestinal problems: Mallory-Weiss tears, malnutrition and anorexia
• Dehydration relating to ketosis and venous thromboembolism
• Metabolic disturbance such as hyponatraemia, Wernicke’s encephalopathy, kidney failure, hypoglycaemia
• Psychological sequelae such as depression, PTSD and resentment toward the pregnancy.
  If the condition is very severe, the foetus may be affected due to maternal metabolic disturbance.
• Foetal complications include low birth weight, intrauterine growth restriction and premature labour.

Question 5

What complication can occur if chorionic villus sampling is done too early?

Answer 5

Risk of foetal limb abnormalities if CVS done <11 weeks gestation.

Question 6

What is menorrhagia?

Answer 6

Menorrhagia is defined as blood loss during a menstrual period to the extent in which the woman’s quality of life is affected.

Question 7

What are some causes of menorrhagia?

Answer 7

In around half of cases there is no underlying pathology. This is referred to as dysfunctional uterine bleeding.

Pathological causes can be split into:

Local:

• Fibroids
• Adenomyosis
• Endometrial polyps
• Endometriosis
• Pelvic inflammatory disease
• Endometrial cancer (be very suspicious of this if there is postmenopausal bleeding)

Systemic:

• Bleeding disorders
• Hypothyroidism
• Liver and kidney disease
• Obesity

Question 8

What are the investigations and management of menorrhagia?

Answer 8

Investigations:

• A full blood count should be done as a minimum to exclude iron deficiency anaemia.
• Clotting studies should be performed if clinically indicated, such as bleeding elsewhere.
• Trans-vaginal ultrasound should be considered to look for underlying causes such as fibroids or endometrial polyps.
• Other tests for endocrine disease (e.g. TFTs) should only be done if clinically indicated

Management depends on the underlying cause. If there is dysfunctional uterine bleeding this may be treated with:

• Mirena coil (often first line)
• Mefenamic acid
• Tranexamic acid

Question 9

What are placenta accreta, increta and percreta?

Answer 9

Placenta accreta: The adherence of the placenta directly to the superficial myometrium but does not penetrate the thickness of the muscle.

Placenta increta: The villi invade into but not through the myometrium

Placenta percreta: The villi invade through the full thickness of the myometrium to the serosa. There is increased risk of uterine rupture and in severe cases the placenta may attach to other abdominal organs such as the bladder or rectum.

Question 10

What is the management of pregnancy-induced hypertension?

Answer 10

In women with gestational hypertension (hypertension with onset after 20 weeks gestation and no proteinuria) above 150/100mmHg, the first line management is oral labetalol.

If there is only mild hypertension (140/90 to 149/99mmHg) during pregnancy then regular blood pressure monitoring should be carried out and no treatment is recommended.

If labetalol is not tolerated then alternative medications which can be used include methyldopa and nifedipine.

For all women, regular blood pressure monitoring and urinalysis should be carried out.

Question 11

What is a miscarriage?

Answer 11

Miscarriage is defined as the loss of a pregnancy prior to 24 weeks gestation. Just over 10% of recognised pregnancies end in miscarriage, although the total number of miscarriages is higher as many occur without the woman realising she is pregnant.

Question 12

What causes a miscarriage?

Answer 12

The cause is often idiopathic. Known causes can be split into:

Foetal pathology:

• Genetic disorder
• Abnormal development
• Placental failure

Maternal pathology:

• Uterine abnormality
• Cervical incompetence
• Polycystic ovary syndrome
• Poorly controlled diabetes
• Poorly controlled thyroid disease
• Anti-phospholipid syndrome

Question 13

What are the signs of the third stage of labour?

Answer 13

The third stage of labour begins at delivery of the foetus and ends with delivery of the placenta and foetal membranes.

Generally, it lasts 30 minutes to an hour when allowed to occur naturally or 5-10 minutes with administration of oxytocin.

Signs of placental separation and imminent placental delivery:

• Gush of blood
• Lengthening of the umbilical cord
• Ascension of the uterus in the abdomen

The delivery of the placenta is commonly managed manually by controlled cord traction. This must be gentle, or else there is increased risk of causing complications such as uterine inversion and postpartum haemorrhage.

Question 14

Do you need to increase a woman’s thyroxine if she is euthyroid during pregnancy?

Answer 14

Yes - NICE recommends increasing levothyroxine by 25 mcg as soon as pregnancy is confirmed despite a euthyroid state. This patient is currently euthyroid but because of her pregnancy, needs an increased dose of levothyroxine. The explanation for this is that in pregnancy there is a physiological increase in serum free thyroxine until the 12th week of pregnancy as the foetus is dependent on mother’s circulating thyroxine until the 12th week of development when the foetal thyroid develops.

Untreated hypothyroidism can lead to neurodevelopmental delay of the foetus. This surge is not seen in hypothyroid patients. Therefore, levothyroxine should be increased to mimic this surge.

Question 15

How often should a woman with severe preeclampsia have a blood test?

Answer 15

Patients with severe pre-eclampsia should have blood tests (including U&E, FBC, transaminases and bilirubin) three times per week to anticipate if a patient is developing HELLP syndrome, a complication of pre-eclampsia involving haemolysis, elevated liver enzymes and low platelets.

Question 16

Why is amiodarone contraindicated in breast feeding?

Answer 16

Can cause hypothyroidism due to large amounts of iodine released when the drug is taken.

Question 17

What are the steps of the second stage of labour?

Answer 17

The second stage of labour begins with complete cervical dilation and ends with delivery of the foetus. The steps of the second stage of labour are:

1. Foetus head is flexed and descends and engages into pelvis
2. Foetus internally rotates to face towards the maternal back
3. Foetal head extends to deliver the head
4. Foetus externally rotates (restitution) after delivery of the head so that shoulders are now AP position
5. The anterior shoulder is delivered first and then the rest of the foetus is expelled.

A common sign of the second stage of labour is maternal desire to push. The second stage can last from 20 minutes to 2 hours.

Question 18

What is classed as a prolonged second stage?

Answer 18

A prolonged second stage is defined as: in nulliparous women > 3 hours with epidural or > 2 hours without; in multiparous women > 2 hours with epidural or > 1 hour without.

A prolonged second stage is an indication for instrumental delivery if possible. Caesarean section in the second stage is associated with increased maternal morbidity.

Question 19

What are the clinical features of toxoplasmosis in the infant?

Answer 19

Clinical features in the infant include:

• CNS problems such as cerebral palsy, epilepsy and hydrocephalus
• learning disability
• visual impairment
• hearing loss
• Most people infected are asymptomatic and develop only mild flu-like symptoms.

However, if a pregnant woman becomes infected for the first time during her pregnancy, the infection may spread to the developing foetus and cause serious illness known as congenital toxoplasmosis.

Infection in the earlier weeks of gestation leads to a worsened outcome.

Question 20

How is congenital toxoplasmosis diagnosed and managed?

Answer 20

Neonatal infection can be diagnosed with amniocentesis, and maternal IgM testing can be used to check for previous exposure.

Management: The antibiotic spiramycin is used to treat toxoplasmosis during pregnancy and is thought to reduce transmission to the baby.

Question 21

Give some examples of tocolytics

Answer 21

There are several agents which can be used, for example:

Nifedipine (Calcium channel antagonist)
Atosiban (Oxytocin receptor antagonist)
Indomethacin (NSAID)
Terbutaline (beta-2-agonist)
Magnesium Sulphate may be administered for its foetal neuroprotective effects

Currently in the UK, nifedipine is recommended as the first line tocolytic agent.

Note that tocolytics can only be used to suppress contractions for a few days and should not be used for long term delay of delivery.

Question 22

What are tocolytics and when are they used?

Answer 22

Tocolytics are drugs used during pregnancy which suppress contractions and thus labour. They are indicated in pre-term labour to delay delivery by a few days, usually to buy time for maternal steroids to work or allow transferal of the mother to the appropriate care unit.

THEY ARE NOT GIVEN IN ACTIVE LABOUR!

Question 23

What are some contraindications to tocolysis?

Answer 23

General contraindications to tocolysis include:

Greater than 34 weeks gestation
Non-reassuring cardiotocograph, fatal foetal anomaly or intrauterine death
Intrauterine growth restriction or placental insufficiency
Cervical dilation greater than 4cm
Chorioamnionitis
Maternal factors such as pre-eclampsia, ante-partum haemorrhage, haemodynamic instability
The drug-specific contraindications should also be considered, for example cardiac disease such as severe hypotension or heart failure is a contraindication to nifedipine.

Question 24

When does the booking appointment take place and what does it involve?

Answer 24

Booking appointments occur around 10 weeks gestation and serve to determine which women require additional support throughout their pregnancy.

Comprehensive medical, psychiatric, surgical, obstetric, gynaecological and social histories are taken which guide further testing and treatment to reduce the risk to patient and foetus during pregnancy and labour.

Initial blood tests, BMI, urinalysis, blood pressure and ultrasound scan are conducted to further assess for risk and provide the patient with as much information as possible about the pregnancy to help determine if and how they want to proceed.

Question 25

What are some causes of polyhydramnios?

Answer 25

Causes of polyhydramnios can be due to excessive production of amniotic fluid or insufficient removal of amniotic fluid.

Excess production can be due to increased foetal urination:

Maternal diabetes mellitus
Foetal renal disorders
Foetal anaemia
Twin-to-twin transfusion syndrome

Insufficient removal can be due to reduced foetal swallowing:

Oesophageal or duodenal atresia
Diaphragmatic hernia
Anencephaly
Chromosomal disorders

Question 26

What are some complications of Polyhydramnios?

Answer 26

Maternal complications:

Maternal respiratory compromise due to increased pressure on the diaphragm
Increased risk of urinary tract infections due to increased pressure on the urinary system
Worsening of other symptoms associated with pregnancy such as gastro-oesophageal reflux, constipation, peripheral oedema and stretch marks
Increased incidence of caesarean section delivery
Increased risk of amniotic fluid embolism (although this is rare)

Foetal complications:

Pre-term labour and delivery
Premature rupture of membranes
Placental abruption
Malpresentation of the foetus (the foetus has more space to “move” within the uterus)
Umbilical cord prolapse (polyhydramnios can prevent the foetus from engaging with the pelvis, thus leaving room for the cord to prolapse out of the uterus before the presenting part)

Question 27

What are some causes of secondary amenorrhoea?

Answer 27

Pregnancy (most common cause) and breastfeeding
Menopause
Intrauterine adhesions causing outflow tract obstruction (Asherman’s syndrome)
Polycystic Ovary Syndrome (PCOS)
Drug-induced amenorrhoea (e.g. oral contraceptive)
Physical stress, excess exercise and weight loss
Pituitary gland pathology such as Sheehan syndrome or hyperprolactinaemia
Hypothyroidism or hyperthyroidism

Question 28

What is secondary amenorrhoea?

Answer 28

Secondary amenorrhoea is the absence of menstruation for 6 months or longer in a woman with previously present menstrual cycles.

Question 29

What is cord prolapse?

Answer 29

Cord prolapse occurs when, during labour, the umbilical cord exits the cervix prior to delivery of the infant. This causes acute compromise of the umbilical blood supply to the infant and necessitates immediate delivery.

Question 30

What are the risk factors for cord prolapse?

Answer 30

Abnormal lie (e.g. transverse, breech)
Multiple pregnancy
Polyhydramnios
High head
Multiparity

Question 31

What is the management of cord prolapse?

Answer 31

The foetus should be delivered as rapidly as possible, e.g. via an instrumental delivery, or if the cervix is not fully dilated, caesarean section
While preparing for delivery, prevent further prolapse by adopting a ‘knees-to-chest’ position
Filling the bladder with 500ml warmed saline can aid in preventing further prolapse
Avoid exposure and handling of the cord, reduce cord into the vagina
Tocolytics e.g. terbutaline to stop uterine contractions

Question 32

What is preterm labour and what is the screening test?

Answer 32

Pre-term labour is the onset of regular uterine contractions and cervical changes occurring before 37 weeks gestation.

Preterm birth is the delivery of a baby after 20 weeks gestation but before 37 weeks gestation.

A screening test which is sometimes used to assess the risk of preterm delivery after the onset of pre-term labour is the foetal fibronectin test (fFN test). A negative fFN test means that there is likely to be low risk of delivery occurring within the next 7-14 days.

Question 33

What is PROM, PPROM and prolonged rupture of membranes?

Answer 33

Premature rupture of membranes (PROM) is rupture of membranes at least one hour before the onset of contractions.

Prolonged premature rupture of membranes is the rupture of membranes more than 24 hours before the onset of labour.

Pre-term premature rupture of membranes (PPROM) is early rupture of the membranes before 37 weeks gestation.

Question 34

What are the risk factors for pre-term labour?

Answer 34

Conditions associated with pre-term labour and delivery:

Conditions which may cause “overstretching of the uterus”
Multiple pregnancy (commonly due to assisted conception) and polyhydramnios
Conditions where foetus is at risk
Pre-eclampsia, intrauterine growth restriction, placental abruption etc.
Problems with the uterus or cervix
Fibroids, congenital uterine malformation, short or weak cervix, previous uterine or cervical surgery
Infection including chorioamnionitis, maternal or neonatal sepsis, bacterial vaginosis, trichomoniasis, Group B Streptococcus, sexually transmitted infections (e.g. Chlamydia) and recurrent urinary tract infections
Maternal co-morbidity (for example: Hypertension, diabetes, renal failure, thyroid disease etc.)

Question 35

What is the management of pre-term labour?

Answer 35

Corticosteroids should be given to accelerate foetal lung maturation (betamethasone or dexamethasone).
Intravenous antibiotics should be given if there is increased risk of infection (evidence of Group B Streptococcus (GBS) in current or previous pregnancy, presence of maternal fever).
Penicillin is the antibiotic of choice if there is no allergy.
Tocolytic agents may be considered to buy time for administration of corticosteroids, but risk of side effects and benefits should be weighed up.
Nifedipine is the recommended first-line tocolytic agent.

Question 36

What is the Bishop scoring system?

Answer 36

The Bishop Score

The Bishop score is used to assess whether a patient is likely be a good candidate for an induction of labour.

Usually a score of 9 or more means that the patient is likely to achieve a successful vaginal delivery and would be a favourable candidate for induction. The lower the score, the less favourable the cervix is.

Calculating the Bishop score

The following components are assessed:

Cervical Score	0	1	2	3
Position	Posterior	Middle	Anterior	N/A
Consistency	Firm	Medium	Soft	N/A
Effacement	0-30%	40-50%	60-70%	≥80%
Dilation	Closed	1-2cm	3-4cm	≥5cm
Foetal station	-3	-2	-1, 0	+1, +2
The components can be remembered with the following mnemonic: Pregnancy Can Enlarge Dainty Stomachs! (Position, Consistency, Effacement, Dilation, Station).

Certain circumstances call for addition or subtraction of points (Bishops score modifiers):

1 point is added to the score for each of the following:
Presence of pre-eclampsia
Each previous vaginal delivery
1 point is subtracted for each of the following:
Post-dates pregnancy
No previous vaginal deliveries
Premature pre-term rupture of membranes

Question 37

What are the maternal risk factors for congenital cardiac disease?

Answer 37

Maternal risk factors for congenital cardiac disease include infection, drugs and diabetes:

• Infectious causes of congenital cardiac disease include maternal rubella infection during pregnancy.
• Drugs that increase the risk of congenital heart disease include teratogenic medicines (e.g. thalidomide, isotretinoin, lithium) and substance misuse (alcohol, smoking).
• Maternal diabetes increases the risk of congenital cardiac disease, although this only applies to poorly controlled type 1 and 2 diabetes, and not gestational diabetes. This is likely because by the time gestational diabetes has developed, the heart is mostly formed.

Question 38

How would you distinguish an intrauterine pregnancy vs ectopic pregnancy by looking at bHCG measurements?

Answer 38

In the first trimester of normal pregnancy, bHCG doubles approximately every 48 hours until reaching a peak at around week 8-10. Ectopic pregnancies are associated with a suboptimal rise in bHCG.

Serial serum B-hCGs 48 hours apart can help give an indication of the location and prognosis of the pregnancy.

If the levels fall then it is suggested that the foetus will not develop or there has been a miscarriage.

If there is only a slight increase or a plateau in B-hCG levels then this may indicate an ectopic pregnancy.

A large increase in B-hCG suggests the foetus is growing normally intrauterine.

A trans-vaginal ultrasound may help to identify the location of the pregnancy, but in the early days of gestation the foetus may be too small to be accurately identified by ultrasound. In this instance it may be best to repeat the scan at a later date.

Question 39

What is the difference between a threatened vs inevitable miscarriage?

Answer 39

Threatened miscarriage - This is where there are some mild symptoms of bleeding with the foetus retained within the uterus as the cervical os is closed. Hence there is the ‘threat’ of a miscarriage, but it is not certain. There may be little or no pain. Ultrasound reveals that the foetus is present intrauterine.

Inevitable miscarriage - There is often heavy bleeding and pain, where the foetus is currently intrauterine but the cervical os is open. Hence it is inevitable that the foetus will be lost. Ultrasound reveals that the foetus is present intrauterine.

Question 40

What is the medical and surgical management of fibroids?

Answer 40

In many cases fibroids can be asymptomatic, in which case they do not require treatment.

When treatment is required, it can be tailored towards the symptoms which the woman is experiencing.

Non-surgical management:

If abnormal bleeding and under 3cm in size with no uterine distortion can be targeted with medical options:

NSAIDs
Anti-fibrinolytics
Combined hormonal contraception
Levonorgestrel-releasing intrauterine system (Mirena)
The Mirena is often used first-line, however the other treatments may be selected depending on the patient’s wishes to remain fertile, any contraindications, or patient preference.

Surgical management:

Where the symptoms are due to the mass effect of the fibroid (e.g. pressure on the bladder), there are several surgical options which may be used:
Myomectomy involves removing the fibroid from the uterine wall, and is generally fertility-sparing.
Ablation involves using a laser or radiofrequency(generates heat) to induce necrosis of the fibroid, and so the dead vessels no longer bleed.
Uterine artery embolisation may provide a targeted degeneration of the fibroid. This may also preserve fertility.
Hysterectomy involves removing the uterus. It is obviously extremely effective but will not preserve fertility.

Question 41

What is vasa praevia and how is it managed?

Answer 41

In vasa praevia, the foetal vessels lie over the internal os, partially or completely. There is a high risk of bleeding and foetal distress as a result if there is a premature rupture of membranes. It presents with rupture of membranes followed immediately by vaginal bleeding.

Clinical features of vasa praevia (classic triad):

• Painless vaginal bleeding
• Rupture of membranes
• Foetal bradycardia (or resulting foetal death)

Foetal bradycardia is classically seen on the cardioectography (CTG). Caesarean section is recommended as the mode of delivery to prevent foetal and maternal complications arising from uncontrolled haemorrhage.

Management is with elective Caesarean section prior to rupture of membranes. This can be difficult to predict and so is usually arranged at 35-36 weeks gestation. If the mother does however rupture her membranes or go into labour then emergency Caesarean section should be carried out immediately.

Question 42

What is Asherman’s syndrome?

Answer 42

Asherman’s syndrome is characterised by intrauterine adhesions commonly as a result of previous uterine surgery such as dilation and curettage. It can lead to obstruction to the menstrual outflow tract which presents as secondary amenorrhoea. In this case, the cyclical abdominal pain may be a sign that menstruation is occurring. Ultrasound examination is not particularly sensitive for making the diagnosis so an HSG or hysteroscopy might be needed for confirmation.

Question 43

What are some causes of secondary amenorrhoea?

Answer 43

Secondary amenorrhoea is the absence of menstruation for 6 months or longer in a woman with previously present menstrual cycles.

Causes include:

Pregnancy (most common cause) and breastfeeding
Menopause
Intrauterine adhesions causing outflow tract obstruction (Asherman’s syndrome)
Polycystic Ovary Syndrome (PCOS)
Drug-induced amenorrhoea (e.g. oral contraceptive)
Physical stress, excess exercise and weight loss
Pituitary gland pathology such as Sheehan syndrome or hyperprolactinaemia
Hypothyroidism or hyperthyroidism

Question 44

What is endometriosis and how does it present?

Answer 44

Endometriosis is a condition where endometrial tissue grows outside the uterine cavity.

Presentation:
Dysmenorrhoea
Dyspareunia
Subfertility
Rarely, the endometrial tissue can grow outside the female reproductive system, such as in the bowel leading to cyclical rectal bleeding.
Pelvic examination may reveal tender, nodular masses on the ovaries or the ligaments surrounding the uterus.
The main differentials are other causes of dysmenorrhoea. These include primary dysmenorrhoea, uterine conditions (e.g. fibroids, adenomyosis), adhesions, and pelvic inflammatory disease (PID).

Question 45

What are the investigations for endometriosis?

Answer 45

Trans-vaginal ultrasound is often normal. In some cases it may identify an ovarian endometrioma, which is a cyst made of endometrial tissue in the ovary.

A diagnostic laparoscopy may be done. Laparoscopy is the gold standard diagnostic tool, however it carries a small risk of complications (e.g. bowel perforation) so is not the first-line investigation.

Question 46

What is the management for endometriosis?

Answer 46

Medical Management:

The treatment for endometriosis depends on the symptoms, and the severity of these symptoms.

For managing pain, when only mild the use of simple analgesia such as paracetamol or NSAIDs (beware of peptic ulcer disease) may be all that is needed.

In cases where this is insufficient, creating an artificial menopause is used, with the use of medications such as

Combined oral contraceptive pill
Medroxyprogesterone acetate
Gonadotrophin-releasing hormone agonists

Surgical Management:

Diathermy of lesions
Ovarian cystectomy (for endometriomas)
Adhesiolysis
Bilateral oophorectomy (sometimes with a hysterectomy)

For managing infertility, menstrual suppression would be unsuitable, and so ablation or surgery is more appropriate.

Question 47

How would you diagnose rubella in pregnancy and what are the consequences?

Answer 47

Rubella is a condition caused by the rubella togavirus, which is transmitted via aerosols. Children are routinely vaccinated for Rubella as part of the MMR vaccine starting at 12 months of age.

Rubella presents with nonspecific symptoms and signs such as fever, coryza, arthralgia, a rash, which classically starts on the face and moves down to the trunk, sparing the arms and legs), and lymphadenopathy (classically post-auricular). Classically, the rash spares the limbs, as opposed to the rash of measles which involves the limbs.

The diagnosis of rubella is confirmed with serological testing. Management of rubella is supportive.

The prognosis of rubella is good; symptoms are generally mild and resolve in 7-10 days.

Rubella poses a serious risk to unvaccinated pregnant women. Congenital rubella infection (in the first 20 weeks of pregnancy) can cause cataracts, deafness, patent ductus arteriosus, brain damage.

Question 48

What are some causes of recurrent miscarriage?

Answer 48

Genetic disorder - refer to a clinical geneticist for genetic counselling. Options include continuing pregnancy attempts with prenatal diagnosis or use of a donor egg/sperm.
Uterine structural abnormality - may be treated surgically. For some congenital uterine malformations there is insufficient evidence to recommend surgical treatment.
Cervical incompetence - regular ultrasound monitoring of the cervix. May use cervical cerclage.
Polycystic ovary syndrome - difficult to manage as pathophysiology is not fully understood. There is no consensus on the most appropriate management. Suppression of the high LH has not been found to be effective.
Antiphospholipid syndrome - heparin and low-dose aspirin
Thrombophilia - heparin may increase the live birth rate
Diabetes - improve glycaemic control

Question 49

What is a missed miscarriage?

Answer 49

The uterus still contains foetal tissue, but the foetus is no longer alive. The miscarriage is ‘missed’ as often the woman is asymptomatic so does not realise something is wrong. The cervical os is closed.