Recurrent miscarriage Flashcards
A 26-year-old had 3 previous 1st trimester miscarriages. What is your management?
Impression
With this 26 year-old patient, I am concerned about the recurrence of miscarriage that she has experienced.
Definition: recurrent miscarriage is >/=3 consecutive miscarriages. Altho 50% is unexplained, would want to further investigate for an underlying cause and provide appropriate counselling and ongoing management.
Underlying causes to consider include:
- Anatomical: adhesions, uterine abnormality, PID
- Immunological: APLS,
- Endocrine: thyroid, DM
- Genetic: chromosomal (fetal)
- Infection (TORCH), toxins
Recurrent Miscarriage - History
History
- PC: timing, past miscarriage, events surrounding, symptoms experiences (pain, discharge, bleeding, fevers, etc)
- sx: VTE sx,
- RISK: advanced maternal age, hx of miscarriage
- Obstetric Hx
- Sexual Hx
- SNAP
Recurrent Miscarriage - Examination
Examination
- General appearance + vital signs
- system review: immunological sx
- abdominal/pelvic examination: abnormalities, masses, tenderness
Recurrent Miscarriage - Investigations
Investigations
Undertake complete work-up for underlying causes:
- bedside: anthropometric measurements,
- bloods: autoimmune screen (APLS, SLE, Thyroid), coags, FBC, HbA1C, BSL, TORCH serology screen,
- Imaging: abdo ultrasound for uterine abnormalities, hysteroscopy +/- salpingostomy
- Other: Karyotypic of POC to check for genetic abnormalities, further genetic testing of parents
Recurrent Miscarriage - Management
Management
Supportive
- Referral to early pregnancy assessment unit (EPAS)
- patient education re diagnosable causes, reassurance that if unexplained there is excellent prognosis for future pregnancies
- optimise existing/ongoing health issues (diabetes, thyroid, lifestyle changes)
Definitive
Depends on the underlying cause:
- genetic counselling if genetic cause, IVF/pre-implantation screen and referral
- APLS: low-dose aspirin + heparin and careful antenatal surveillance in subsequent pregnancies
