Symposium: loss of a baby

Question 1

Why is it important to think about pregnancy loss?

Answer 1

It is common - 1/4 pregnancies end in miscarriage in the UK
Major cause of death in women
Long lasting emotional and mental health impact
Most women and their families will be affected at some point in their life
Taboo subject
Some causes can be prevented

Question 2

What is a threatened miscarriage?

Answer 2

Symptoms of bleeding / pain but intrauterine pregnancy is still present

Question 3

What is an inevitable miscarriage?

Answer 3

Symptoms of bleeding / pain, cervical os is open

Question 4

What is an incomplete miscarriage?

Answer 4

Symptoms of bleeding, os is open, some tissue remaining

Question 5

What is a complete miscarriage?

Answer 5

No tissue remaining

Question 6

What is a missed miscarriage?

Answer 6

Diagnosed at scan with no symptoms

Question 7

What is a molar pregnancy?

Answer 7

Foetus doesn’t form properly in the womb and abnormal cells develop instead of a normal foetus.

Question 8

What is a complete molar pregnancy?

Answer 8

There is a mass of abnormal cells in the womb and no foetus develops

Question 9

What is a partial molar pregnancy?

Answer 9

Abnormal foetus starts to form but it can’t survive or develop into a baby

Question 10

Give facts for risk of miscarriage at certain ages

Answer 10

20 years = 15%
30 years = 18%
40 years = 38%
45 years = 70%

Question 11

What factors affect the risk of miscarriage?

Answer 11

Age
Obesity
Antiphospholipid syndrome
Parental chromosomal translocation
Poorly controlled diabetes
Alcohol, smoking, recreational drug use
Uterine anomaly
High levels of natural killer cells

Question 12

How does a miscarriage present?

Answer 12

Bleeding
Pain
Found at time of routine scan - missed miscarriage
Loss of pregnancy symptoms
Acute collapse (cervical shock, hypotension, tachycardia, bleeding)
Sepsis (pyrexia, hypotension, tachycardia, raised respiratory rate, confusion)

Question 13

How is a miscarriage in the first trimester managed?

Answer 13

Conservative / expectant
Medical management - at home or on the ward
Surgical management
Follow up - support, counselling

Question 14

What are the risks of surgical management?

Answer 14

Infection
Bleeding
Uterine perforation
Cervical damage
Retained tissue and need for repeat procedure

Question 15

What is a recurrent miscarriage?

Answer 15

3 consecutive pregnancy losses less than 24 weeks

Affects 1% of couples

Question 16

How is a recurrent miscarriage managed?

Answer 16

On 3rd or later miscarriage, offer karyotyping of tissue from products of conception
Recurrent miscarriage clinic
Blood tests- thrombophilia screen, anti-cardiolipin antibodies, lupus anticoagulant
Uterine anomalies

Question 17

What is an ectopic pregnancy?

Answer 17

Pregnancy developing outside the uterine cavity.

• 97% in fallopian tube
• 2% interstitial

Question 18

What is the frequency of ectopic pregnancies?

Answer 18

11 per 1000 pregnancies (12,000 in UK each year)

Question 19

What are the risk factors for an ectopic pregnancy?

Answer 19

Previous ectopic pregnancy
Tubal damage
History of sub fertility / IVF
Presence of IUCD
Use of progesterone-only contraception
Cystic fibrosis

Question 20

What are the 3 ways an ectopic pregnancy can present?

Answer 20

Classical
Emergency
Modern presentation

Question 21

Describe the classical presentation of an ectopic presentation

Answer 21

Pain and bleeding in 6-8 weeks gestation
Positive pregnancy test
Empty uterus on transvaginal ultrasound scan

Question 22

Describe an emergency presentation of ectopic pregnancy

Answer 22

Collapsed patient in A&E
Hypotension, tachycardia, acute abdomen
Managed with emergency surgery

Question 23

How is an ectopic pregnancy diagnosed?

Answer 23

Always be suspicious for any patient presenting with pelvic pain, possible bleeding and a positive pregnancy test.
From visualised ectopic on ultrasound scan
Laparoscopy
After patient has collapsed

Question 24

What is the treatment for an ectopic pregnancy?

Answer 24

Conservative
Medical - methotrexate injections
Surgical - salpingectomy, salpingostomy

Question 25

What can cause an in utero death in second trimester?

Answer 25

Foetal abnormality - structural / chromosomal
Infection
Placental dysfunction, growth restriction
SLE / anti-phospholipid syndrome

Question 26

What can cause pre-term labour?

Answer 26

Cervical weakness / incompetence 
Uterine abnormality
Infection
Rupture of membranes
Bleeding

Question 27

What are the indications for cervical sutures?

Answer 27

Past history of miscarriage
Past history of cervical surgery
Known uterine anomaly
Cervical dilatation noted on speculum examination or TV scan

Question 28

What is the definition of a stillbirth?

Answer 28

Baby delivered with no signs of life after 24 completed weeks

Question 29

What is early neonatal death?

Answer 29

Baby dies within 7 days of delivery

Question 30

What is late neonatal death?

Answer 30

Baby dies within 7-28 completed days of delivery

Question 31

What are the causes of stillbirth?

Answer 31

Antepartum / intrapartum bleeding
Intrauterine growth restriction 
Foetal abnormality - structural / chromosomal
Placental factors
Infection
Poorly controlled diabetes

Question 32

What are the causes of neonatal death?

Answer 32

Prematurity
Congenital abnormalities
Infection
Intrapartum asphyxia

Question 33

What happens after a stillbirth?

Answer 33

Offer investigations 
Post-mortem
Creating memories
Funeral options
Ongoing support
Follow-up with consultant to go through investigations