Miscarriage

Question 1

Define Miscarriage.

Answer 1

Pregnancy loss <24 weeks of gestation.

Question 2

What are the types of miscarriage?

Answer 2

• Threatened - PV bleed with FH present → os must be closed
• Inevitable - PV bleed with open cervical os
• Incomplete - passage of products of conception but uterus isn’t empty on USS
• Complete - passage of products of conception and uterus is empty on USS
• Missed - USS diagnosis of miscarriage in absence of symptoms

Question 3

What are the risk factors for miscarriage?

Answer 3

• Increasing maternal age
• Previous miscarriage
• Chronic conditions
• Uterine/cervix abnormalities
• Smoking
• Alcohol
• Illicit drugs
• Underweight or Obese

Question 4

What should be thought of in patients with recurrent miscarriages?

Answer 4

• Structural abnormalities - fibroids, bicornuate or septate uteri
• Cervical incompetence - if later miscarriages (>13w)
• Medical conditions - renal, diabetes, SLE
• Clotting abnormalities - FV-L, AT-III deficiency, antiphospholipid syndrome

Question 5

What are the signs and symptoms of miscarriage?

Answer 5

• PV bleeding (scanty, brownish/red)
• Cramping abdominal pain
• Fever
• O/E
  
  • Speculum → quantity and location of bleeding, os open/closed
  • PV exam → exclude ectopic - unilateral tenderness, cervical excitation, adnexal mass
  • General → assess for signs of shock, pyrexia

Question 6

What are the appropriate investigations for a suspected miscarriage?

Answer 6

• Pregnancy test → Speculum → TVUSS
• TVUSS:
  
  • 1st = Look for FH
  • 2nd = Foetal poles for CRL → if not foetal pole, look for GS:
    
    • If no FH and CRL >7mm = Miscarriage
    • If no FH and CRL <7mm = PUV → TVUSS in 7 days
    • If GS >25mm + no foetus = Miscarriage
    • If GS <25mm + no foetus = PUV → TVUSS in 7 days

Question 7

What investigations should be done for women with recurrent miscarriages?

Answer 7

• Cytogenic analysis of products of conception
• Pelvic USS (structural abnormalities)
• Anti-phospholipid antibodies
• Anticardiolipin antibodies
• Screen for BV → explain that the cause is often never found

Question 8

What is the management of a miscarriage <6 weeks?

Answer 8

• Expectant management → no USS, just send them on their way
• Do a pregnancy test in 1 week
  
  • If positive result or symptoms persist follow-up in clinic in 2 weeks
    
    • If RPC, proceed as per medical/surgical management

Question 9

What is the management of a miscarriage >6 weeks?

Answer 9

• EPAU referral → USS and tests
• Viable pregnancy → expectant management
• Complete missed miscarriage → council and go home
  
  • Psychological awareness of patient’s state of mind
  • Advice - Menstruation will begin in 4-8 weeks, try for another when mentally ready
• Miscarriage with retained products:
  
  • 1st line = Expectant management for 7-14 days
    
    • If bleeding/pain settle → pregnancy test after 3 weeks → return if +ve
    • If bleeding/pain persist → follow-up clinic in 4 weeks
    • Patient declines/Not appropriate if:
      
      • Infection
      • Coagulopathy
      • Late 1st trimester
      • Previous traumatic experience
  • 2nd line - Medical = Misoprostol
    
    • Indications = expectant failed, patients choice
      
      • Advise - bleeding, pain, nausea
  • 2nd line - Surgical
    
    • Manual vacuum aspiration (LA)
      
      • Indicated: medical failed, pt. choice
    • Surgical ERPC (GA)
• If signs of ectopic or severe bleeding symptoms = admission → surgical management

Question 10

When should anti-RhD be administered in the context of a miscarriage?

Answer 10

• BCSH guidelines
  
  • Administer if mother rhesus -ve and >12w GA (any method of management)
• NICE guidelines
  
  • Administer if mother rhesus -ve and not solely managed medically

Question 11

What are the signs and symptoms of anti-phospholipid syndrome?

Answer 11

• VTE
• Arterial thrombosis
• Thrombocytopenia
• RMC
• Pre-eclampsia
• Assess for features of SLE

Question 12

What are the appropriate investigations for suspected anti-phospholipid syndrome?

Answer 12

Lupus anticoagulant AB ± Anti-cardioliptin AB

Question 13

What is the management of anti-phospholipid syndrome?

Answer 13

• Acute → warfarin + LMWH
• Chronic → DOAC
• Pregnancy → low-dose aspirin + LMWH

Question 14

What is the prognosis of miscarriages?

Answer 14

• Most patients go on to have successful pregnancies
  
  • 1 miscarriage → 85% chance next will be successful
  • 2 miscarriages → 75% chance next will be successful
  • 3 miscarriages → 60% chance next will be successful