Miscarriage

Question 1

What is the epidemiology of miscarriage?

Answer 1

1 in 3 pregnancies or 1 in 8 of known pregnancies
Peak 30-40yrs

Question 2

Define miscarriage

Answer 2

Spontaneous loss of pregnancy before 24weeks gestation

Question 3

What is recurrent miscarriage?

Answer 3

3 or more miscarriages

Question 4

What are some risk factors for miscarriage?

Answer 4

Fetal development -> chromosomal abnormalities, genetics
Maternal health -> infections, APLS, thrombophilia, endocrine disorders, genetic abnormalities, maternal age and history of miscarriage, smoking, stress, BMI extremes
Uterine conditions -> Bicornuate, cervical impotence, endometriosis
Environmental -> high dose radiation, heavy metal exposure

Question 5

What paternal factors can increase the risk of miscarriage?

Answer 5

Tight clothing
Sperm abnormalities
Old paternal age.

Question 6

What pathological process underlying a miscarriage?

Answer 6

Ovum unable to develop in the uterus -> initiates uterine contractions, cervix dilates and loss of foetus and pregnancy tissue.
Haemorrhage in the decidua basalis leading to necrosis and inflammation.

Question 7

How does the stage of gestation influence the type of miscarriage that is most likely?

Answer 7

Prior to 12 weeks -> complete is most likely as placent has not yet developed

If between 12-24 -> gestation sac may rupture and expel fetus byt placenta tissue may remain -> incomplete miscarriage

Question 8

What are the different types of miscarriage?

Answer 8

Cervical os closed:
Missed -> foetus not viable, may have bleeding
Threatened -> bleeding, foetus still viable
Complete -> no tissue remains, bleeding will stop, closed os as finished

Cervical os open:
Incomplete -> tissue still being lost, placenta may need assistance
Inevitable -> non-viable pregnancy with an open os, all tissue remains

Question 9

What further risks are associated with a threatened miscarriage?

Answer 9

Higher risk of preterm delivery and premature rupture of membranes

Question 10

How can miscarriages be classified by gestation?

Answer 10

Prior to 13 weeks is early
13 w and later gestation is late

Question 11

What are the clinical features of a miscarriage?

Answer 11

Vaginal bleeding
Lower cramping abdominal pain
Vaginal fluid discharge/tissue discharge
Loss of pregnancy symptoms
Lower back pain

Question 12

When should patients with miscarriage be referred?

Answer 12

To hospital for -> haemodynamically unstable
EPAU -> ?ectopic
EPAU -> unknown gestation or more than 6w, with doubt of viability and problems

Question 13

When is the expectant management of miscarriage often considered the most beneficial?

Answer 13

Bleeding but NO pain and <6w gestation.
Repeat pregnancy test after 7-10days.
If pos refer to EPAU or out of hours.

Question 14

What are some key investigations for a miscarriage?

Answer 14

Transvaginal ultrasound scan
Serum bHCG -> expect to decrease

Question 15

What further investigations should be done for recurrent miscarriage?

Answer 15

Karyotyping to identify chromosomal abnormalities
Transvaginal ultrasound scans -> for structural or anatomical abnormalities
Blood tests -> antiPLS, lupus anticoagulant

Question 16

What is the key difference between a miscarriage and an ectopic pregnancy?

Answer 16

Ectopic -> cervical motion tenderness

Question 17

What is the expectant management of miscarriage?

Answer 17

Waiting for spontaneous miscarriage within 7-14 days
Then consider medical or surgical management

Question 18

When is it recommended that a medical or surgical management of a miscarriage is used?

Answer 18

Increased risk of haemorrhage -> late first trimester, coagulapathies, unable to have blood transfusion
Previous traumatic/adverse experience
Evidence of infection

Question 19

What medical management is used for missed miscarriage?

Answer 19

Oral mifepristone -> progesterone receptor antagonist -> weakens endometrial wall, softens and dilates cervix, begins contractions

48hrs later -> misoprostol -> prostaglandin analogue -> strong myometrial contractions.

Question 20

What medical management should be offered for an incomplete miscarriage?

Answer 20

Single dose of misoprostol -> triggers strong uterine contractions

Question 21

How long after medical management of a miscarriage should a pregnancy test be done?

Answer 21

3 weeks

Question 22

What surgical management may be given after a miscarriage?

Answer 22

Vacuum aspiration (surgical curettage) -> LA as outpatient

Surgical management in theatres in GA

Question 23

When is anti_D required after a miscarriage?

Answer 23

To rhesus neg mothers -> after surgical management
-> after medical management of incomplete miscarriage
Increased risk of consequitive miscarriage

Question 24

What additional management might be used for a woman with a threatened miscarriage?

Answer 24

Vaginal progesterone 400mg BD
Helps thicken the cervical mucus and prevent thinning of wall.

Question 25

How long would you expect bleeding to last in a miscarriage before additional management is needed?

Answer 25

14 days

Question 26

How does the management vary between a missed and an incomplete miscarriage?

Answer 26

Missed  Oral mifepristone 200mg; 48 hours later- Misoprostol 800micrograms (PV / oral/ sublingual) Incomplete  Single dose Misoprostol 600micrograms (PV / oral/ sublingual)