Miscarriage

Question 1

Miscarriage - definition

Answer 1

Spontaneous loss of IUP

Question 2

Miscarriage - incidence

Answer 2

1. 15% of all pregnancies result in miscarriage
2. 24-50% of women will have at least one miscarriage in their lifetime
3. 50-60% of all miscarriages are due to spontaneous chromosomal defects

Question 3

Miscarriage - types

Answer 3

1. Threatened miscarriage
   - Vaginal spotting/light bleeding with minimal pelvic or lower back pain. On VE, cervix is closed. U/S reveals a live intrauterine fetus
2. Inevitable miscarriage
   - Lower abdominal pain and vaginal bleeding. VE - lower uterus appears to be ballooning. Open cervix. U/S shows an intrauterine gestational sac +/- fetal pole +/- fetal heart activity
3. Incomplete miscarriage
   - Bleeding and pain. VE - products of conception often in canal. Open cervix. U/S shows heterogenous tissues +/- gestational sac. Any endometrial thickness
4. Complete miscarriage
   - Pain and bleeding stop. Closed cervix. Empty uterus. Endometrial thickness

Question 4

Miscarriage - ix

Answer 4

1. Serum hCG level

2. Transvaginal ultrasound scan

Question 5

Miscarriage - mx

Answer 5

1. Threatened miscarriage = anti-D for non-sensitised Rhesus negative. 250IU of anti-D IgG within 72hrs of miscarriage if 12 weeks. Reassure woman and organise follow-up

Other forms of miscarriage:

2. Give anti-D if non-sensitised rhesus negative. 250IU of anti-D IgG within 72hrs of miscarriage if 12 weeks.
3. Expectant management in first trimester. Need regular follow-up. May still need surgical evacuation
4. Medical evacuation is an accepted alternative to expectant management. Use misoprostol (prostaglandin analogue) and/or mifepristone (antiprogesterone). Note - incomplete miscarriage is usually managed with misoprostol alone. In missed miscarriage, higher doses and longer duration of use may be needed, or priming with anitprogesterone. Success rates are high (85%) but bleeding may continue for 14-21d after treatment
5. Surgical evacuation with suction curettage - preferred for pts who have heavy bleeding or who wish to avoid the inconvenience of not knowing when a miscarriage will take place. Necessity if haemodynamically unstable or if signs of sepsis are present. Serious complications = perforation, cervical tears, intra-abdominal trauma, haemorrhage and intrauterine adhesions (Ashermann’s syndrome). Tissue obtained at the time of miscarriage should be histologically examined to confirm products of conception (and to exclude EP/GTD)

Question 6

Recurrent miscarriages

Answer 6

1. After one miscarriage, the risk of another is the same as for the general population
2. After two miscarriages = risk is 25%
3. After three miscarriages = risk is 40%
4. Reasonable to refer and start ix after at least two miscarriages under 12 weeks and after one miscarriage in the second trimester. Refer to specialised services. Counselling and support
5. Ix = looking for modifiable factors such as thrombophilia, medical disorders and structural abnormalities (e.g. cervical incompetence -> 2nd trimester loss). Genetic counselling if abnormal parental karyotype