Miscarriage

Question 1

Miscarriage

Answer 1

1. the most complication of pregnancy and experience by 1 in 4 pregnancy
2. Spontaneous loss of pregnancy before 24 weeks

Question 2

Aetiology of miscarriage ( 5 )

Answer 2

FETAL CAUSES
1. Fetal abnormality - 50% of miscarried fetuses are gentically ( trisomy ) or structurally ( neural tube defects ) abnormal
2. Infection of fetus - toxoplasma/rubella/tb/
- bacterial vaginosis : change in the natural flora of the vagina linked to second trimester miscarriage.
MATERNAL CAUSES
3. Maternal age - miscarriage rate increases after 35 years of age
4. Abnormal uterine cavity - fibroids/septums/adhesions/presence of intrauterine contraceptive devices
5. Maternal illness - poorly controlled diabetes/Wilson’s disease
- Antiphospholipid antibodies
- Cervical weakness ‘incompetence’

Question 3

Investigation of miscarriage

Answer 3

Investigation of the cause of miscarriage is delayed until the woman has had 3 consecutive miscarriages

• Ultrasound = aid diagnosis where there is bleeding and os is closed
• Os is open = miscarriage inevitable and scan is unecessary

Question 4

Management of miscarriage

Answer 4

1. Operative route - evacuation of retained products of conception.
   - The cervix is dilated to allow suction or sharp curettage
   - Syntocinon : given intravenously during procedure to encourage uterine contraction and minimum blood loss
   - Products of conception are sent for histology
2. Expectant management - risk of infection with retained products
   - wait for uterus to expel products of conception
   - may take weeks if left to happen spontaneously
   - booked for follow up appointment and scan to confirm uterus is empty
3. Miscarriage increases risk of endometriosis and must be told to be aware of symptoms:
   - fever, feeling unwell, lower abdominal pain and change in vaginal bleeding which can become heavy, smell

Question 5

Recurrent miscarriage

Answer 5

defined as three or more consecutive miscarriages

Question 6

causes of recurrent miscarriage

Answer 6

1. Parental genetic abnormality - 3 - 5%
2. Uterine abnormality - submucosal/spetal/fibroid
3. PCOS
4. Antiphospholipid antibodies
5. Thrombophillic defects - factor V Leiden mutation/Protein s/Antithrombin
6. Cervical weakness/incompetence- secondary to cervical trauma caused by damage to child birth
   - operation causes forcible dilatation for late termination of pregnancy
7. Bacterial vaginosis - imbalance of vaginal flora with lack of lactobacilli results in vaginosis

Question 7

Treatment of recurrent miscarriage

Answer 7

treatment is aimed at the cause, if no cause is found, support and reassurance

1. Genetic abnormality - IVF/prenatal diagnosis
2. Treat uterine septae/fibroids hysteroscopically
3. help PCOS women maintain normal weight
4. Antiphospholipid antibodies women given 75 mg asprin as soon pregnancy test is positive
5. Cervical suture for weakness either
   - transvaginally to be removed at 36 weeks for vaginal delivery
   - transabdominally before conception left in for caesarean delivery
6. Bacterial Vaginosis - metronidazole or intravaginal antibiotic cream

Question 8

Fetal causes of miscarriage

Answer 8

FETAL CAUSES

1. Fetal abnormality - 50% of miscarried fetuses are gentically ( trisomy ) or structurally ( neural tube defects ) abnormal
2. Infection of fetus - toxoplasma/rubella/tb/
   - bacterial vaginosis : change in the natural flora of the vagina linked to second trimester miscarriage.

Question 9

Maternal causes of miscarriage

Answer 9

3. Maternal age - miscarriage rate increases after 35 years of age
4. Abnormal uterine cavity - fibroids/septums/adhesions/presence of intrauterine contraceptive devices
5. Maternal illness - poorly controlled diabetes/Wilson’s disease
   - Antiphospholipid antibodies
   - Cervical weakness ‘incompetence’