Miscarriage

Question 1

Define a miscarriage?

Answer 1

The premature loss of a fetus up to 23 weeks of pregnancy and weighing up to 500 g

Question 2

What are the different types of miscarriage?

Answer 2

• Threatened
  
  • The fetus is “threatened” (i.e. a miscarriage may happen)
  • There is some vaginal bleeding BUT the cervical os is CLOSED and ultrasound reveals a VIABLE intrauterine pregnancy.
  • 90% of threatened miscarriages will continue to grow to normal gestation.
• Inevitable
  
  • The miscarriage is “inevitable” i.e. a miscarriage is going to happen.
  • There is vaginal bleeding +/- cramping abdominal pain AND the cervical os is OPEN but the products of conception have not yet passed
• Incomplete
  
  • i.e. currently happening. There is heavy and increased vaginal bleeding, intense lower abdominal pain and passage of some products of conception.
  • On examination the cervical os is OPEN and there are PRODUCTS OF CONCEPTION present in the canal.
• Complete
  
  • The miscarriage is “complete”.
  • Products of conception have been passed.
  • On examination the cervical os is CLOSED. Ultrasound reveals an EMPTY uterine cavity.
• Missed (silent)
  
  • where the fetus has died and the patient has not realised yet, products of conception may or may not have been passed
  • The patient is amenorrhoeic but has not had any vaginal bleeding or abdominal pain.
  • On examination there is no passage of tissue and the cervical os is CLOSED. Ultrasound confirms a non-viable intrauterine pregnancy.

Question 3

How common are miscarriages?

Answer 3

15% of clinically recognised pregnancies end in miscarriage

(10-25%)

Question 4

What causes miscarriages?

Answer 4

Often no cause is known, but of this that are known it is usually caused by a chromosomal abnormality.

Most commonly, trisomy’s monosomy’s and polyploidy (wrong number of chromosomes aka 69 XXX)

Sometimes happens because there is a weakness of the cervix, called an incompetent cervix, which cannot hold the pregnancy

Question 5

What are some risk factors for miscarrying?

Answer 5

• Increased age.
• PCOS (polycystic ovary syndrome) and poorly controlled diabetes
• Thrombophilias
• Presence of anti phospholipid antibodies (cause a hyper-coaguable state)
• Uterine abnormalities
• Maternal Infection (Rubella and CMV particularly)

Question 6

Define recurrent miscarriage and how common is it?

Qhat investigations should you always do?

Answer 6

1. 3 or more miscarriages which occur in succession 1% of pregnancies
2. • Bloods:
   • TFT’s + fasting glucose Karyotype of both parents to check for a balanced reciprocal or robertson translocation (3- 5%)
     * Maternal blood test for antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibodies.)
     * Thrombophilia screen
     * Imaging:
   • Pelvic ultrasound – to check for abnormalities of the uterus.
     * Hysterosalpingogram
     * Invasive:
   • Hysteroscopy or laparoscopy
     * Luteal phase endometrial biopsy

Question 7

What is the likely diagnosis and management plan?

Hx: Amenorrhoea for 2 months. PV bleeding and cramp like abdo pain 2 days. O/e: HR: 126 BP:90/62 Cervix dilated and products of conception (POC) is felt through OS.

Answer 7

Inevitable miscarriage; will either be complete or incomplete. Patient appears shocked: Haemorrhagic shock or cervical shock (vasovagal attack following stimulation of the dilated cervix) Manage shock: Cervical = remove contents from cervix, high flow O2, fluid bolus Hemorrhagic: replace blood loss + stop bleeding + ABC

Question 8

What is the likely diagnosis and management plan? Patient comes in for 12 week scan. Hx: Amenorrhoea for 3 months. PV dark red bleeding 8 weeks into pregnancy. O/e: Cervix closed Ix: Beta-HCG +ve No fetal heart on doppler scan. No fetus in gestational sac. Uterus small for dates.

Answer 8

Ectopic preganancy or Missed miscarriage Consider the bHCG level, typically lower in ectopic pregnancies. Ectopic pregnancy should be some pain on movement of cervix. Diagnostic test for ectopic = laparoscopy. If patient is stable repeat bHCG in 48hrs, in viable pregnancy should approximately double. Management of missed miscarriage is: Medical: prostaglandins to stimulate uterine contraction Surgical removal of POCs Reassurance

Question 9

What is the likely diagnosis and management plan? Hx: Amenorrhoea for 3 months. PV bleeding. O/e: Stable, no uterine tenderness, uterine size = dates, cervix closed Ix: Beta-HCG +ve Fetal heart sounds on US

Answer 9

Threatened miscarriage. Reassure.

Question 10

What is the likely diagnosis and management plan? Hx: Amenorrhoea for 2 months. 3 days ago heavy vaginal bleeding which then becomes very light, cramp like abdo pain which then resolves. O/e: Uterine size smaller than dates, cervix closed.

Answer 10

Complete miscarriage. MGMT: US Scan uterus, ensure no remaining POC. Rule out ectopic (always have a high index of suspicion) Reassurance

Question 11

What is the likely diagnosis and management plan? Hx: Amenorrhoea for 2 months. Today heavy vaginal bleeding , cramp like abdo pain. O/e: Uterine size smaller than dates, cervix dilated products felt in vagina. Ix: bHCG +ve, products on US scan

Answer 11

Incomplete Miscarriage (risk of sepsis) MGMT: General resus (be wary of cervical shock) Medical management (prostaglandins)/Surgical removal/Expectant Give Anti D if mother is resus -ve If septic (obvious signs of infection) Manage by giving 24hrs of antibiotics followed by surgical removal.

Question 12

When counselling on expectant management what information should you give the patient?

Answer 12

Onset, duration and magnitude of the inevitable bleeding are unpredictable.

Question 13

If on US scanning there is an empty uterus in a patient who has had previously tested +ve on betaHCG what are the potential diagnoses? How would you investigate?

Answer 13

Ectopic pregnancy Complete miscarriage Viable early pregnancy If stable repeat bHCG after 48 hours. Normal pregnancy the bHCG level approximately doubles every 48hrs. Ectopic pregnancy it increases at a slower rate. Complete miscarriage the bHCG level should be dropping. If unsure after the second test and patient is stable repeat US in 1 week. (only if patient is reliable and can easily come to hosiptal) Note intrauterine sac is usually visible when bHCG>1000

Question 14

What are the different causes of recurrent miscarriage?

Answer 14

50% Idiopathic 10-15% Uterine malformations 10-15% Endocrine (luteal phase deficiency or metabolic aka diabetes/thyroid) Genetic/Immunological/Infective Note ~ 35% of couples with recurrent miscarriage will have lost pregnancies by chance and fall into the idiopathic category. They will have a 75% chance of a successful pregnancy with no therapeutic intervention. For this reason empirical treatment is not used.

Question 15

What is antiphospoholipid syndrome?

Answer 15

Antiphospholipid syndrome is the presence of anticardiolipin or lupus anticoagulant antibodies on 2 separate occasions with one of the following: - 3 or more consecutive miscarriages before week 10 - 1 miscarriage after 10 weeks - 1 or more births of a morphologically normal foetus at less than 34 weeks associated with severe pre-eclampsia or placental insufficiency -Venous thrombosis

Question 16

What is the significance of antiphospholipid syndrome?

Answer 16

Cause of 5-10% of recurrent miscarriage and is very treatable. Causes a hypercoaguable state therefore treat with aspirin and low molecular weight heparin as soon as viability is confirmed.

Question 17

When doing parental karyotyping what is being looked for and what is it?

Answer 17

3-5% of recurrent miscarriages. Balanced reciprocal or robertson’s translocations. Robertson’s translocation’s. The carrier is phenotypically normal. However during meiosis several of the chromosomes undergo whole arm translocations with the paired chromosome being lost. Therefore leaving unbalanced gametes. Balanced reciprocal translocations: Is when there is a translocation between to pairs of chromosomes often this does not cause problem but on certain occasions it can cause a foetus to not be viable.

Question 18

Outline a general management plan for miscarriage?

Answer 18

Admit to hospital if: ectopic/septic/heavy bleeding Products of conception in the cervical os cause pain, bleeding and vasovagal shock and should be removed on speculum examination. Fever, must make sure not septic Anti D to all non sensitised Rh-ve women: -Greater than 12 weeks and bleeding -Less than 12 weeks needing uterine evacuation