Miscarriage + TOP

Question 1

Def threatened miscarriage (4)

Answer 1

Up to 13 weeks (first crimester)

• os closed
• Spotting
• with or without lower abdominal pain
• fetus alive

Question 2

Presentation of inevitable miscarriage

Answer 2

First trimester: up to 13 weeks

• Os dilated
• increased PV bleed: clots
• lower abdominal pain-tender uterus
• fetus alive
• Products still in uterus

Question 3

Presentation of incomplete miscarriage (5)

Answer 3

First or second trimester

• Os open with or without POC in os
• passed some products of conception: clots
• uterus smaller than expected for GA, bulky uterus
• lower abdominal pain-tender uterus, pain better after passing products of conception
• ultrasound: retained POC or ET >15mm

May have hypovolaemic shock

US: still retained products conception

Question 4

Presentation complete miscarriage

Answer 4

Second trimester: 13 - 20 weeks

• os open OR closed
• passed ALL products of conception. Examine foetus and placenta for completeness
• bleeding subsides within 48 hours
• ultrasound: no POC, ET <15mm

Question 5

Presentation missed miscarriage

Answer 5

Can be first or second trimester. Usually seen on routine examination as no symptoms

• os closed
• no bleeding
• No pain
• Fetus dead

Question 6

Rx threatened miscarriage

Answer 6

• Conservative /expectant: 60% do not abort.
• Reassurance and follow up

Question 7

Rx inevitable miscarriage (5)

Answer 7

• Resus if shocked: crystalloids and blood products
• if haemodynamically stable 1st trimester: expectant management, allowed to abort. Then reassess for further rx
• later pregnancy: active management with iv oxytocin + acute pain relief
• medical management options: iv oxytocin (decrease bleeding) , misoprostol
• surgical options: <14 weeks(first trimester) = mva or suction curettage

Question 8

incomplete miscarriage rx! (5)

Answer 8

• Resus if shocked. Can only intervene when haemodynamically stable, not septic (end organ involvement - kidney, liver, haematological). Do hysterectomy if 2 or more organs involved.
• Remove visible retained products W/ ovum forceps to enable uterus to contract and stop further vaginal blood loss
• expectant or medical management (misoprostol and mifepristone) only if easy access to health facility should bleeding persist as most early miscarriage (<6 weeks amenorrhoea) bleeding subsides in 48 hours
• surgical management preferred to medical
• <14 weeks - MVA or surgical curettage
• > 14 weeks - evacuation

Antibiotics: gentamicin, ampicillin, flagyl

Question 9

Rx complete miscarriage (3)

Answer 9

• Expectant management
• uterine evacuation not indicated. Observe for possible haemorrhage.
• second trimester: examine foetus and placenta for completeness to make diagnosis. Where indicated, send tissue eg calf muscle for chromosomal analysisand placenta biopsy for histology and Chorioamnionitis

Question 10

Rx missed miscarriage (2)

Answer 10

• First trimester (<14 weeks): medical management with misoprostol and mifepristone or surgical with primary dilatation cervix and curettage or MVA
• > 14 weeks - medical management followed by uterine evacuation if indicated. Expert can do dilatation and extraction of foetus

Question 11

Differential vaginal bleeding in early pregnancy? (4)

Answer 11

• Threatened miscarriage
• Implantation bleeding
• anembryonic pregnancy (blighted ovum)
• Ectopic pregnancy

Question 12

Diagnosis anembryonic pregnancy (blighted ovum) (2)

Answer 12

• Irregular gestational sac without foetus in pregnancy 8 or more weeks gestation , or
• empty gestational sac > 25 mm

Question 13

Name 4 types miscarriages that can occur in first trimester (up to 13 weeks)

Answer 13

• Threatened
• inevitable
• incomplete
• missed

Question 14

Name 4 types miscarriages that can occur in second trimester (13 - 20 weeks)

Answer 14

• Incomplete
• complete
• septic
• missed

Question 15

Diagnosis septic miscarriage?

Answer 15

Miscarriage complicated by fever (38 or more)

Question 16

Name 4 warning signs for serious underlying septic miscarriage

Answer 16

• Generally: distress, agitation, lethargic, hyperventilate, bed bound
• vitals: weak peripheral pulse > 100, rr > 20, T< 36,5 or > 37,8
• abdomen: tender or signs peritonism
• gynae: excessive bleed, foul smell discharge, vaginal lacerations, gangrenous cervix

Question 17

Management protocol septic miscarriage? (7)

Answer 17

Determine status and Resuscitate , admit

Hysterectomy indications
- septic shock
- multi organ dysfunction
- necrotic cervix
- pus in abdomen detected by colpopuncture
- uterine perforation

If not meet criteria/decline:
- evacuation of septic uterine contents under ga.

Question 18

Special investigations for miscarriage? (4)

Answer 18

• Screen for syphilis (rpr)
• Rh factor (give anti-d if Rh negative and second trimester miscarriage)
• cervical cytology
• hb

Question 19

Name 3 risk factors miscarriage

Answer 19

• AMA
• previous miscarriage
• maternal smoking

Question 20

Name 8 possible causes early (12 - 14 weeks/ first trimester ) miscarriage

Answer 20

Medical

• sporadic chromosomal abnormalities
• HLA status ( human leukocyte antigen)
• auto-immune diseases

Structural

• corpus luteum defect
• poor placentation
• uterine septum

Other

• Chance occurrence
• environmental factors

Question 21

Name 6 possible causes late ( 14 - 24 weeks/ second trimester ) miscarriage

Answer 21

• Cervical incompetence!
• congenital abnormality uterus
• submucous myomata
• poor placentation
• infections
• medical diseases: hypothyroid, diabetes

Question 22

Antibiotics for unsafe abortion? (3)

Answer 22

• Cefuroxime 750 mg 8 hourly iv +
• metronidazole 500 mg 8 hourly iv +/ -
• gentamicin 240 mg daily iv or ertapenem 1 g daily iv

Question 23

Name 6 contraindications mva

Answer 23

• Gestation > 14 weeks
• extreme patient anxiety
• active pelvic infection
• uterine anomalies
• unsafe top
• unstable pt: P > 100, SBP < 100, hb < 9, temp 37,5

Question 24

Define recurrent early pregnancy loss

Answer 24

3 or more consecutive losses of pregnancy <14 weeks

Question 25

Workup for recurrent early pregnancy loss? (6)

Answer 25

- Uterine study pre-pregnancy: sonohysterography, hysterosalpingogram, hysteroscopy or MRI - maternal antiphospholipid antibodies (2 positive tests > 12 weeks apart) - paternal karyotype (>2 miscarriages < 10 weeks) - fasting glucose - thyroid functions - genetic evaluation of products of conception

Question 26

Which law governs termination of pregnancy

Answer 26

Choice of termination of pregnancy act no 92, 1996

Question 27

According to Choice of termination of pregnancy act no 92, 1996, when may pregnancy be terminated (8)

Answer 27

First 12 weeks - upon request 12 weeks - 20 weeks (need 1 Dr) - risk injury to woman physical/mental health - substantial risk to foetus, would suffer severe physical/mental abnormality - significantly affect social/ economic circumstances woman - rape or incest After 20 weeks (need 2 Drs or Dr + midwife) - endanger woman's life - severe malformation of foetus - risk injury to foetus

Question 28

Name 5 indications for surgical evacuation over MVA

Answer 28

- active bleeding - severe anaemia - uncontrolled medical conditions - septic ICA - Large height of fundus (>14 weeks)

Question 29

Antibiotics for septic miscarriage?

Answer 29

Clindamycin 900mg tds (anaerobes, strep, staph) Plus Gentamicin 5mg/kg IVI dly (gram neg) With or without Ampicillin 2g IVI 4HRLY (gram pos) OR ampicillin + gentamicin + flagyl 500 IVI tds