Miscarriages

Question 1

What is a miscarriage?

Answer 1

A miscarriage, or spontaneous abortion, is the loss of a pregnancy before 20 weeks of gestation.

but in Malawi it is any pregnancy loss before 28 weeks gestation, the age of viability in Malawi, or with a fetus <1000 g.

Question 2

what are risk factors (9)

Answer 2

1. Maternal systemic infection – UTI, Malaria, TORCH
2. Maternal age > 35 years
3. Trauma
4. Abnormalities of the uterus (fibroids)
5. Immunological disorders e.g. SLE
6. Endocrine disorders e.g. Diabetes
7. Psychological factors – stress
8. Previous miscarriage
9. Chromosomal abnormalities e.g. Trisomy

Question 3

What are the types of miscarriage? (6)

Answer 3

1. Threatened miscarriage (vaginal bleeding with closed cervix)
2. Inevitable miscarriage (vaginal bleeding with open cervix)
3. Incomplete miscarriage (retained products of conception, cervix is open)
4. Complete miscarriage (all products of conception expelled, cervix is closed)
5. Missed miscarriage (retention of a non-viable fetus with closed cervix)
6. Septic miscarriage (infection associated with miscarriage)

Question 4

what do you see in threatened miscarriage (5)

Answer 4

• Pregnancy still viable and may continue.
• minimal bleeding
• minimal/ no abdominal pain
• closed cervix
• uterine size+ GA

Question 5

what investigations do you do for threatened miscarriages (2)

Answer 5

• ultrasound for viability
• grouping and save

Question 6

what management do you give for threatened miscarriage (3)

Answer 6

• self limiting rx
• avoid heavy lifting/ work
• pelvic rest/ avoid coitus

Question 7

what is an inevitable miscarriage

Answer 7

Pregnancy may still be viable but will inevitably proceed to incomplete or complete abortion

Question 8

what are the s/s of inevitable miscarriage (4)

Answer 8

• Heavy bleeding but no passage of POCs
• Abdominal pains/cramping
• Open cervix
• Uterine size=GA

Question 9

what investigations do you do for an inevitable miscarriage (2)

Answer 9

• blood sample for Hb, grouping and save
• check vital signs for signs of infection

Question 10

what management do you give for inevitable miscarriage (8)

Answer 10

1. Expectant management (in hospital) for up to 2 days
2. Medical management
   - For <13weeks: misoprostol 400 mcg SL or 600 mcg orally
   - For >13weeks can consider misoprostol 400 mcg PV/SL every 3hrs x 5 doses
3. Surgical Management (still give misoprostol for cervical ripening and dilatation)
   - MVA preferred if <9 weeks GA, D & C if MVA not available
4. Bereavement counseling
5. Syphilis testing, offer HIV testing
6. Iron supplement if needed
7. FP: can start immediately
8. for suspected infection treat with DCN 100 mg orally BD X 7days plus Metronidazole 800 mg stat

Question 11

what s/s do you see in an incomplete miscarriage(5)

Answer 11

• Heavy bleeding
• Abdominal pain/cramping
• Open cervix
• Uterine size<GA
• POCs are partially expelled

Question 12

what investigations do you do for incomplete miscarriage

Answer 12

Blood samples for Hb, grouping and save/cross match as needed

Question 13

what management do you give for incomplete miscarriage (9)

Answer 13

1. Expectant management (in hospital) for up to 2 days
2. Medical management
   - For <13weeks: misoprostol 400 mcg SL or 600 mcg orally
   - For >13weeks can consider misoprostol 400 mcg PV/SL every 3hrs x 5 doses
3. Surgical Management (still give misoprostol for cervical ripening and dilatation)
   - MVA preferred if <9 weeks GA, D & C if MVA not available
4. Bereavement counseling
5. Syphilis testing, offer HIV testing
6. Iron supplement if needed
7. FP: can start immediately
8. for suspected infection treat with DCN 100 mg orally BD X 7days plus Metronidazole 800 mg stat
9. If in shock, resuscitate with IV fluids and/or blood transfusion proceed with surgical management

Question 14

what are the s/s pf complete miscarriage (6)

Answer 14

• POCs are completely expelled
• Minimal bleeding
• History of passage of POCs
• Minimal abdominal pain
• Closed cervix
• Small uterus

Question 15

what investigations do you do for complete miscarriage (2)

Answer 15

• Blood samples for Hb, grouping and save
• Ultrasound to confirm empty uterus (no gestational sac)

Question 16

what is the management for complete miscarriage (5)

Answer 16

• Evacuation not necessary
• Bereavement counselling
• Syphilis testing, offer HIV testing
• Iron supplement if needed
• FP: can start immediately if passage of POCs within 2 past weeks

Question 17

what are the s/s for missed miscarriage (5)

Answer 17

• Pregnancy is no longer viable but no POCs have been expelled
• No history of bleeding
• No abdominal pains
• Closed cervix
• Loss of pregnancy symptoms (Nausea /vomiting, breast tenderness/engorgement)

Question 18

what investigations do you do for missed miscarriage (2)

Answer 18

• Blood for Hb, grouping and save
• Ultrasound to confirm non-viability

Question 19

what is the management of missed miscarriage (8)

Answer 19

1. Expectant management in the hospital up to 2wks
2. Medical management
   - For <12 wks: Misoprostol 800mcg PV or 600mcg SL, may be repeated every 3hrs, up to 2 additional doses
   - For 12-24 wks, Misoprostol 400 mcg PV every 6hrs until uterine contractions are fully establshed
   - For 24-28 wks, Misoprostol 200mcg PV every 4 hrs until uterine contractions are fully established
3. Surgical Management: (Still give misoprostol to for cervical ripening before surgical intervention)
   - 1st TM: MVA preferred, if not available D& C
   - Consider cervical ripening with Misoprostol 400mcg PV or SL 2-3hrs prior to procedure
   - 2nd TM: dilation and evacuation
4. Bereavement counseling
5. Syphilis and HIV testing
6. Iron supplementation if needed
7. FP can start immediately
8. DCN 400mg STAT, Metronidazole 400mg STAT if infection suspected

Question 20

what s/s do you see in a septic miscarriage (4)

Answer 20

any of the miscarriages with (incomplete/ missed/ inevitable) :
- T ≥ 38°C
- Maternal PR > 100 bpm
- Purulent vaginal discharge/POCs
- Pelvic pain/tenderness

Question 21

what investigations do you do for septic miscarriage (3)

Answer 21

• FBC
• Grouping & save/crossmatch
• Bedside clotting time

Question 22

what is the management for septic miscarriage (5)

Answer 22

• Resuscitation: IV fluids +/- blood transfusion
• Monitor Vital Signs and urine output
• Benzyl Penicillin 2 MU IV Q6H, Gentamycin 320mg IV OD, Metronidazole 500mg IV Q8H
• Switch to DCN 100mg BD plus Metronidazole 400mg TDS X 7 days when able to take oral drugs
• Evacuation by experienced doctor to avoid perforation