Miscarriage Flashcards Preview

B - Gynaecology > Miscarriage > Flashcards

Flashcards in Miscarriage Deck (88)
1

What is a miscarriage?

When there is loss of pregnancy before 24 weeks gestation

2

What % of recognised pregnancies end in miscarriage?

12-24%

3

Why is the rate of miscarriage probably higher than we know?

They may occur before pregnancy is realised

4

What number of hospital admissions occur due to miscarriage annually?

42,000

5

What % of miscarriages occur in the first trimester?

85%

6

How does the risk of miscarriage change with gestational age?

Falls rapidly

7

What are the risk factors for miscarriage?

- Maternal age >30
- Cigarette smoke
- Excess alcohol
- Low pre-pregnancy BMI
- Paternal age >45 years
- Fertility problems and taking longer to conceive
- Illicit drug use
- Uterine surgery or abnormalities
- Uncontrolled DM
- Stress, anxiety or traumatic events

8

Why does risk of miscarriage increase with maternal age?

Due to risk of chromosomal abnormalities increasing

9

What are some protective factors against miscarriage?

- Previous live birth
- Nausea
- Healthy diet

10

Is a cause for miscarriage always identified?

No in many cases it isn't

11

How does the prognosis of future pregnancies in miscarriage with an unidentifiable cause compare to a miscarriage with a known cause?

It is generally better

12

What are some identifiable causes of miscarriage?

- Chromosomal abnormalities
- Endocrine factors
- Maternal illness and infection
- Maternal lifestyle and drug history
- Abnormalities of the uterus
- Cervical incompetence
- Autoimmune factors
- Thrombophilic defects
- Alloimmune factors

13

What is the most common type of chromosomal abnormality?

Autosomal trisomies

14

What % of miscarriages due to chromosomal abnormalities are caused by autosomal trisomies?

50%

15

What endocrine factors can lead to miscarriage?

- Failure of corpus luteum
- PCOS
- Poorly controlled diabetes
- Untreated thyroid disease

16

Why can corpus luteum failure lead to miscarriage?

Progesterone production is predominantly dependant on the corpus luteum in the first 8 weeks

17

What maternal illnesses can lead to miscarriage?

- Severe febrile illness
- Syphilis
- Listeria
- Mycoplasma
- Bacterial vaginosis
- Other systems illness e.g. cardiac, renal or hepatic disease

18

What maternal lifestyle factors can lead to miscarriage?

- Smoking
- Alcohol use
- Caffeine
- Cocaine
- Cannabis
- Stress

19

What drug history can lead to miscarriage?

- Anti-depressant sue
- Peri-conceptual NSAID use

20

What uterine abnormalities can lead to miscarriage?

- Congenital abnormalities
- Asherman's syndrome

21

What congenital abnormalities of the uterus can lead to miscarriage?

- Bicornuate uterus
- Subseptate uterus

22

Congenital uterine abnormalities are present in what % of women with recurrent miscarriage?

15-30%

23

What is Asherman's syndrome?

Where damage to the endometrium and inner uterine walls cause the surfaces to become adherent, partially obliterating uterine cavity

24

When can cervical incompetence lead to?

2nd trimester miscarriage or early preterm delivery

25

How does a miscarriage due to cervical incompetence present?

Usually painless, rapid and bloodless

26

How can cervical incompetency be diagnosed?

- Passage of a Heger 8 dilator without difficulty in a non-pregnant woman
- USS
- Pre-menstrual hysterogram

27

What is the most common cause for cervical incompetency?

Physical damage by mechanical dilation of the cervix or during childbirth

28

What autoimmune factor can commonly cause miscarriage?

- Antiphospholipid antibodies

29

What % of women with recurrent miscarriage have antiphospholipid antibodies present?

15%

30

What is the live birth rate in women with untreated antiphospholipid syndrome?

As low as 10%

31

What is thought to cause pregnancy loss in antiphospholipid syndrome?

Thrombosis of uteroplacental vasculature and impaired trophoblast function

32

What other risks in pregnancy are associated with antiphospholipid syndrome?

- IUGR
- Pre-eclampsia
- Venous thrombosis

33

What is the commonest presentation of miscarriage?

Vaginal bleeding with pain worse than a period

34

What should be looked for on examination in suspected miscarriage?

- Signs of haemodynamic instability
- Abdominal distension with localised tenderness
- Assess diameter of os and look for products of conception on speculum
- Assess uterine tenderness and adnexal mass on bimanual

35

What are some signs of haemodynamic instability?

- Pallor
- Tachycardia
- Tachypnoea
- Hypotension

36

What are the types of miscarriage?

- Threatened miscarriage
- Inevitable miscarriage
- Missed miscarriage
- Incomplete miscarriage
- Complete miscarriage
- Recurrent miscarriage
- Septic miscarriage

37

What are the features of a threatened miscarriage?

- USS shows viable pregnancy
- Mild bleeding
- Usually little to no pain
- Os is closed

38

What percentage of women with a threatened miscarriage will go on to have a complete miscarriage?

50%

39

What is an inevitable miscarriage?

- Heavy bleeding with clots and pain
- Os is open
- Pregnancy will not continue

40

What is a missed miscarriage?

- Fetus is dead but retained
- History of threatened miscarriage and persistent, dark-brown discharge
- Decreased or absent early pregnancy symptoms

41

What is an incomplete miscarriage?

Products of conception are partially expelled

42

What is a complete miscarriage?

Confirmed uterine pregnancy in history followed by bleeding and clots with subsequent USS showing no pregnancy tissue in uterus

43

What is recurrent miscarriage?

3 or more consecutive miscarriages

44

What is a septic miscarriage?

When products of conception get infected

45

What are the features of a septic miscarriage?

- Fever
- Rigors
- Uterine tenderness
- Bleeding/discharge
- Pain

46

What might investigations show in septic miscarriage?

- Leucocytosis and raised CRP
- Features of complete or incomplete miscarriage

47

What are the differentials for a miscarriage?

- Ectopic pregnancy
- Hydatiform mole
- Cervical/uterine malignancy

48

When is a patient suspected for a miscarriage?

- Positive urine pregnancy test
- Vaginal bleeding with or without pain

49

What investigations should a patient with a suspected miscarriage receive initially?

- Transvaginal ultrasound scan in an early pregnancy assessment unit
- Serum beta-HCG

50

What must be looked for on USS in suspected miscarriage?

- Fetal cardiac activity
- Fetal crown-rump length
- Mean sac diameter and fetal pole

51

What is the most important finding on USS to exclude miscarriage?

Fetal cardiac activity

52

When can fetal cardiac activity normally be observed on transvaginal USS?

5.5-6 weeks gestation

53

Why is crown-rump length an important measure in assessing a suspected miscarriage?

To estimate gestation

54

When can a conclusive diagnosis of miscarriage not be made?

When CR length <7mm and no fetal heart activity detected

55

When should a scan be repeated if a conclusive diagnosis of miscarriage cannot be made due to CR length?

7 days later

56

How can an intrauterine pregnancy be confirmed on USS if fetal pole is not visible?

Gestational sac and yolk sac

57

What does the management of a suspected miscarriage depend on if using the gestational and yolk sacs to confirm intrauterine pregnancy?

Mean sac diameter

58

How is the mean sac diameter obtained?

By measuring the sac in three dimensions

59

When can a diagnosis of failed pregnancy be made based on mean sac diameter?

If >25mm

60

When must a repeat scan in 10-14 days be made based on mean sac diameter?

<25mm

61

When can a transabdominal USS be used to assess miscarriage?

If TVUS is not acceptable to the patient or in later gestation

62

Why is transabdominal USS not readily used to assess miscarriage?

It is less sensitive and specific

63

What can a serum beta-HCG be useful for in assessing suspected miscarriage?

Differentiating from an ectopic pregnancy

64

How can an ectopic pregnancy be differentiated from miscarriage using beta-HCG?

Serial measurements:

- Lowering suggests miscarriage
- Steady suggests ectopic

65

What other blood tests may be useful in suspected miscarriage?

- FBC
- Blood group and Rh status
- CRP

66

What are the three types of management for miscarriage?

- Conservative
- Medical
- Surgical

67

What do women require regardless of management if they are Rh -ve and > 12 weeks gestation in miscarriage?

Anti-D prophylaxis

68

What do women require if they are having surgical management for miscarriage and are Rh -ve regardless of gestation?

Ant-D prophylaxis

69

What is involved in conservative management of miscarriage?

Allowing the products of conception to pass naturally

70

What should patients have if choosing conservative management of miscarriage?

24 hour access to gynaecological services

71

What are the advantages of conservative management of miscarriage?

- Can remain at home
- No side effects
- No anaesthetic or surgical risk

72

What are the disadvantages of conservative management of miscarriage?

- Unpredictable timing
- Heavy bleeding and pain
- Chance of being unsuccessful and requiring further intervention

73

What follow up should be given for conservative management of miscarriage?

Either:

- Repeat scan in 2 weeks
- Pregnancy test in 3 weeks

74

What are the contraindications to conservative management of miscarriage?

- Infection
- High risk of haemorrhage e.g. coagulopathy or haemodynamically unstable

75

What is involved in medical management of miscarriage?

Use of vaginal misoprostol to stimulate cervical ripening and myometrial contractions

76

What is misoprostol?

A prostaglandin analogue

77

What is usually given 24-48 hours prior to misoprostol?

Mifepristone

78

What are the advantages of medical management of miscarriage?

- Can be at home if desires (with 24/7 access to gynae)
- Avoids anaesthetics and surgical risks

79

What are the disadvantages of medical management of miscarriage?

- Can cause vomiting and diarrhoea
- Heavy bleeding and pain
- Chance of emergency surgery required

80

What follow up is given in medical management of miscarriage?

Pregnancy test 3 weeks later

81

What are the types of surgical management miscarriage?

- Manual vacuum aspiration
- Evacuation of retained products of conception (ERPC)

82

Under what anaesthetic is manual vacuum aspiration performed?

Local

83

When can manual vacuum aspiration be performed?

If <12 weeks gestation

84

Under what anaesthetic is ERPC performed for miscarriage?

General

85

How is an ERPC for miscarriage performed?

- Speculum is passed to visualise cervix
- Cervix is dilated and suction tube passed to remove products of conception

86

What are the clinical indications for surgical management miscarriage?

- Persistent excessive bleeding
- Haemodynamic instability
- Evidence of infected retained tissue
- Suspected gestational trophoblast disease

87

What are the advantages of surgical management miscarriage?

- Planned procedure
- Can help patient cope
- Unaware during ERPC

88

What are the disadvantages of surgical management miscarriage?

- Anaesthetic risk
- Infection
- Uterine perforation
- Haemorrhage
- Asherman's syndrome
- Bowel or bladder damage
- Retained products of conception