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what is spontaneous miscarriage?
- spontaneous loss of a pregnancy BEFORE 24 completed weeks of gestation
- fetes dies or delivers dead
when do the majority of miscarriages occur?
before 12 weeks, ie first trimester
what is the relationship between miscarriage and maternal age?
rate of miscarriage increases with maternal age
what % of clinically recognised pregnancies spontaneously miscarry?
15% (more go unrecognised as happen very early)
what are the 6 types of miscarriage?
- 1. complete
- 2. incomplete
- 3. threatened
- 4. missed
- 5. septic
- 6. inevitable
how does miscarriage present?
- pregnancy test positive
- bleeding or pain or both
what is a complete miscarriage?
all fetal tissue has been passed
what are the symptoms or features of complete miscarriage?
bleeding and pain that is significant but EASES OFF
what is the size of the uterus? and cervix open/closed? for complete
- uterus: no longer enlarged, becoming normal size
- cervix: os closed
what is USS of complete?
what is treatment of complete?
- reassurance: its not their fault. 2/3 de novo mutation - bad luck
- when next period? in 4-6 weeks
- miscarriage association group
what is an incomplete miscarriage?
some fetal parts have been passed, but the os is usually open
what are the symptoms or features of incomplete miscarriage?
ONGOING bleeding and pain that is intermittent (as incomplete…bits still coming out)
what is the size of the uterus? and cervix open/closed? for incomplete
- uterus: smaller than gestational age, but not normal
- cervix: open as things still coming out
what is USS of incomplete?
products of conception still left - BRIGHT echo in uterus
what is treatment of incomplete?
- need to get remaining fetal parts out
- natural (expectant management): wait and FU scan in 2 weeks check all out as long as no signs of infection (septic miscarriage)
- medical: misoprostol - soften cervix and make uterus contract
- surgical: ERPC under anaesthesia, using vacuum aspiration (tissue examined to exclude molar pregnancy)
what is a missed miscarriage?
- the fetes has note developed or died in uteri
- but this is not recognised until bleeding occurs or USS is performed
what are the symptoms or features of missed miscarriage?
- its silent
- then go for eg dating scan and no fetal heart beat can be detected
what is the size of the uterus? and cervix open/closed? for missed
- uterus is consistent or smaller than gestation
- cervix is closed
what is USS of missed?
- no fetal heartbeat and either:
- 1. embryo at least 6 mm (ie at least 6 weeks old) - because before that normally cant see heartbeat
- 2. or gestation sac > 20m (if no fetal pole)
what is treatment of missed?
- the uterus is bigger and cervix is very hard - so difficult to operate
- most need ERPC, especially as there may be a bigger pregnancy so to reduce distress of seeing it ERPC is encouraged
what is a threatened miscarriage?
- there is bleeding but the fetes is still ALIVE
- (is miscarriage hasn't actually happened, but seemed threatened due to symptoms)
what are the symptoms or features of threatened miscarriage?
minimal bleeding and pain
what is the size of the uterus? and cervix open/closed? for threatened
- uterus normal size, consistent with dates
- cervix closed
what is USS of threatened?
fetal heartbeat PRESENT
what is treatment of threatened?
- BOOK for pregnancy
what is a septic miscarriage? when does it happen
- contents of uterus are infected, causing endometritis
- happens in INCOMPLETE miscarriages as dead pregnancy tissue and blood attracts infection
when is septic miscarriage RARE? and why?
- after 12 weeks
- as the thick MUCUS PLUG
- in the cervix prevents ascending infection and is a barrier
what are the symptoms or features of septic miscarriage?
- fever, pain
- offensive discharge
- bleeding, clots
what is the size of the uterus? and cervix open/closed? for septic
- uterus: small for days
- cervix: open
- (same as incomplete)
- speculum examination: pregnancy tissue, very SMELLY
- bimanual examination: tender and get cervical excitation
what is USS of septic?
- retained products of conception (same as incomplete)
- tender on probing
what is treatment of septic?
- MUST have operation to clean the womb - ERPC
- under antibiotic cover - iv
- ASAP!!! cannot wait
how do you counsel after miscarriage?
- 1. tell them it was not their fault and could not have been prevented (exercise, intercourse and emotional trauma do NOT cause miscarriages)
- 2. cause: 2/3 de novo mutations - bad luck
- 3. reassure: high chance of successful further pregnancies
- 4. when next period? 4-6 weeks. may be painful, irregular, heavy bleeding due to hormonal imbalance
- 5. when can start trying for another baby? after next period (as needed for dating!)
- 6. what to do if going to try for another baby? start folic acid 400ug/day
- 7. refer to support group: miscarriageassociation.org.uk
does miscarriage need to be investigated further?
no because miscarriage is so common, further Ix is reserved for women who have had 3 miscarriages
if a woman is Rh -ve, what needs to be given if she miscarries? dose?
- need to give her antiD
- < 20 weeks: 250 IU
- > 20 weeks: 500 IU
what is exception to rule for antiD in Rh-ve?
- if < 12 weeks and complete miscarriage don't need antiD (as little leakage of fetal cells)
- if < 12 weeks and threatened miscarriage as long as minimal-moderate bleeding don't need antiD (but if signify bleed/pain do need antiD)
if pregnant lady gets bleeding and pain what should she do?
- go to EPAU where they do
- hx, examination, urine pregnancy test, USS and blood tests as indicated (FBC, Rh group)
what things in EPAU do they look for on USS?
- is it viable? heartbeat
- detect retained fetal tissue
how would you differentiate between ectopic and viable intrauterine pregnancy when no intrauterine gestation is visible on scan?
HCG levels in blood: normally increase by >66% in 48 hours with a viable intrauterine pregnancy
what is the management of spontaneous miscarriage?
- 1. may need admission if ectopic is suspected, miscarriage is septic or inevitable
- 2. reuses: if blood loss heavy. also products of conception in the os cause pain, bleeding and vasovagal shock (fergusons reflex). POC removed via speculum using polyp forceps.
how can bleeding be reduced?
bleeding reduced by im injection of ergometrine - as it contracts uterus (but only use if NON VIABLE fetes)