Makindo Medical Notes.com

If this is a miscarriage, there is nothing medically that the patient or doctor can do to stop it

About

• Miscarriage occurs in 10-20% of clinical pregnancies and accounts for 50 000 inpatient admissions to Hospital's in the UK annually
• Miscarriage, also known as spontaneous abortion and pregnancy loss, is the natural death of an embryo or fetus before it is able to survive independently.
• Some use the cutoff of 20 weeks of gestation, after which fetal death is known as a stillbirth others use the term up to 24 weeks
• Early Miscarriage < 12 weeks and Late miscarriages 12-24 weeks

Risks

• Age > 30 which is higher after 35, Smoking, Excess alcohol
• Low pre pregnancy BMI, Paternal age > 5 years
• Fertility issues with conception, illicit drug use
• Uterine surgery, Uncontrolled diabetes
• Stress, anxiety, Stressful/traumatic events

Clinical

• The common clinical features include varying amounts of pain and vaginal bleeding.

Miscarriage

• Miscarriage is defined as a spontaneous loss of the pregnancy before 24 weeks (20 weeks in some books the US). It is very very common and occurs in 25% of women and most occur within the first 12 weeks.
• The incidence of miscarriage is directly related to maternal age with increasing incidence. Previous advice was to wait before further attempts at conception but that advice is now in question. Patients should continue to try when they feel emotionally ready.
• The miscarriage at whatever stage is a loss and a bereavement for the parents and family and should be treated as such by staff. Advise to not smoke during pregnancy. Consider reducing or no alcohol intake. Ensure the patient takes folate.
• In a woman presenting with bleeding if the os is open a miscarriage is inevitable. Evacuation of the retained products of conception may be required. The concern is infection and development of endometritis and patients should be warned to seek help urgently with the development of fever, lower abdominal pain or change in vaginal bleeding/discharge. The patient should also be considered for anti-D if Rhesus negative

The 6 different types

Investigations

• FBC - anaemia
• USS - shows uterus and fetus and fetal heartbeat if present and may be done if there are any concerns of retained POC
• Beta HCG - will fall with miscarriage and needs to be repeated when managed conservatively to ensure that after 3 weeks it is back to negative

Management: Miscarriage is generally managed in 3 ways and therefore women have 3 treatment options

• 1. Expectant management: await spontaneous miscarriage, success approx 70-80%
• 2. Medical management: medicines administered to hasten natural process of miscarriage, success approx 80%
• 3. Surgical management: ERPC or MVA, success approx 95%

Details

• Medical management involves the administration of drugs to assist the passage of POC's naturally. Anti-progesterone oral tablet, Mifepristone and prostaglandin analogue, Misoprostol as a vaginal tablet are commonly used to achieve this. Recent NICE guideline (CG154) recommends that missed miscarriage and incomplete miscarriage be treated with misoprostol alone. A single dose of 800 mcg of misoprostol intra-vaginally is recommended. This can be managed as an outpatient procedure. The woman should be advised that if bleeding has not started 24 hours after treatment, she should contact the early pregnancy assessment unit and care be individualised.
• Surgical management includes completion of miscarriage using vacuum aspiration. It is the most successful treatment option and can be effectively undertaken either under local anaesthetic (Manual Vacuum Aspiration-MVA) or under General anaesthetic. The advantages of prostaglandin administration prior to surgical management are well established, with significant reductions in dilatation force, haemorrhage and uterine/cervical trauma. Antibiotic cover may be given.

Recurrent Miscarriage

• Recurrent miscarriage is defined as 3 or more consecutive miscarriages. An underlying cause is rarely found but may be associated with parental genetic abnormality in 3-5% and referral to a clinical geneticist may be indicated.
• Patients with recurrent miscarriage and APS are treated with Aspirin 75 mg od and Heparin s/c until 34 weeks pregnant
• Recurrent miscarriage is associated with Polycystic Ovarian Syndrome and has been attributed to higher levels of LH. weight loss and lowering BMI has been found to improve outcome. With RM a thrombophilia screen and antiphospholipid antibodies should be checked - exclude Antiphospholipid syndrome (APS), Protein C/S abnormalities and Factor V Leiden mutation which are associated with recurrent abortion