204: Pregnancy Loss Symposium

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Questions and Answers

What percentage of pregnancies end in miscarriage in the UK?

1 in 20

1 in 5 (correct)

1 in 3

1 in 10

What accounts for the majority of pregnancy loss?

Second trimester miscarriage

First trimester miscarriage (correct)

Molar pregnancy

Third trimester miscarriage

What is the approximate percentage of chromosomal abnormality in first trimester miscarriages?

40% to 50% (correct)

30% to 40%

50% to 60%

20% to 30%

What is the term for a fetus that doesn't develop properly, and abnormal cells develop instead of a normal fetus?

Molar pregnancy Signup and view all the answers

What is the term for a diagnosed miscarriage at scan with no symptoms?

Missed miscarriage Signup and view all the answers

What is the term for a mass of abnormal cells in the womb, with no fetus developing?

Complete mole Signup and view all the answers

What is the percentage of couples who suffer from recurrent miscarriage?

1% to 2% Signup and view all the answers

What symptoms are associated with acute collapse?

Cervical shock, hypotension, and tachycardia Signup and view all the answers

At what crown–rump length can a miscarriage be diagnosed?

Less than 7.0 mm Signup and view all the answers

What is the minimum time interval between the first and second ultrasound scan?

7 days Signup and view all the answers

What is the primary indicator of fetal viability?

Fetal heartbeat Signup and view all the answers

What is the maximum gestational sac diameter for a single ultrasound scan diagnosis?

25 mm Signup and view all the answers

What is the symptom of sepsis?

All of the above Signup and view all the answers

Why can't a miscarriage be diagnosed with a single ultrasound scan?

Because it may be too early to determine viability Signup and view all the answers

What is the recommended course of action for a woman with a confirmed intrauterine pregnancy with a fetal heartbeat who presents with vaginal bleeding but has no history of previous miscarriage?

Advise her to return for further assessment if bleeding worsens or persists beyond 14 days Signup and view all the answers

What is the increased risk of miscarriage associated with a BMI > 30 compared to normal BMI?

25% increase Signup and view all the answers

At what age does the risk of miscarriage increase to 70%?

45 years Signup and view all the answers

What is the success rate of conservative management of miscarriage?

40-80% success Signup and view all the answers

What is the primary medication used in medical management of miscarriage?

Misoprostol Signup and view all the answers

What is the potential risk of surgical management of miscarriage?

Infection, bleeding, uterine perforation, cervical damage, retained tissue and need for repeat procedure Signup and view all the answers

At what gestation should vaginal progesterone pessaries be continued until in women with a history of miscarriage?

16 completed weeks Signup and view all the answers

What is the primary criterion for suspecting an ectopic pregnancy?

Pelvic pain and bleeding Signup and view all the answers

What is the primary role of hCG monitoring in suspected ectopic pregnancy?

To rule out an ectopic pregnancy Signup and view all the answers

What is the significance of an hCG level of less than 20 pmol/l?

It is unlikely to be a normally developing pregnancy Signup and view all the answers

What is the expected rate of increase in hCG levels in a normal intrauterine pregnancy?

A doubling every 48 hours Signup and view all the answers

At what hCG level can an intrauterine pregnancy usually be visualized on scan?

1000 iu/l Signup and view all the answers

What is the primary goal of diagnostic investigations in suspected ectopic pregnancy?

To rule out an ectopic pregnancy Signup and view all the answers

When is laparoscopy or laparotomy indicated in the management of ectopic pregnancy?

When the patient has collapsed and requires emergency surgery Signup and view all the answers

What is the primary cause of very pre-term labor in the context of second trimester miscarriage?

Intrauterine death Signup and view all the answers

What is the role of a speculum in the examination of a second trimester miscarriage?

To examine the cervix Signup and view all the answers

What is the purpose of taking tissue for karyotyping after a miscarriage?

To determine the cause of the miscarriage Signup and view all the answers

What is the consequence of a rupture of membranes due to infection?

Abruption Signup and view all the answers

What is the relevance of asking about previous cervical surgery in the history of a second trimester miscarriage?

To assess the risk of cervical weakness Signup and view all the answers

What is the primary reason for performing a scan in the evaluation of a second trimester miscarriage?

To detect fetal heart activity Signup and view all the answers

What is the consequence of placental dysfunction in the context of second trimester miscarriage?

Fetal growth restriction Signup and view all the answers

What is the relevance of screening for fetal abnormality in the context of second trimester miscarriage?

To identify the cause of the miscarriage Signup and view all the answers

What is the significance of uterine anatomy in the evaluation of a second trimester miscarriage?

To identify potential uterine abnormalities Signup and view all the answers

What is the primary focus of the history-taking in the evaluation of a second trimester miscarriage?

Bleeding and contractions Signup and view all the answers

Study Notes

Miscarriage Overview

1 in 5 pregnancies end in miscarriage in the UK
Miscarriage is a major cause of death in women worldwide
It has a long-lasting emotional and mental health impact
Affects most women and their families at some point in their life
It is a taboo subject with hidden misery, but some causes can be prevented

First Trimester Miscarriage

Miscarriage is the death of a fetus up to 24 weeks of pregnancy
1st trimester miscarriage accounts for 85% of pregnancy loss
50% of first trimester miscarriages have chromosomal abnormality
1-2% of couples suffer from recurrent miscarriage

Types of Miscarriage

Complete miscarriage: no tissue remaining
Incomplete miscarriage: symptoms of bleeding, usually with an open cervical os, and some tissue remaining
Missed miscarriage: diagnosed at scan with no symptoms, also known as early fetal demise or anembryonic pregnancy
Molar pregnancy: abnormal cells develop instead of a normal fetus, known as hydatidiform mole

Clinical Presentation

Bleeding
Pain
Found at time of routine scan (missed miscarriage)
Loss of pregnancy symptoms
Acute collapse
Cervical shock, hypotension, tachycardia, bleeding
Sepsis
Pyrexia, hypotension, tachycardia, raised respiratory rate, confusion

Diagnosing Miscarriage

Diagnosis cannot be made following 1 ultrasound scan alone (particularly at very early gestational ages)
Measure crown-rump length (CRL) if fetal pole is visible
If CRL < 7.0 mm or gestational sac >25mm (TVUSS) and no visible heartbeat, seek a second opinion or perform a second scan a minimum of 7 days after the first scan
Give women a 24-hour contact telephone number

Factors Affecting Risk of Miscarriage

Age: 15% at 20, 18% at 30, 38% at 40, and 70% at 45
Obesity: 25% increase in risk with BMI > 30 compared to normal BMI
Antiphospholipid syndrome / SLE
Parental chromosomal translocation
Poorly controlled diabetes
Alcohol, smoking, recreational drug use
Uterine anomaly
High levels of natural killer cells (limited evidence)

Management of Miscarriage

Conservative/expectant (40-80% success)
Medical management: misoprostol, can be managed at home or on the ward depending on size of pregnancy (CRL length) / patient preference
Surgical management (SMM): surgical risks include infection, bleeding, uterine perforation, cervical damage, retained tissue, and need for repeat procedure

Ectopic Pregnancy

Suspect ectopic in patients with pelvic pain +/bleeding + positive pregnancy test
Always perform more investigations to rule out ectopic
Diagnosis may be from visualised ectopic on USS or at laparoscopy
Treatment: conservative, medical (methotrexate injections), or surgical (salpingectomy, salpingotomy)

Second Trimester Miscarriage

Loss of baby between 12-24 weeks
May be due to death of the baby in utero or due to premature labour/delivery
Causes include fetal abnormality, infection, placental dysfunction, growth restriction, SLE, anti-phospholipid syndrome, cervical weakness/incompetence, and uterine anomaly

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Description

Learn about the common occurrence of miscarriage, its causes, and its emotional impact on women and their families. This quiz covers the first trimester of pregnancy, accounting for 85% of pregnancy loss.