38 Questions
What percentage of pregnancies end in miscarriage in the UK?
1 in 5
What accounts for the majority of pregnancy loss?
First trimester miscarriage
What is the approximate percentage of chromosomal abnormality in first trimester miscarriages?
40% to 50%
What is the term for a fetus that doesn't develop properly, and abnormal cells develop instead of a normal fetus?
Molar pregnancy
What is the term for a diagnosed miscarriage at scan with no symptoms?
Missed miscarriage
What is the term for a mass of abnormal cells in the womb, with no fetus developing?
Complete mole
What is the percentage of couples who suffer from recurrent miscarriage?
1% to 2%
What symptoms are associated with acute collapse?
Cervical shock, hypotension, and tachycardia
At what crown–rump length can a miscarriage be diagnosed?
Less than 7.0 mm
What is the minimum time interval between the first and second ultrasound scan?
7 days
What is the primary indicator of fetal viability?
Fetal heartbeat
What is the maximum gestational sac diameter for a single ultrasound scan diagnosis?
25 mm
What is the symptom of sepsis?
All of the above
Why can't a miscarriage be diagnosed with a single ultrasound scan?
Because it may be too early to determine viability
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
What is the increased risk of miscarriage associated with a BMI > 30 compared to normal BMI?
25% increase
At what age does the risk of miscarriage increase to 70%?
45 years
What is the success rate of conservative management of miscarriage?
40-80% success
What is the primary medication used in medical management of miscarriage?
Misoprostol
What is the potential risk of surgical management of miscarriage?
Infection, bleeding, uterine perforation, cervical damage, retained tissue and need for repeat procedure
At what gestation should vaginal progesterone pessaries be continued until in women with a history of miscarriage?
16 completed weeks
What is the primary criterion for suspecting an ectopic pregnancy?
Pelvic pain and bleeding
What is the primary role of hCG monitoring in suspected ectopic pregnancy?
To rule out an ectopic pregnancy
What is the significance of an hCG level of less than 20 pmol/l?
It is unlikely to be a normally developing pregnancy
What is the expected rate of increase in hCG levels in a normal intrauterine pregnancy?
A doubling every 48 hours
At what hCG level can an intrauterine pregnancy usually be visualized on scan?
1000 iu/l
What is the primary goal of diagnostic investigations in suspected ectopic pregnancy?
To rule out an ectopic pregnancy
When is laparoscopy or laparotomy indicated in the management of ectopic pregnancy?
When the patient has collapsed and requires emergency surgery
What is the primary cause of very pre-term labor in the context of second trimester miscarriage?
Intrauterine death
What is the role of a speculum in the examination of a second trimester miscarriage?
To examine the cervix
What is the purpose of taking tissue for karyotyping after a miscarriage?
To determine the cause of the miscarriage
What is the consequence of a rupture of membranes due to infection?
Abruption
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
What is the primary reason for performing a scan in the evaluation of a second trimester miscarriage?
To detect fetal heart activity
What is the consequence of placental dysfunction in the context of second trimester miscarriage?
Fetal growth restriction
What is the relevance of screening for fetal abnormality in the context of second trimester miscarriage?
To identify the cause of the miscarriage
What is the significance of uterine anatomy in the evaluation of a second trimester miscarriage?
To identify potential uterine abnormalities
What is the primary focus of the history-taking in the evaluation of a second trimester miscarriage?
Bleeding and contractions
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
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.
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