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what is spontaneous miscarriage?
- spontaneous loss of a pregnancy BEFORE 24 completed weeks of gestation
- fetes dies or delivers dead
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when do the majority of miscarriages occur?
before 12 weeks, ie first trimester
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what is the relationship between miscarriage and maternal age?
rate of miscarriage increases with maternal age
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what % of clinically recognised pregnancies spontaneously miscarry?
15% (more go unrecognised as happen very early)
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what are the 6 types of miscarriage?
- 1. complete
- 2. incomplete
- 3. threatened
- 4. missed
- 5. septic
- 6. inevitable
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how does miscarriage present?
- amenorrhoea
- pregnancy test positive
- bleeding or pain or both
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what is a complete miscarriage?
all fetal tissue has been passed
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what are the symptoms or features of complete miscarriage?
bleeding and pain that is significant but EASES OFF
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what is the size of the uterus? and cervix open/closed? for complete
- uterus: no longer enlarged, becoming normal size
- cervix: os closed
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what is USS of complete?
normal scan
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what is treatment of complete?
- reassurance: its not their fault. 2/3 de novo mutation - bad luck
- when next period? in 4-6 weeks
- discharge
- counselling
- miscarriage association group
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what is an incomplete miscarriage?
some fetal parts have been passed, but the os is usually open
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what are the symptoms or features of incomplete miscarriage?
ONGOING bleeding and pain that is intermittent (as incomplete…bits still coming out)
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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
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what is USS of incomplete?
products of conception still left - BRIGHT echo in uterus
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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)
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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
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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
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what is the size of the uterus? and cervix open/closed? for missed
- uterus is consistent or smaller than gestation
- cervix is closed
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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)
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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
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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)
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what are the symptoms or features of threatened miscarriage?
minimal bleeding and pain
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what is the size of the uterus? and cervix open/closed? for threatened
- uterus normal size, consistent with dates
- cervix closed
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what is USS of threatened?
fetal heartbeat PRESENT
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what is treatment of threatened?
- reassurance
- discharge
- BOOK for pregnancy
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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
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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
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what are the symptoms or features of septic miscarriage?
- fever, pain
- offensive discharge
- bleeding, clots
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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
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what is USS of septic?
- retained products of conception (same as incomplete)
- tender on probing
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what is treatment of septic?
- MUST have operation to clean the womb - ERPC
- under antibiotic cover - iv
- ASAP!!! cannot wait
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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
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does miscarriage need to be investigated further?
no because miscarriage is so common, further Ix is reserved for women who have had 3 miscarriages
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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
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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)
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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)
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what things in EPAU do they look for on USS?
- fetus
- is it viable? heartbeat
- detect retained fetal tissue
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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
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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.
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how can bleeding be reduced?
bleeding reduced by im injection of ergometrine - as it contracts uterus (but only use if NON VIABLE fetes)
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