Miscarriage & Ectopic Pregnancy Miscarriage Any pregnancy lost before 24 weeks not showing signs of life after delivery Occurs in approx 25% of pregnancies Threatened – vaginal bleeding & ongoing pregnancy (offer reassurance) Inevitable – the cervix begins to dilate Incomplete – passage of some but not all products of conception Complete – all products of conception have been expelled Missed (silent) – fetus has died in utero before 20 weeks but not expelled Anembryonic pregnancy – the sac develops but there are no fetal parts Septic – a complication of incomplete miscarriage where intrauterine infection occurs Recurrent – 3 or more consecutive miscarriage Causes At least 50% have no identifiable cause Fetal chromosomal abnormalities – approx ½ of 1st trimester miscarriage Endocrine factors – PCOS (due to higher hormone levels), DM (with poor control at time of conception) Immunological causes – Antiphospholipid Ab, lupus anticoagulant Ab (low dose aspirin may be of help) Uterine abnormalities – bicornuate or septate uterus. On occasion fibroids affect growth Infections - any serious maternal infection causing high fever. Rubella, CMV, malaria, typtanosomiasis, chlamydial, mycoplasma, listeria, syphilis Presentation History of PV bleed and lower abdominal pain with passage of aborted tissue Bleeding may be life threatening or merely brown spotting USS scan required to confirm if pregnancy is viable or not Empty gestational sac > 25mm is likely to non viable. Fetal pole should be visible from 6 weeks + on transvaginal US Fetal pole with no heart beat (should be visible if fetal pole > 15mm Empty uterus – complete miscarriage, < 5 weeks or ectopic Retained products – arrange ERPOC for those with continued bleeding Rhesus Isoimmunization All Rh-ve women should be offered anti-D as there is no way to assess fetal blood group Afterwards Offer support & bereavement counselling Septic abortion Rare unless following illegal abortions. Pyrexia, tachycardia, malaise, abdo pain, marked tenderness, purulent vaginal loss Recurrent spontaneous miscarriage Approx 1% of population - Remains 60% chance of normal pregnancy after 3 Consecutive loss of three or more fetuses weighing < 500g Karyotype both parents, maternal Abs, thrombophilia screen, hysterosalpingogram If recurrent mid trimester loss consider cervical incompetence (try cervical suture) Offer support before next pregnancy, psychological support, folic acid & optimise treatment of any disease (DM, thyroid etc). Give serial scans for reassurance. Ectopic Pregnancy Any non-uterine pregnancy - 1/2-400, 50% occur in ampulla, 28% in isthmus. Largest cause of direct deaths in early pregnancy May be history of previous ectopic, tubal surgery, pelvic infection. 50% have no risk factors Symptoms – amenorrhoea, lower abdominal pain, pv bleeding, intra-abdominal haemorrhage, collapse O/E – be gentle to avoid rupturing ectopic. Assess heamodynamic status, abdominal tenderness, peritonism, cervical excitation (pathology on side fingers move towards if pain) Management – resuscitate as appropriate (crossmatch for 6 units) FBC Anti D if appropriate BHCG US Laparoscopy/otomy and remove POC & tube (providing other is intact) Medical management with methotrexate if completely stable (follow up until bHCG is 0)