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Miscarriage - Coggle Diagram

- - - - Definition
        
        No intervention
      - MOA
        
        POC pass spontaneously
      - Indications
        
        Incomplete miscarriage
      - Contraindications
        
        ↑ Risk of haemorrhage
        
        Adverse effects of haemorrhage (VwD, anaemia)
      - Benefits
        
        Treats > 80% of incomplete
        
        Avoids risk of medical / surgical tx
      - Disadvantages
        
        Experiences miscarriage
        
        Longer treatment interval (1-2week)
        
        Failure requiring tx)
      - Follow up
        
        Urinary PT after 3 weeks
        
        Possibly TVUS after 2 weeks
    - - Definition
        
        Misoprostal (PGE1)
        800μg
      - MOA
        
        POC pass using induced uterine contractions causing cervical dilation
      - Procedure
        
        Vaginal or oral misoprostal tablets
      - Indications
        
        Missed miscarriage
        
        Incomplete miscarriage
      - Contraindications
        
        ↑ Risk of haemorrhage
        
        Adverse effects of haemorrhage
        
        Septic miscarriage
      - Benefits
        
        Effective treats >80% of incomplete
        
        Avoids risk of srugical management
      - Disadvantages
        
        Experiences miscarriage
        
        Longer treatment interval
        
        Failure requiring treatment
        
        Side effects
      - Follow up
        
        TVUS after 2 weeks
  - - - Evacuation of Retained Products of Conception (ERPC)
      - Definition
        
        ERCP
      - MOA
        
        Surgical removal of POC
      - Procedure
        
        Dilate cervix
        Remove POC using suction aspiration
        Send POC for histology
      - Indications
        
        Missed miscarriage
        
        Inevitable miscarriage
        
        Incomplete miscarriage with havey persistent bleeding
        
        Failre expectant / medical managment
        
        Septic miscarriage
        
        Maternal preference
      - Contraindications
        
        2nd trimester miscarriages
      - Benefits
        
        Effective treats >95%
        
        Shorter treatment interval
        
        Avoids drawbacks of expectant / medical management
      - Disadvantages
        
        Invasive - surgical risks
        
        Intrauterine adhesions (Asherman's syndrome)
        
        Failure requiring no further treatment
      - Follow up
        
        None required
  - - - Medical
      - Expectant
    - - Surgical ERPC
    - - Emergency care if unstable
      - Medical management if increased risk of haemorrhage / adverse effects of haemorrhage
  - - - Position flat
        Give O2
        Secure IV access
        Give IV fluids
        Place urinary catheter
    - - Hypovolaemic - give blood
      - Cervical shock - Remove POC using ring forceps
      - Septic shock - Abx
    - - Perform ERPC
- - - - Pregnancy that ends spontaneously <23 weeks gestation
    - - ≥3 consecutive miscarriages
  - - - Isolated non-recurring Foetal chromosomal abnormality
    - - Parental chromosomal abnormality
      - Antiphospholipid syndrome
      - Anatomical abnormality
        Congenital uterine abnormality
        Cervical incompetence
      - Infection
      - Systemic causes
        Thyroid dysfuntion
        PCSO
        Often lead to recurrent miscarriage
  - - - Caused by bleeding from decidua (endometrium in pregnancy) as pregnancy seperates from it
      - External bleeding - revealed
    - - Caused by vasovagal response as products of conception / blood clots lodge in cervical canal
    - - Caused by infection of retained products of ceonception / blood clots
      - May lead to septic shock
  - - - Missed Miscarriage
        
        Pain / bleeding absent
        
        Closed cervix and small uterus
        
        TVUS
        
        Fetus not developed (Gestational Sac > 20mm with no fetus) or
        Died in utero ( fetus >7mm with no Fetal Heart activity) but unrecognised (no bleeding to date)
    - - Threatened Miscarrige
        
        Pain and bleeding
        
        Closed cevical os
        
        TVUS
        
        Fetus is alive FH acitvity present
      - Inevitable
        
        Pain and bleeding
        
        Cervical os open
        
        TVUS
        
        Products of conception (POC) not yet passed
        Fetus may or may not be alive
      - Incomplete
        
        Pain and bleeding
        
        Cervical os open
        
        TVUS
        
        Some but not all POC have passed (≥ 15mms)
        Retained POC
      - Complete
        
        Stopped pain and bleeding
        
        Closed cervical os
        
        TVUS
        
        All POC have passed (<15mm)
      - Septic
        
        Offensive discharge
        
        Cervical os usually open
        
        TVUS
        
        Features of incomplete miscarriage
- - - - Bleeding from decidua
      - VArying severity
      - Consider complete miscarriage in hx of significant PV bleed that has stopped
    - - From uterine contractions
        Crampy, varying severity
    - - Hypovolaemic shock
        Cervical shock
        Septic shock
    - - Infection / sepsis
  - - - Advanced maternal age
    - - Medical fitness (for misoprostol and tolerate haemorrhage - anaemia)
      - Surgical fitmess for GA
    - - Smoking
    - - Pregnancy dating
        LMP date and certainty
        Cycle regularity
        +ve Pregnancy test
      - Contraceptive use
  - - - Unwell
      - Pale
      - Unresponsive (shock)
    - - Tachycardia
      - Hypotension (shock)
      - Pyrexia
    - - NO acute abdomen
      - Uterine tenderness may be present - not prominent except if inx
      - Small uterine size for gestational age - if missed miscarriage
    - - Small or large amount of bleeding
      - POC in cervical os
      - Open / closed cervix
      - Offensive discharge - infection
    - - Open cervix - admits finger
      - Closed cervix - does not admit finger
      - Uterine tenderness - infection
  - - - From 4.5 weeks
    - - From 5 weeks
      - Confirms Viable pregnancy
    - - 5 weeks
      - Confirms intrauteine pregnancy
  - - - Positive
    - - Missed miscarriage
        
        Gestational sac > 20mm with no yolk sac or foetal pole
        
        Fetus >7mm with no fetal heartbeat
        Observe for 10d if smaller
      - Incomplete miscarriage
        
        Retained products of conception (RPOC) or ≥ 15mm endometrial thickness
      - Complete miscarriage
        
        No Retained products of conception (RPOC) and < 15mm endometrial thickness
    - - Serum HCG levels
      - Serum progesterone - limited evidence
    - - FBC
        
        Anaemia
      - G&S / Crossmatch
        
        If transfusion needed
        
        Anti D if rhesus negative
    - - C&S if possible infection
- - - - Viable
      - Missed
      - Molar
  - - - +ve pregnancy test
        No intrauterine pregnancy
        No ectopic
        No retained products of conception of TVUS
        
        Could be
        
        Viable intrauterine
        
        Miscarriage
        
        Ectopic
      - Management
        
        Serial β-HCG
    - - Does not meet criteria for viable Intrauterine pregnancy or miscarriage - too early!
      - No fetal heartbeat
      - Gestational sac <20mm without visible embryonic stucture (eg yold sac)
      - Management
        
        Scan in 7-10 days