The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes336
EMQ1502
SBA2115
Do you realy want to delete this discussion?
Forum >>

Essay 311 - Miscarriage

Posted by Harry B.
HB
A. The non surgical management options for this woman with a early missed miscarriage at 8 weeks are expectant and medical.
The expectant management involves waiting for the nature to take its course and to spontaneously, completely miscarry and expel the products of conception. The advantages of this procedure are that about 70% of women completely miscarry in 3 weeks time and these women can avoid the anaesthetic and operative risks associated with the surgical evacuation and the interventions of medical management. This woman is already having some brown discharge and possibly she may miscarry completely with expectant management. The disadvantages of this procedure will be waiting for things to happen, is associated with pain, bleeding, infection (no increased risk when compared to other two methods) and may not be successful and in which case the woman needs to opt for either the medical or surgical evacuation of products. The telephone number for 24 hour advise and emergency admission should be given. This management may not be appropriate for a woman who lives on her own or who does not have enough support at home to bring her to the hospital or if she lives far away from the emergency admission unit where associated severe bleeding can be managed effectively.
The medical management includes the use of prostaglandins with or without the use of mifepristone (anti-progesterone). It has the advantage of avoiding to wait for expectant management and the anaesthetic and operative risks with the surgical management. The woman may feel more in control of the situation. There is about 85% chace of complete miscarriage with the medical management and the rest may have to either opt for expectant management or the surgical evacuation depending on the symptoms and the size of the retained products. There is also associated increase in the bleeding and pain and may not be favourable for a woman who wants to avoid these.

B. For this woman with three recurrent early miscarriages, relevant investigations to find out any particular cuase for her miscarriages should be offered. Firstly is karyotyping of both partners (if these three miscarriages were with the same partner) to identify any genetic factors such as balanced or unbalanced translocations. The cytogenetic analysis of the products of conception should also be offered to look for any evidence of chromosomal abnormalities.
A pelvic ultrasound scan (transvaginal) should be organized to look for any anatomical factors such as septate uterus, submucous fibroids, asherman’s syndrome etc and also to look for any evidence of polycystic ovaries. Where facilities are available, HyCoSy (hysterosalphingo contrast ultrasonography) should be considered. Depending on the history, if there is any evidence of oligomenorrhoea, further investigations such as serum FSH, LH, testosterone, SHBG and free androgen index should be organized to look for evidence of PCOS. There is no RCT to suggest the benefits of surgery for uterine malformations will benefit the pregnancy rates.
Screening for antiphospholipid antibody syndrome should be organized and evidence of IgG or medium or high titres of IgM for lupus anticoagulant and anticardiolipin antibodies 6 weeks apart should indicate the prophylaxis with low dose aspirin and low molecular weight heparin in subsequent pregnancies.
Thyroid function tests, screening for diabetes and hyperprolactinaemia should be limited if there are any symptoms suggestive of these disorders.
Posted by Latha. P.
The non surgical management options are the expectant and medical line of management.
The expectant management can be offered to woman who are otherwise healthy and have support and safe plan in place to bring her into the hospital in emergency.She will need to be given direct contact numbers/ access to Emergency services.while this is a non interventional management where the woman is in control it ,involves waiting for the nature to take its course to expel the products of conception. About 70% of women completely miscarry in 3 weeks time and the complications associated with the anaesthetic and procedure risks are avoided. The disadvantages of this procedure will be waiting for things to happen is associated with pain, bleeding, infection and may still not be successful in which case the woman needs to opt for either the medical or surgical evacuation of products. .
The medical management includes the use of prostaglandins with or without the use of mifepristone which on its own has a success rates of 85 % and along with PG the effect rates are about 90- 95%. It has the advantage of avoiding the wait of expectant management and the anaesthetic and operative risks with the surgical management. The woman may feel more in control of the situation. A small number of them may still have to undergo the surgical evacuation for RETAINED PRODUCTS. There is also associated increase in the bleeding and pain and may not be favourable for a woman who wants to avoid these.
Recurrent pregnancy loss has an incidence of about 1%.
A large number of these are explained and the couple will have to be councelled that the outcome without any intervention is about 70 % success and hence reassurance and adequate support will be all that is needed.
About 40 % of them are associated with PCOS-the woman is offered sonological evaluation of the ovaries, FHS/ LH and day 21 Progesterone, along with Testosterone levels to support this diagnosis when hx has ellicted a clinical impression of PCOS.
With family of personal hx suggestive of Thrombophillia- screeing is offered . Association rates are around 18-%.
Parental karyotyping is offered when there has been abnormal karyotype of the abortus. 3-5 % of the couple carry balanced/ robertsonian\'s translocations.
A small minority of them may have uterine anomalies and hence a 3-D USG may help in identify and classify them.
TFT and Screening of diabete is not routinely offered.
Studies have not supported supplementation with progesterone / hCG where luteal phase lag is suspected.
Periconceptual folic acid, weight loss when BMI is more than 30, healthy diet, stopping to smokeand reducing alcholol intake all go a long way in helping these couples achievea successful pregnancy.
Posted by Dr Dyslexia V.
X

a) The non surgical option include medical management and expectant management for missed miscarriage. Medical management include more patient acceptability and control of events and not requiring admission. But a dedicated early pregnancy assessment unit is required for addressing patients anxiety or in need of admission. Usually medical administration or prostaglandin sometimes is associated with severe crampy abdominal pain which might necessitate analgesia and could cause excessive bleeding which could be distressful if at home. Occasionally the abortion could be incomplete which could require further surgical evacuation. Other major drawbacks include histopathology samples might not be acquired most of the instances. Side effects of the prostaglandin which also include nausea and vomiting is cumbersome.

Expectant management include awaiting spontaneous expulsion which is associated with failure which might require surgical evacuation. It is also associated with bleeding and abdominal pain which could be less severe compared to medical management as a product of conceptus might have involuted. Histopathology specimens are usually not available in most cases. It involves more patient satisfaction and control but with the drawback of waiting.

b) The investigation of recurrent miscarriages include the screening for acquired and inherited thrombophilia. There is a small proportion of patient with recurrent miscarriage are attributable to this and could be prevented with antenatal aspirin and heparin. Investigation include lupus anticoagulant or anti cardiolipin taken 6 weeks apart. Other investigation include to check for factor V leiden especially if homozygous.

Other investigation include high vaginal swaps and screening for bacterial vaginosis which could be treated for subsequent pregnancies. Ultrasound especially a transvaginal ultrasound to assess for uterine anomaly or fibroid which could be amenable to surgical correction. Sometimes morphology of a polycystic ovary could be gathered from this.

Parapheral blood for both parents for karyotyping for any form of balance translocation or any genetic disease which could be the cause for recurrent miscarriage. The usual example include Robertsonian translocation and in the event of this preimplantation genetic diagnosis could be used in the case of IVF for this patients. Cytogenetic study of product upon conceptus could be offered in the subsequent pregnancy to diagnose chromosomal abnormality.

Occasionally screening for diabetes or thyroid disease could be beneficial by doing an oral glucose tolerance test and thyroid function test.

TORCHES screening could be done but is of no value as it does not cause recurrent miscarriage.
Posted by H H.
Non surgical options include expectant and medical management. Expectant mean to wait for the products of conception to be extruded with no intervention. This could take up to 8 weeks or more. It has the advantage that the patient feel being in control , there is no risk of infection and with no costs unless heavy bleeding occurs and is transferred to hospital. The patient will not need anti D if she is RH-ve and father RH+ve and so also lower costs. Limitations iclude, patient anxiety and wish to get rid of the pregnancy as soon as possible, patient living in area where 24hr emergency medical facility not available, need for getting the products of conception for cytological and histological analysis as these would be lost or not obtained , presence of infection of concetus or heavy bleeding which is not present in this patient .

Medical methods include the use of mifprestone and prostaglandins or the later alone. It has the advantage that it would take shorter time to miscarry than expectant management. Infection risk is less than surgical management. There is no risk of surgical trauma or complications. General anesthesia with its complications is avoided but the patient will need analgesia. Patient still has some control of the situation. The limitations are the same as expectant management but in addition to , the presence of allergy to prostaglandins.




Investigations will be needed to detect the cause of recurrent miscarriages in this patient. Paternal and maternal karyotyping are done to detect if either has a chromosomal abnormality such as a translocation that might be the cause of chromosomal abnormality of fetus. The products of conception are analyse cytologicaly and histologically. Fetal karyotype is done and abnormality detected. Other tests are done around 6wk after miscarriage to prevent false positive results. Thrombophilia screen is done specially if patient has a personal or family history.Antiphospholipid antibodies ,lupus anticoagulant , anticardiolipin antibodies and other autoantibodies are screened for as they may be a cause of recurrent miscarriage. I would do a transvaginal ultrasound to look for polycystic ovaries ( >12 small follicles 3-5 mm in diameter on periphrery of cortex surrounding a dense thick stroma) as this is associated with recurrent miscarriage.
In most of the cases ,test results are negative and patient support and assurance are vital for the next pregnancy .

Posted by L S.
LS :
a) Non-surgical options would be either expectant management or medical management of miscarriage. The advantage of expectant management is that it has lower risk of clinical pelvic infection as compared to surgical option with no adverse effects on future fertility. Women undergoing this option have the benefit of avoiding potential surgical and anaesthetic intervention. Anti-D would not be needed if she is Rhesus negative. However in a missed miscarriage as there is an intact gestational sac and closed cervix the success of this option is lower. Pregnancy may take several weeks to resolve. Bleeding is often unpredictable and may be prolonged. Often they may present as an emergency with heavy bleeding requiring emergency surgical evacuation. Therefore this option is only available in units which have 24hours telephone contact and emergency admissions. The other option is medical management which uses prostaglandins with or without anti-progesterone for cervical priming. This has higher patient acceptability due to the ability to retain a degree of control and is more cost effective than surgical management. This option may be undertaken as out-patient basis. It also has lower risk of infection as compared to surgical management. Surgical and anaesthetic risk and complication is also reduced. The main limitations are bleeding which may persist for up to 3 weeks and more severe pain compared to surgical option. Sometimes heavy bleeding may necessitate emergency evacuation. Pain induced by prostaglandins can be more severe compared to surgical management. Success of this option can be variable.

b) From her history, medical disorders like polycystic ovarian syndrome (PCOS), systemic lupus erythematosis (SLE), underlying poorly controlled diabetes or thyroid disease should be identified as they are associated with recurrent miscarriage. A clinical examination to check her height and weight so that her body mass index can be calculated as obesity can be a cause of recurrent miscarriage. Other endocrine stigmata for PCOS (hirsutism), thyroid or autoimmune disorders like SLE (malar rash, photosentivity) should be looked for clinically to tailor appropriate blood investigations. If she is asymptomatic routine endocrine investigation cannot be justified and should not be offered. Karyotyping of both couple should be recommended as prevalence of chromosomal anomaly is about 3-5% of recurrent miscarriages. The most common is balanced translocation. Screening for anti-phospholipid antibodies (lupus anticoagulant and anti-cardiolipin) is recommended are they are positive in 15% of women with recurrent miscarriage. However false positive may occur due to presence of infections and need to be repeated in 6 weeks if positive. A third test is needed if both first and second results are discordant. If confirmed she should be counselled and offered low dose aspirin with heparin during next pregnancy. Thrombophilia screen for Protein C & S and anti thrombin III deficiency, Factor V Leiden mutation are reported more common in recurrent miscarriage and should be screened. Pelvic ultrasound should be done to look for ovarian morphology (PCOS) and uterine anomalies though no proven treatment or value of uterine surgery has been known. Screening for infection TORCH screen has no indication and should not be done. However opportunistic screening for HIV and rubella can be offered and appropriate vaccine or intervention can be taken if found.
Posted by Ulduz A.
a)Non-surgical options for management of missed miscarriage are including expectant and medical managements.
They are decreasing need for GA and eliminating risks are associated with GA.
Complications associated with surgery decreased.With expectant management no side-effects of drugs.
No need for anti-D if expectant management succeeded.
Infection rate will be decreased if compared with surgical management.
More cost-effective than surgical management.
Can be more acceptable for the women.
But usually non-surgical management takes longer time to be resolved.
Severe bleeding can necessitate surgical evacuation.
Pain can be severe.
No tissue can be available for hystopathology.
Woman should be properly councelled and contact numbers of the hospital given.
b)The diagnosis is recurrent first trimester miscarriages.
Approximately 3-5% of couples with recurrent m/carriages are carriers of a balanced chromosomal anomalies,so karyotyping of peripheral blood should be carried out.
When number of m/carriages are increasing,the chance of recurring maternal cause is increasing.In all couples with history of recurrent m/carriage cytogenic analysis of POCs should be done.
Range of uterine abnormalites in recurrent m/carriage is between 2-38%.All woman with history should have pelvic USS.
Antiphospholipid antibodies are present in 15% of woman with recur.m/carriage.Pt should have 2 +ve tests at least 6 wks apart for either LA or ACL antibodies of IgGand/or IgM present in medium or high titre.
There is association between inherited thrombophilias and recurrent m/car because they are estabilished cause of systemic thrombosis.screening for thrombophilias as deficiency of Protein C&S,Factor V Leiden,Antitrombin III,hyperhomocysteniaemia,protein gene mutation advised.
Routine screening for Dm and thyroid function is not advised in asymptomatic women.
No sufficient evidence to advise to do prolactin level.
TORCH screening not advised.
Posted by Gowrishankar S.
a) The non surgical options available are conservative or expectant and medical management. The expectant management in an effective and an acceptable method for management of miscarriage. There is no risk of anaesthetic or complications of surgery . There is no side-effects of drugs as in medical management. Women may feel that they remain in control and it is cost effective compared to medical or surgical management. It also reduces need for anti-D if Rh negative. But expectant management may take several weeks for complete resolution and the overall efficacy rates are lower ie, 47% compared to 95% with surgical management. It may be associated with pain and heavy bleeding needing surgical management. The expectant management may only be offered in units where women can access 24 hour telephone advise and emergency admission if required.
With medical management the advantages are reduction in complications associated with general anaesthetic and surgery. Women may still retain a degree of control and it is cost effective compared to surgical management. Women can be managed on an outpatient basis and there is a high level of patient acceptability with medical management. To avoid unnecessary anxiety women should be advised that the bleeding may last for atleast 3 weeks. As with expectant management it may be associated with more pain and bleeding needing surgical management. It should also be offered in units where women can access 24 hour telephone advise and emergency admission if required
b) Recurrent miscarriage affect 1% of all women. Karyotyping of the couple should be arranged as 3-5% of the couple may have abnormal karyoptype such as balanced translocation. If any abnormality detected prompt referral to geneticist should be made. Genetic counselling offers the couple a prognosis for future pregnancy, familial chromosoamal studies, counselling and appropriate prenatal diagnosis in future pregnancies. A cytogenetic analysis of the products should be arranged if the next pregnancy fails as it may be due to an abnormal embryo. As the number of miscarriages increases the prevalence of chromosomal abnormality decreases. A pelvic ultrasound scan should be offered to assess uterine anatomy and morphology as there there is a high rate of miscarriage and midtrimester losses in women with untreated uterine malformation. But open uterine surgery is associated with postoperative infertility and uterine rupture in subsequent pregnancy. The role of hysterosalphingogram is questionable. Screening for anti-phospholipid antibodies on two occasions at least 6 weeks apart should be offered as early treatment with low dose aspirin and heparin has showed to have significantly improve the live birth rate. Screening for inherited thrombophilias especially Factor V Leiden(FVL) should also be done as it is shown to be associated with recurrent miscarriage. Offering thromboprophylaxis in patients with FVL mutation may be assocated with reduced risk of miscarriage. And finally supportive care should be offered as it is shown to have excellent prognosis for future pregnancy outcome without pharmacological intervention.
Posted by Bindi J.
BJ:

A) The patient should be approached in a sensitive and sympathetic way as she would be emotionally distressed. Give her time to take in the news and if she wishes to have her accompanied by her partner. Since she is not bleeding profusely and is not showing signs of infection she may be offered either expectant or medical management. Expectant management involves involves spontaneous expulsion of products of conception. The advantages of expectant management are it is devoid of morbidity due to surgery or anaethesia. The woman feels more in control and it doesnot involve hospital admission. Also, it is more cost effective than surgical management. The limitations are that it has variable success rate of 25-95%. She may need a surgical intervention if she bleeds or has retained products. Also, it may take up to 3 weeks for complete resolution. The tissue may not always be available for histological examination. This option can only be provided in units with 24 hrs emergency services. The medical option involves various medical regimens like Mifepristone 200 mg followed by vaginal/oral Misoprostol or cervical priming with Gemeprost followed by Misoprostol. There is no evidence that any one regimen is better than the other, it depends on unit protocol. The advantages are- No surgical or anaethetic morbidity associated, the patient feels more in control and it is more costeffective than surgical management. The limitations are that it is more painful, it has variable success rate of 15-95%, may need surgery if complications like retained products or profuse bleeding occur. Also the tissue may not always be available for histological examination. The woman should be provided with written information and proper documentation should be done in her notes. Her rhesus status should be known to give her 250mcg Anti D following medical procedure.

B:
Since she has had three recurrent miscarriages she is bound to be emotionally distressed. It is important to reassure her that in most cases there is no underlying abnormality. It is known that most cases have unexplained aetiology and 75% have healthy pregnancy outcome following supportive care alone. However some investigations should be done to identify a small number of women who may have an underlying cause. ELISA test for antiphospholipid antibodies, dilute Russel viper venom test, activated partial thromboplastin time and Kaolin clotting time should be done for anticardiolipin antibodies. These tests are done to identify antiphospholipid syndrome which causes recurrent miscarriage in 15% cases. The prognosis may be improved in subsequent pregnancy to 70% by giving aspirin and low molecular weight Heparin . Trans vaginal scanning(TVS) to identify polycystic ovarian morphology as 45% cases are implicated in recurrent miscarriage. PCOS can also be diagnosed by raised LH and FSH levels. Also TVS can identify uterine anomalies although they are more a causative reason for midtrimester miscarriages. Parental peripheral blood karyotyping should be done to identify any chromosomal abnormalities. 3-5% of causes of recurrent miscarriage is due to genetic factors. If a genetic cause is identified referral to a Geneticist should be done to improve future prognosis. Tissue should be sent for cytogenetic analysis. There is no role of routine screening for TORCH although testing for bacterial vaginosis by amslers criteria should be done. There is no role of Glucose tolerance test for screening for occult Diabetes. There is no role of thyroid function test for asymptomayic Thyroid condition. There is no role of routine Prolactin measurement for hyperprolactenemia. It is important to inform the woman that despite all these tests no cause may be identified. She should be provided with written information . Another appointment should be made for Recurrent Miscarriage clinic.
Posted by Roba R.
RR(a) Discuss the non-surgical options for her management, indicating the advantages and limitations of these options [10 marks].

With sympathized manner explain the following options:
1) Expectant management ( Spontaneous MC)
Advantages
. Non medicated ( more natural)
. avoid possible side effects of medical treatment
. Avoid possible risks of surgical treatment
. Avoid risk if infection
Disadvantages:
. Longer period of bleeding
. More painful
. might end with incomplete MC that will require surgical evacuation.
. Require 24hrs access to health services
. Can’t send tissues to HP and in her case for karyotyping

2) Medical Treatment

Taking Mifepristone followed by Prostaglandin
Advantages:
. Avoid risk of surgery including anaesthesia
. Avoid risk of infection
. around 70% will have complete MC

Disadvantages:
. Longer period of bleeding
. require 24hrs access to health services
. Might not be complete and require surgical intervention
. No tissues for HP and karyotyping
. More painful





(b) Discuss and justify the investigations that you will undertake to identify the cause of her miscarriages [10 marks].

This is her third miscarriage, which indicates that she has recurrent miscarriage. This requires the need to identify cause if possible as unknown cause still the most common cause.
. Parents karyotyping ( 3-5%) . Balanced translocation
. Thyroid function test. Hypothyroidism associated with increase risk of MC
. Antiphosoplipid Syndrome ( APS) around 15% of recurrent MC . Diagnosed if anticardiolipin ab elevated in 2 occasion 6 weks apart
. Uterine anomalies need to be excluded. Hystrescopy to exclude possible ureins septum , however it is more related to 2nd trimester miscarriage.
. Cervical incompetence is typical of second trimester miscarriage , however clear history of previous treatments on the cervix for example LLETZ or cone Bx . If this is the case it worths observing cervical length in the following pregnancies.
. Immunological causes : As mother’s body reject fetus , no clear evidence .
. Thrombophilia screening. Associated with recurrent MC in particular after 10weeks . Tests include FVL, MTHFR, homocystine , prohrombin genes 2010 .
. Genital infection needs to be ruled out . Doing Vaginal swabs , however screening and treatment for bacterial vaginosis found to effective only in patients who have had preterm deliveries


Posted by Green K.
Green:

a) Non-surgical options would include expectant management and medical management.

Advantages of expectant management would be that it avoids the risk of anesthesia and surgery if successful. Patient feels more \"in control\" of her miscarriage. Does not require admission. Limitation would be that it carries a low efficacy rate of 50%. Bleeding may be unpredictable and may require admission for heavy bleeding or severe pain. Bleeding may last up to 3 weeks once started. Only feasible in units with 24 hours telephone advice or emergency admission. Tissue may not be available for histological diagnosis which is required to confirm pregnancy, exclude ectopic pregnancy and gestational trophoblastic disease.

Advantages of medical management would be that it carries a efficacy rate of 85%. It potentially avoids the risk of anesthesia and surgery if successful. Patient can be managed as out-patient after prostaglandin administration. It is also cost effective for the National Health Service. Limitation would be that pain and bleeding may be increased. Bleeding may persist unto 3 weeks after medical evacuation. Only feasible in units with 24 hours telephone advice or emergency admission. Tissue may not be available for histological diagnosis if expulsion occurs at home Failure of medical treatment would require a recourse of surgical evacuation.

b) Patient has 3 consecutive first trimester miscarriages and the probability of that occurring by chance is low since 10 to 15% of clinically recognized pregnancies ends in a miscarriage.

Peripheral blood karyotyping for the patient and her partner. This is to detect presence of abnormal parental karyotype such as balanced reciprocal or Robertsonian translocations. A positive result would warrant a referral to a clinical geneticist for counseling.

Cytogenetic testing of the product of conception. This is to detect abnormal embryo with chromosomal abnormalities which is incompatible with life. If the karyotype of the product of conception is abnormal then it carries a better prognosis for the next pregnancy.

Patient will be screened for antiphospholipid antibodies (Lupus anticoagulant and anti cardiolipin antibodies). That would require 2 samples taken 6 weeks a part showing moderate to high titters of either antibodies (IgG and /or IgM class). It\'s presence would warrant treatment with Aspirin and Low Molecular Weight Heparin in her next pregnancy as it is shown to increase the life birth rate to 70%.

Patient would be screened for inherited thrombophilic defects such as Factor V Leiden gene mutation,protein C and S, antithrombin III, homocysteinemia and prothrombin gene mutation. Positive findings would warrant thromboprophylaxis in her future pregnancy.
Posted by SRABANI M.
SM
a. For this clinical situation, nonsurgical options will be either expectant management or medical management of missed miscarriage. Advantages of expectant management are less risk of anaesthetic complication than surgical & less risk of post-surgical complication than surgical option.Also less side effects of drug in this option .Woman will be more ‘in control’ of the situation and may avoid hospital stay in uncomplicated situation. There is reduced risk of infection as well as reduced need of Anti-D ( if Rh negative) in this option as well. This is also cost effective compared to surgical option. Disadvantage of this options are pregnancy may take few days to few weeks to resolve and also heavy bleeding may lead to urgent ERPOC.this option is available in the units which are available 24/7 for contact or admission. Pain may be severe and intolerable. Tissue may not be available for histological examination.Success rates vary widely in different units from 25- 100%.
Medical management has got quite similar advantages and disadvantages like expectant management.Advantages are less risk of anaesthetic hazards,less chance of infection, less complication than surgical option.Patient satisfaction is higher with less hospital stay, women feels more in control of their situation.It is more costeffective & can be done as outpatient basis in uncomplicated situation. Disadvantages are bleeding may continue for few days upto three wks, associated with more blleding and pain, success rate varies from 15-95%.Heavy bleeding may necessitate urgent ERPOC. Tissue may not be available for histology and also medical option is available in the units which are accessible/ contactable 24/7

b. This lady has already got two miscarriages .So by definition she is suffering from recurrent miscarriage which is a distressing problem affecting 1% of all women.It is a heterogenous condition having many possible causes. This couple should have peripheral blood karyotyping as in 3-5% of couples with RM , one of the partners suffers from chromosomal anomaly.Abnormal parental karyotyping will necessitate referral to clinical geneticist for further management. RM may be due to abnormal embryo & hence cytogenetic analysis of product of conception may be helpful .But it is very expensive tool & should be reserved for research trial or who ever undergone for index pregnancy.Pelvic USS may be helpful to exclude uterine anatomy & morphology as these have reported to contribute 1.8-37.6% of RM.although there is no RCT to assess benefit of surgical correction of uterine abnormality on pregnancy outcome.Cervical weakness is mainly a cause of midtrimester miscarriage & hence this is not applicable for this lady.there is insufficient evidence of evaluating HCG in this situation.Prevalance of diabetes & thyroid dysfunction are not significantly higher in this group & hence these are not indicated. Routine screening for thyroid antibody is not recommended & also insufficient evidence to assess hyperprolactinaemia in RM. this lady is highly suggestive of suffering from APS & she should have two positive tests at least 6 wks apart showing either lupus anticoagulant or aCL antibodies of IgG and /or IgM present in medium or high titre .Lupus anticoagulant detection by dRVVT test more sensitive and specific than aPTT or KCL test. 15% of women with RM has got APA..Anticardiolipin antibody is detected by ELISA test. These tests are very important as live birth rate in women with aPL without any pharmacological intervention is as low as 10%.TORCH screening is unhelpful in RM as role of infection in miscarriage is unclear.Inherited thrombophilia defect should be investigated as several studies have suggested association between RM and this defect.Mainly activated protein c/S ( FVL ) .antithrombin III , hyperhomocysteinaemia etc are important causes of fetal loss. Finally unexplained fetal loss may have excellent prognosis without any intervention if offered supportive care by a dedicated EPU.
Posted by Bee N.
A 25 year old nulliparous woman with two previous first trimester miscarriages is referred to the emergency gynaecology clinic with a 24 hour history of brown vaginal discharge at 10 weeks gestation. Ultrasound scan shows an 8 weeks size missed miscarriage. (a) Discuss the non-surgical options for her management, indicating the advantages and limitations of these options [10 marks]. (b) Discuss and justify the investigations that you will undertake to identify the cause of her miscarriages [10 marks].
Answer (BN)
A)The non surgical options of her management include expectant and medical management. Expectant management entails a \"wait and see\" approach allowing nature to take its course. Medical management entails the use of medications which include administering an anti progestogen and then 36-48 hours later, a prostaglandin to evacuate the uterus. Expectant management is less invasive to the mother and tends to protect privacy. It allows nature take its course and for some people is more acceptable. It avoids the risk of surgery e.g uterine perforation. The disadvantages are however include that timing of actual expulsion of fetus is unpredictable. It may take longer than is anticipated. Bleeding may be excessive and potentially dangerous at home or outside hospital. It will require easy access to hospital even if embarked upon and will not be suitable for patients living far from hospital. .Expectant management also has the disadvantage of potentially losing tissues expelled which will therefore not be available for further studies or investigation. Patients who embark on this may not be able to get the reassurance from hospital staff that tissues passed are complete and this can potentially end up with infection if incomplete miscarriage has occured.
Medical management on the other hand is more controlled and monitored in hospital setting. The timing is predictable as appointment are given. The disadvantages however include the fact that patients still have to wait for their appointment during which time they may spontanoesly miscarry. It is more invasive with administration of drugs. patients will also have to put up with the side effects of these drugs which include increasing blood pressure and precipitating asthmatic attacks. It is contraindicated in patients with asthma. Approximate 6 % of patients will fail to evacuate the uterus and end up with repeat procudure or surgery. Non steroidal anti inflammatory drugs not suitable for analgesia.

B)3-5% of recurrent miscarriages have abnormal parental karyotype. I will therefore take bloods from parents for this. Blood from patient will also be taken to check for both inherited and acquired thrombophylia. Antiphospholipid lipid syndrome is associated with recurrent miscarriage.Tissues obtained will be sent for histology as well as cytogenetic studies as over 70% of miscarriages are due to chromosomal abnormalities. I will organise a pelvic ultrasound scan to look for uterine abnormalities. High vaginal swab to look for bacterial vaginosis will be obtained. Treatment for this in early pregnancy has be shown to reduce the incidence of 2nd trimester losses and pre term labour. Screening for infection such as toxoplasmosis, rubella and syphilis not of proven value. Immuno chemistry studies such as looking for sperm antibodies or immunoglobulin therapy has no proven value nor is treatment with prostaglandins. If patient has clinical features suggestive of diabetes or hypothyroidism, I will take blood for fasting blood sugar and thyroid function test because poorly controlled state of these diseases can cause recurrent miscarriage. Reaasurance alone is of great benefit in achieving conception in the future.
Posted by drvimaladkm@yah K.
The nonsurgical management options in this nulliparous woman are: Expectant management or medical management. Advantages of expectant management are –It is a natural method where the woman waits for spontaneous expulsion of products of conception. By this method ,she would avoid the risk of anaesthesia and operative risk such as cervical/uterine injury or visceral injury.She would not require antiD in cases of spontaneous expulsion as there is no instrumentation with the least possibility of fetomaternal haemorrhage.Lower risk of sepsis.Patient may feel the situation under her own control.Disadvantages are the woman may still need evacuation if expulsion becomes incomplete. There is a possibility of risk of acute haemorrhge & pain.Woman may develop severe anxiety in the waiting period. pregnancy may take several weeks to resolve.Tissue may not be available for histology. It is associated with more pain.Success rate may vary from 25 to 100%.
Medical management involves usage of prostaglandin Misoprostol with or without Mifipristone. Advantages are :There is reduced risk of anaesthesia & its complications.It is highly acceptable.Patients feel under control.Lower risk of sepsis without any extraneous manipulation. It can be undertaken on an outpatient basis. Disadvantages are: variable success rate between13 to 96%.Associated with more bleeding & pain.Bleeding may persist for upto3 weeks.May require emergency evacuation.Patient has to be undercare where24 hrs contct & service is available.
B) This patient requires investigation as it is recurrent consecutive3 miscarriages. Preferably products of conception has to be subjected for cytoanalysis. Parents have to get karyotyping done to detect any carrier of balanced translocation,(~0.4%) mosacism & may need genetic counseling & preimplantation diagnosis in the future pregnancy.Uterine anomalies may be detected by transvaginal scans or by hysterosalpingogram with similar diagnostic sensitivity.But sepsis risk is increased in hysterosalpingogram.Antiphospholipid antibodies(Lupus anticoagulant & anticardiolipin antibodies IgG& IgM)may be found in 15% of recurrent miscarriages. Medium or high titre of antibodies with interval of 6weeks is diagnostic.Inherited Thrombophilias (Protein C&S, antithrombinIII deficiency, activated protein C resistance, hyperhomocystinemia, prothrombinG mutation)more so of factorVLeiden needs detection due to potential consequences in pregnancy.Endocrine factors such as progesterone deficiency may be a failing pregnancy rather than luteal phase defect & supplementation of progesterone or humanchorionic gonadotropin does not improve pregnancy outcome. Screening & treating for bacterial vaginosis in early pregnancy may reduce recurrent late miscarriage.TORCH screening may not be of any value.Maternal immunotherapy with leukocytes has more risk without benefit.
VDKM
Posted by fluffy F.
a)Medical management and expectant management are the 2 options available.
For medical management , the advantages are it can avoid general anesthesia and its related complications . Studies done show it has higher acceptance among patients as they feel more in control.Medical management can be done as a outpatient basis , provided the patient has good access to a early pregnancy assessment unit(EPAU).It is also cost effective. THe limitation of medical management is , if fail medical management she will still need a surgical evacuation. The chances of successful medical management is higher for incomplete miscarriage compared to missed miscarriage as in the case discussed .
With expectant management , the advantages are the chances of pelvic inflammatory disease is less and there is no effect on the future fertility.However limitations are , patients who are given the option of expectant care should be those with good access to a nearby EPAU unit .The patient should be explained regarding the risk of prolong bleeding and prolong duration for resolution of symptoms 2-3 weeks. Patient should be explained regarding lower abdominal cramps which can be relieved with oral analgesics.

b)Genetic factors and most commonly balanced translocation contribute to 3-5% of the cause for recurrent miscarriages.Thus peripheral blood karyotyping from both parents can be sent for analysis.The products of conception sent for cytogenetic analysis, as if presence of a karyotype abnormality chances of a future pregnancy is better.
Primary Antiphospholipid syndrome (APS) causes 15 % of recurrent miscarriages. Thus the antiphospholipid and lupus anticoagulant titre should be sent twice 6 weeks apart and a significant titre from these investigations done twice will clinch the diagnosis of APS.Treatment with heparin and aspirin in these patients has a 70% successful pregnancy outcome.
Uncontrolled diabetes mellitus is cause of recurrent miscarriages. however diabetes screening and thyroid screening is recommended only if patient has symptoms. If she was previously diagnosed with diabetes mellitus a good control prior to embarking on a pregnancy will ensure better outcome.
Screening for bacterial vaginosis should be done as , it can cause miscariages but usually late miscarriages . Treatment with metronidazole is effective if diagnosed.There is no need to perform the TORCHES ( toxoplasmosis, rubella, cytomegalovirus ,herpers and syphilis ) screening as it is not useful as the role of infection in recurrent miscarriages is questionable.Inherited thombophilia , protein c and s deficiency , anti thrombin 111 deficiency can be done as this can cause recurrent miscarriages
Posted by S S.
(A) The non surgical options in this case are either medical or expectant management. In the medical management mifepristone 200mg is given orally after informed consent and 48hrs later prostaglandin is given. It could be either PGF2alfa (misoprostol) given vaginally or orally 600-800micg at 3hourly interval upto 3 doses or PGE2 depending on the unit\'s protocal. The advantages are that if successful she avoids surgical method and the risks associated with it like infection, perforation, future infertility and anaesthetic risks. The success rate is upto 85%. Prostaglandin course can be repeated if unsuccessful in first attempt. The disadvantages are the side effects of prostaglandins like fever, nausea, vomiting, diarrhoea and excessive pain. It is contraindicated in asthmatics and cardiac patients. Though the patient goes home after mifepristone she has to come back as in patient for prostaglandin. She can bleed heavily at any time so a 24hr backup should be there in the form of a dedicated early pregnancy unit and gynae ward. If the miscarriage is incomplete then she will require surgical evacuation.
In expectant management she can wait for events to occur naturally. She is informed that she should contact EPAU or come to hospital in case of excessive bleeding. There is no definite time limit upto which she can wait and it depends on individual unit\'s policy. She will need weekly scans. Advantage is it avoids risks associated with surgical or medical management. It is successful in 75-80% cases. The disadvantage is one can get anxious and apprehensive while waiting for long. She can bleed heavily at any time and may need to come to hospital during insocial hours and may still need surgical or medical evacuation if miscarriage is incomplete.
In either situation patient is counselled about pros and cons of each method, the facilities available in the unit to deal with emergency situation and a 24 hour helpline is given. Verbal information is backed by leaflets. Her views and choice respected.

(B)This woman has had three consequtive miscarriages so she needs a full work-up for recurrent miscarriage. Blood should be sent for antiphospholipid antibodies. Lupus anticoagulant is diagnosed by a raised dilute russel viper venom test and APTT on two cosecutive occasions 6 weeks apart. Anticadiolipin is diagnosed with ELISA. Inherited thrombophilias are also tested like antithombin III, protien S deficiency, activated protein C resistance. Anti DNA, anti Sm, anti Ro and La are tested with history suggestive of SLE. Tests for thyroid and diabetes are done if suggestive history is there. They are not routinely recommended. With a suggestive history PCOS boichemical profile is done otherwise female hormone testing is not routinely recommended. Karyotyping of both parents should be done for translocations. Fetal karyotype should also be offered.
A pelvic ultrasound should be done which will be helpful in identifying polycystic ovaries, and abnormalities of uterus and cervix ( more likely to be related to second trimester miscarriage and preterm labour). Alternatively HyCoSy or HSG may be done which may indicate need for prophylactic sutures.
A high vaginal swab is taken to rule out bacterial vaginosis as it is related to recurrent miscarriages and preterm labour. It shoul be treated with metronidazole or clindamycin. Investigation for other STIs not indicated. Similarly TORCH screening is not routinely indicated.
Posted by tahira jabeen J.
a)
Non surgical management of early miscarriage is expectant or medical .patient should be offered informed choices.An effective early pregnancy unit is essential in expectant or medical management.I will inform patient about expectant manage ment
that it means spontaneous expulsion of products by itself.although expectant management avoids risks associated with surgery or anesthesia,it may take several weeks before complete miscarriage.it is sucessful in 70% cases.satisfaction rates are high.patient will be informed that she may have pain & more bleeding any time she will be given 24 emergecy contact no.aand should have access to hospital any time.but she can end up in unplanned emergecy evacuation due to heavy bleeding or if she aborted incomplete.,infection or if she changes her mind.
patient will be informed about medical management taht athere are variety of effective prostaglandin regimens like gemprost 0.5-1 mg,vaginal misoprostol 800mcg and oral misoprostol 600mcg and mefiprostone can be given in combination with misoprostol.
each unit is having its own protocol for route & dose.can be given single dose or repeated upto total of 1200mcg.pt will be informed about side effects of misoprostol may cause abdominal pain,nausea,vomiting,and diarrhoea(which is less with vaginal route).pt may have increased abdominal pain & bleeding so patient should have 24 direct acess to emergency room.pt should be informed that medical management has >80% success rate,will save from surgical intervention & anesthesia exposure.misoprostol is not licienced for management of miscarriage,but its cheap & effective.pt will be informed about if she is RH negative needs to have anti d if heavy vaginal bleeding or surgical intervention happens.pt will also be informed about limitations of medical management as these medicines can not be used if pt has adrenal insufficiency ,sever anemia,mitral stenosis,glaucoma,severe asthma,pt having anticoagulanttherapy.
b)
this pt is case of recurrent abortion which effects 1% population.she needs to be investigated as per RCOG recomendations,patient should be offered pelvic uss which can give us more information than pregnancy loss.like neural tube defect of fetus thus giving immediately cause of abortion.also gives information about uterine abnormalities such as bicornuate uterus and submucosal fibroids although correcting these abnormalities have not been of proven value.pt will be offered karotyping of parents as 3-5% will be having balanced translocation need immediate refferal to genetist who will help to give idea about next preg prognosis,and option of pre implantaion genetic diagnosis.Cytogenetic analysis of products of
conception if karotyping is abnormal there is better prognosisin next pregnancy as no of miscarriages increases it will decrease prevalance of chromosomal abnormality.it will help to counsell & future management of pregnancy .routine screening for diabtese,hypothyroidism,hyperprolactenemia is not recomended until symptoms are suggestive of.Pt needs to have throbophilia screening. serum level of anti cardiolipin&anticoagulant antibodies titre 6 weeks apart 2 readings to diagnose antiphospholipid syndrome as it is present about 15% patients
with recurrent abortions and if treated with low dose aspirin & heparin will improve live birth rate from 10% to 70%.
TORCH screening is not helpful in recurrent miscarriages.screening & treatment for bacterial vaginosis may help but in late miscarriages or preterm labour .inherited thrombophilia screening should be done as factorV lieden mutation may be a cause of placental thrombosis so thromboprophylaxis can be offered.
Posted by Nadira N.
A) The non surgical management options in this case are expectant management and medical management.Expectantant management is the management of choice.It has decreased risk of side effects as compared to medical management.It is more acceptable to women and causes fewer effects on quality of life as it allows the women to continue her normal daily life .It avoids surgical procedure also.Published data suggest reduction in pelvic infection and no effect on futre fertility.Psychological morbidity is not adversly effected by expectant mangement.However it is associated with more prolonged bleeding than medical or surgical management.It may take several weeks to resolve and overall efficacy rates are low.Medical uterine evacuation is an alternative approach researched and developed in last 10 years .20% women choose this option reason being given they feel more in control ,and avoidance of general anesthesia.Medical methods use prostaglandin analogues with or without priming with antiprogesterone mifipristone.There is 50% reduction in incidence of clinical pelvic infection compared to surgical evacuation.surgical procedure and related morbidity such as perforation and laprotomy is avoided.May be taken successfully on outpatient basis.Efficacy rate vary widely from 13% to 96%.Pain and bleeding scores are high compared to surgical mangement.Bleeding may continue for 3 wks.Medical and expectant management can be offered only in units where women can access 24 hour telephone advice and emergency admission if required.Patient need to be warned that 30% start miscarrying during the 36 hour priming phase.

B) I will ask for paternal peripheral blood karyotyping .3 to 5% couples with recurrant miscarriage have a balanced structural chromosomal anomaly,prevelance in general population is .4%.The most common type are reciprocal or robertsonian translocations.Chromosome inversion is reported in .2% of couples.Identification of abnormal paternal karyotype warrats prompt referral to clinical gentacist for familial chromosomal studies,counselling and appropriate prenatal or preimplantation diagnosis.Cytogenic analysis of products of conception should be offered.If karyotype of the abortus is abnormal ,there is a better prognosis in future pregnancy.It provides useful information for future counselling and management of future pregnancy.Transvaginal ultrasound for uterine antomy and morphology and ovarian morphology should be asked.The prevelance of uterine anomalies in patints with recurrant miscarriage range between 1.8 to 37.6 %.3D ultra sound offers both diagnosis and classification of uterine anomaly and obviate the need of diagnostic hysteroscopy and laproscopy.Benifits of surgical correction of uterine abnormalities on pregnancy outcome are uncertain.Early follicular phase LH and FSH and testosterone level should be measured. LH hypersecretion and hyperandrogenemia are risk factors for early pregnancy loss.Persistantly raised follicular levels are found in small percentage of women with recurrant miscarriage .PCOS ovarian morphology alone,in ovulatory women who concieve spontaneously does not predict increased risk of pregnancy loss.If endocrine profile is normal with PCOS ovarian morphology patient can be reassured.Primary antiphospholipid antibody sydrome is seen in 15 % of women with recurrant miscarriage.To diagnose APS patient should have two positive tests at least 6 weks apart for either lupus anticoagulant or anticardiolipin antibodies of igG or igM class in medium or high titer.In women with recurrant miscarriage associted with APS the live birth rate without any pharmacological intervention is only 10% This is significantly improved with heparin and aspirin to 70%.Factor v Leiden mutation is found in 1% of UK population, it is associated with maternal risk also ,there fore it is reasonable to ask and activated protien c resistance should also be asked.Full thrombophilia screen should be asked in selected patients only.Glucose tolerance test and thyroid function test should be asked if indicated.
Posted by Seham S.
SS

(a) non surgical options will be either expectant or medical managment.Expectant managment has the advantages of avoiding surgical and anaesthetic intervention.It is associated with lower risk of clinical pelvic infection and has no advers effect on future fertility.Anti-d is not required in RH -ve women.However, limitations of this method is that it takes several weeks for resolution and bleeding is unpredictable and may be prolonged and heavy requiring transfusion or emergency admissision for surgical evacuation.Woman should have 24 h telephone advice and admissision if required.The other option is the medical managment by using anti-progesteron (Mifiproston) oraly and prostaglandin (Misoprostol)either oral or vaginal . It has the advantages of cost effecivness and lower risk of pelvic infection compared to surgical evacuation.Also,it avoid surgical and anaesthetic intervention and complications.Medical managment has high rate of patient acceptability and feel more in control.Limitations include lower success rate if intact sac and closed cervix.Bleeding may be prolonged for 3 weeks and may be ended by surgical evacuation for retained products.Anti D is required in RH -ve women.

(b) woman should know that in the majority of cases ,no abnormality was found and subsequent successful pregnancy is high.In cases with recurrent miscarriage ,karyotyping should be done with prompt referral to geneticist in +ve results.Cytogenetic analysis of products of conception should be recommended in couples with recurrent miscarriage.Screening for anti-phospholipids antibodies could be done.Anti cardiolipin and anti lupus anti coagulants on 2 occasions 6w apart can be done.
Pelvic U/S mieght be done to assess uterine anatomy and morphology.THe routine use of hysterosalpingogram as screening test for uterine anomalies in women with recurrent miscarriag is questionable.It is associated with patient discomfort, increase risk of infection and radiation exposure and no more sensitive than pelvic u/s with or without sonohysterography when done by skilled personnel.Three dimentional u/s may obviate use of diagnostic hysteroscopy and laparoscopy however ,it is more expensive . TORCH screen is unhelpful in the investigation of recurrent miscarriage and is no more used nowadays. Screening for occult diabetes and thyroid disease by oral GTT and thyroid function tests should be restricted to symptomatic women only.No evidence to support efficacy of thrombophilia screen if thromboprophylaxis is to be used in next pregnancy.
Posted by Shamita S.
Ans
The non surgical options are expectant and medical management ,the advantage of these above surgical options is that it avoids anaesthesia ,chances of cevical tears .the limitation s of non surgical methods would be requirements of surgical intervention in cases of exxesive bleeding .and these methods should be offered in units where women can access 24 hrs telephone and emergency admission.
Medical management can be undertaken with prostaglandins after priming with antiprogesterones ,it can be used as an out patient basis and the efficacy rates vary from 13%to96% depending on many factors .An increase in pain and prolonged bleeding with medical management are the limitations and the patient should be councelled that she may bleed for about 3wks
Expectant management is another option where is opts for no interventention and awaits for sontaneous bleeding and resortuion of POC, before offering this option she should be councelled that with an intact sac she might take several wks and the overall efficacy rates are lower .inspite of this limitation it gives patient satisfaction.
there is no evidence to support that infective rate with non surgical method is higher ,and there is no effect on future fertility.The woman should be councelled about all the methods of management ,with proper leaflets ,ans decision to be respected and followed. If the woman is Rh + and undegoes medical termination she needs antiD to be given but not required for expectant management.



Since 3-5% of couples with recurent pregangy loss are associated with balanced structural mchromosomal anamoly ,they should be offfered karyotyping from peripheral blood smples
A pelvic ultrasound should be offered to look for any uterine structral malformation or polycystic ovaries Antiphospholipids antibodies are present in 15%of patients with recurrent miscarriage so she should be offered blood test for lupus anticoagulants and anticardiolipins at 6 wks apart ,.the live birth rates in these patints without treatment would be as low as 10%screening for inherted thrombophilia is justified as inherited thrombophilic defects are associated with foetal loss.Screening for and treatment for bacterial vaginosis is justified as the presence of the same is asssociated with miscarriage.Routine screening for torch infetions is not justified foe it cannot cause recurrent loss,simlarly hormonal assays like prolactin gondatropins and thyroid antibodies are not recomended,screeing for diaabetes is not very informative..

Ans
The non surgical options are expectant and medical management ,the advantage of these above surgical options is that it avoids anaesthesia ,chances of cevical tears .the limitation s of non surgical methods would be requirements of surgical intervention in cases of exxesive bleeding .and these methods should be offered in units where women can access 24 hrs telephone and emergency admission.
Medical management can be undertaken with prostaglandins after priming with antiprogesterones ,it can be used as an out patient basis and the efficacy rates vary from 13%to96% depending on many factors .An increase in pain and prolonged bleeding with medical management are the limitations and the patient should be councelled that she may bleed for about 3wks
Expectant management is another option where is opts for no interventention and awaits for sontaneous bleeding and resortuion of POC, before offering this option she should be councelled that with an intact sac she might take several wks and the overall efficacy rates are lower .inspite of this limitation it gives patient satisfaction.
there is no evidence to support that infective rate with non surgical method is higher ,and there is no effect on future fertility.The woman should be councelled about all the methods of management ,with proper leaflets ,ans decision to be respected and followed. If the woman is Rh + and undegoes medical termination she needs antiD to be given but not required for expectant management.



Since 3-5% of couples with recurent pregangy loss are associated with balanced structural mchromosomal anamoly ,they should be offfered karyotyping from peripheral blood smples
A pelvic ultrasound should be offered to look for any uterine structral malformation or polycystic ovaries Antiphospholipids antibodies are present in 15%of patients with recurrent miscarriage so she should be offered blood test for lupus anticoagulants and anticardiolipins at 6 wks apart ,.the live birth rates in these patints without treatment would be as low as 10%screening for inherted thrombophilia is justified as inherited thrombophilic defects are associated with foetal loss.Screening for and treatment for bacterial vaginosis is justified as the presence of the same is asssociated with miscarriage.Routine screening for torch infetions is not justified foe it cannot cause recurrent loss,simlarly hormonal assays like prolactin gondatropins and thyroid antibodies are not recomended,screeing for diaabetes is not very informative..


Posted by Shamita S.
I am sorry the answer got copied twice.
Posted by SYAMALRANJAN S.
A 25 year old nulliparous woman with two previous first trimester miscarriages is referred to the emergency gynaecology clinic with a 24 hour history of brown vaginal discharge at 10 weeks gestation. Ultrasound scan shows an 8 weeks size missed miscarriage. (a) Discuss the non-surgical options for her management, indicating the advantages and limitations of these options [10 marks]. (b) Discuss and justify the investigations that you will undertake to identify the cause of her miscarriages [10 marks

a. Non-surgical options for missed miscarriage are expectant and medical management. Proper history and thorough physical examinations , patient’s informed choice should determine the proper option of management.
The advantages of expectant management are absence of side-effects and complications of drugs , surgery and general anesthesia. She feels more self-control. No need of anti-D immunoglobulin if mother is Rhesus negative. There is less chance of infection. This is also considered cost-effective.
But there are some limitations of expectant management such as resolution of tissues may take several weeks. There may be sudden severe pain and bleeding needing emergency hospital access and management. Success rate is not clearly predictable ( 25-100%) . Histology is not possible here because of non-availabilty of expelled tissue.
Medical management has got advantages of probability of more acceptance. Here , there is also absence of complications and side-effects of surgery , general anaesthesia. The woman feels more self-control. It is also cost-effective and may be treated as out-patient basis.
But it has some limitations like histogical studies can not be possible unless patient collect and bring the tissues after getting specific instructions. Severe pain and / or bleeding may cause emergency hospital attendance and management. Success rate varies from 13-96%.

b. In many cases of recurrent miscarriages, cause remains unexplained and unidentified. This is more often associated with an identifiable cause than isolated cases of miscarriage.
I will take proper relevant history which includes amount of blood loss, associated pain , nausea, vomiting, previous history ( and medical records if available) of miscarriages , any medical history suggestive of diabetes , thyroid disorders, personal and family history suggestive of thrombophilia, genetic disorders. Because I may find some relations with recurrent miscarriages ( such as presense of thrombophilia).
Physical examinations of BP, BMI,stigma of diabetes or thyroid swelling or of PCOS, any abdomino-pelvic mass should be searched for because obesity and PCOS , uncontrolled diabetes, thyroid disorders might have relations with miscarriages.
Histological and kariotyping examinations of evacuated product of conceptions (ERPC) is an important investigations . Peripheral blood of both partner should be sent for karyotyping. Most common types are balanced reciprocal or Robertsonian’s translocations. Identifications of an abnormal karyotype warrants prompt referral to clinical geneticist . Genetic counseling for future pregnancy , familial chromosomal studies , counseling and prenatal diagnosdis for future pregnancy would be discussed and offered. There is possibility of 5-10% chance of unbalanced translocations in future pregnancies.
Pelvic ultrasonographic ( with or without sonohysterography) assessment of uterine cavity when performed by skilled and experienced personnel will detect uterine anomalies. Prevalence of anomalies in recurrent miscarriages populations ranges between 2-35%.
Screening tests for antiphospholipid antibodies(APA) both lupus anticoagulant and anticardiolipin antibodies(IgG,IgM) would be performed on two separate occasions at least six weeks apart(present in medium or hih titre). Discordant results should prompt the performance of a third test. APAs are present in 15% of women with recurrent miscarriage. Women with persistently positive tests for antiphospholipid antibodies are offered treatment with low dose aspirin together with low dose heparin during future pregnancy.
Screening for inherited thrombophilia would be discussed and arranged because of relation with recurrent miscarriage and future pregnancy manangement plan.
Routine screening tests for diabetes , thyroid diseases in an asymptomatic woman presenting with recurrent miscarriage is uninformative.
PCOS investigation might be arranged because of relationship with recurrent miscarriage
TORCH screening is unhelpful investigation in this case.
Posted by Bgk H.
She should be approach in sensitive manner as this will be her third consecutive miscarriages. She need to be explained the diagnosis of recurrent miscarriage as this has the incidence of 1% and need to be investigated. For the current miscarriage she can be offered non surgical management such as conservative and medical management.
Expectant management involve awaiting spontaneous expulsion of POC. This could only be taken place in hospital with 24 hour emergency service and admission. The advantages of this option is the avoidance of surgical procedure and it attendant complication such as anaesthetic risk, uterine perforation, infection. It has variable success rate between 30-80%. It may take weeks or months and may cause anxiety to patients. It is unpredictable when the expulsion will happen and taken place. And it is associated with increased risk of bleeding. It will also result that the POC been mistakenly discarded and not available for collection for laboratory evaluation such as karyotyping. However patient has control with her condition.
Another option of management is medical treatment. It involves giving the patient oral or per vaginal medication to initiate the process of termination of the pregnancy. It also has the advantage of avoiding the surgical management. It has variable success rate as well. Patient has some control of her condition. It however associated with increase pain morbidity and analgesia requirement. It may cause discomfort while inserting the tablet to vagina or it may cause nausea and vomiting if taken orally. The medication also has their own unwanted side effect that may not tolerable to the patient such as diarrhoea, fever and allergic reaction. Patient may need inpatient management if having a lot of pain or bleeding following the medication but majority will be able to rest at home and report to the hospital when they have pain of bleeding.

B. I will collect her POC and sent for karyotyping to look for abnormalities for her next pregnancy. If the result showed abnormalities the prognosis of her next pregnancy will be good. Then parental karyotyping should be done to determine whether the couple is having any genetic problem and may need referral to genetic counsellor if present. I will arrange a ultrasound of pelvis to look for any uterine abnormalities such as uterine structural abnormalities, uterine cavity malformation or any abnormal growth inside the uterus. This has replace hyterosalphingogram as the main investigation. This is because detected abnormalities may cause miscarriage. If patient has signs of hyperandrogenisme and irregular menses, I will look for ovarian feature suggestive of polycystic which associate miscarriage if found to be PCOS. However detection of PCOS will not predict the outcome of future pregnancy. If patient has risk factor for diabetes and thyroid disorder, I will perform OGTT and thyroid function test to rule out these conditions as undiagnosed or uncontrolled medical problem may cause recurrent miscarriage. However it is not indicated if patient has no risk factor to suggest such conditions. Performing thyroid antibody level as routine is not recommended. I will also perform thrombophilia screening to detect any possibilities inherited thrombophilia such as Protien C, Protein S deficiency. Acquired thrombophilia to detct Anti-phospholipid syndrome. These investigations need to be repeated at 6 weeks interval to meet the criteria. Bacterial vaginosis is unlikely to cause first trimester miscarriage. However to investigate outside pregnancy is not recommended. Similarly, TORCHES screening is not indicated for patient with recurrent miscarriage.
Posted by Naheed M.

A.
Non–surgical options for her management are expectant and medical management. Most of the advantages of these conservative management options are common such as no neeed of hospitalization, more cost effective and saving health resources compared to surgical method. There is less risk of infection and no risk of perforation or damage to other pelvic organs as associated with surgical method. No anaethesia is required so there is no risk of its complications.
Expectant management has additional advantage of not suffering prostaglandin associated side effects and no intervention is required at all if the expectant management is successful.
There are certain drawbacks of these methods of management. They can’t be offered or continued to clinically unstable (heavily bleeding) patient or if patient develop heavy bleeding during conservative treatment. The products of conception are not available for histopathology and patient may have mild bleeding or spotting for few weeks which might be distressing for her. Follow up, compliance, and need of emergency arrangements for admission in the clinical setup (EPAU) is required. Patient’s wishes should be respected and if she doesn’t want to pursue conservative management (because of waiting time, anxiety or any other social reason) shouln\'t be employed.
Prostaglandins: Gemeprost (licensed for miscarriages treatment) and misoprostol (not licensed for miscarriage treatment) are associated with abdominal pain, nausea, vomiting and diarrhoea.
Mifepristone (antiprogesterone) is used before prostaglandins and increase uterine response towards the prostaglandins.
B
The investigations should be offered to the woman in the view of her history. Family history and personal history for genetic and medical disorders direct the preference order for investigations.
In this patient history of three first trimester miscarriages suggest the possibility of antiphospholipid antibody syndrome so antibodies (lupus anticoagulant by diluted russel’s viper venom test and anticordiolipin by ELISA) should be investigated at two occasions 8 weeks apart. High titre on both occasion confirm the condition.
Parental karytoyping should be performed as balanced translocation in any parent can be the cause of recurrent miscarriage.
Cytogenetic analysis of the products of conception should be conducted.
Uterine malformations and cervical incompetence are also the causes of recurrent pregnancy loss but more likely in the second trimester. Uterine malformations can be excluded through ultrasound, Hysterosalpingography and hysteroscopy. Cervical incompetence is considered in the presence of typical history of painless cervical dilatation and rupture of membranes. Transvaginal ultrasound may help in the
Diagnosis of cervical incompetence and also diagnose polycystic ovarian morphology. Polycystic ovarian syndrome is associated with hypersecretion of LH which is responsible for the miscarriage.
Tests for diabetes or thyroid antibodies and thyroid dysfunction don’t carry any value in recurrent miscarriages as well controlled diabetes and thyroid disease don’t cause recurrent miscarriage.
Screening for viral and other infections (TORCH) is not required for recurrent miscarriage. These infection can be the cause of a first trimester miscarriage but cant be continually so severe to cause recurrent miscarriages.
Family and personal history of venous thromboembolism should be asked and thrombophilia screen can be ordered in high risk (positive personal or family history) patients as thrombophilic disorders such as factor v leiden deficiency can cause pregnancy loss.
Posted by Jan I.
Jan
a) The non surgical management options available to this patient are expectant management and medical management of her missed miscarriage. This discussion should be done in an empathic manner without other clinical interruption. Written information should also be given to the patient about her situation and the management options. Expectant management involves waiting for the spontaneous completion of the miscarriage. Its benefits include that, if successful, it is non-interventional from a medical and surgical point of view and is a seen as being more natural. It thereby avoids the disadvantages of medical management including the administration (oral and vaginal) of prostaglandins and their side effects. It also avoids the risks of surgical management including infection, bleeding, cervical trauma, uterine perforation and subsequent visceral injury. Expectant management can be undertaken on an outpatient basis thereby allowing the process to take place in an environment that the patient is more comfortable in. The limitations of expectant management are that there may be a potential long wait for the miscarriage to occur and the need for ongoing follow-up, including repeated transvaginal ultrasound scans, which can be stressful for the patient. When the miscarriage does take place there is still a risk of haemorrhage that may require admission, transfusion and/or surgical evacuation of the uterus as an emergency. even once th miscarriage has taken place there is still the potential for retained products of conception requiring surgical management.
Medical management of the miscarriage involves the administration of prostaglandins with the aim of precipitating expulsion of the conceptus. It has the benefits that it avoids the risks of surgical management (as mentioned above) and avoids the potential long wait & follow up needed with expectant management. Its limitations are that it is usually done on an inpatient basis requiring a variable length stay in hospital dependant on the success of the management. There is a risk of haemorrhage that may require transfusion and surgical evacuation of the uterus. Despite being successful in the majority of cases the time taken for completion of miscarriage is variable and this may cause distress to the patient. There is a risk of failure and retained products of conception which may require revisiting the option of surgical management.
b) As the patient has now had 3 recurrent miscarriage she warrants investigation for a cause of this. Blood investigations would be performed with follow up, ideally in a specialist clinic. These tests include blood chromosomal karyotyping of the patient and her partner looking for evidence of balanced or Robertsonian translocations which precipitate miscarriage. Blood tests would be performed to investigate the anti-phospholipid syndrome. These include anti-cardiolipin antibodies and lupus anticoagulant. If positive for these, with a history of recurrent miscarriage, the patient would require treatment with heparin & aspirin in subsequent pregnancies which will greatly improve her chances of successfully carrying a pregnancy to term. Tests would also be performed looking for thrombophilias that predispose to miscarriage. These would include Antithrombin 3, Protein S and Protein C levels looking for deficiencies in these. The Factor 5 Leiden status of the patient would also be tested as hetero- and homozygosity in this predisposes to miscarriage. If any of these abnormalities are found then specialist clinic follow up and a haematological opinion may be warranted to guide treatment aimed at reducing subsequent miscarriage. Vaginal swabs should be taken looking for bacterial vaginosis or other atypical vaginal infections that may predispose to miscarriage. These should be treated if found. A transvaginal ultrasound scan should be performed to look for any uterine anomalies, including degrees of uterine septae and fibroids. If found these may warrant consideration of surgical removal to improve outcome in subsequent pregnancies.
Posted by G. K.
GSK
A)
The nonsurgical options include expectant and medical. The advantage ofexpectantl Mx is that the miscarriage can resolve naturally over time without the need for a medical and surgical approach alongwith the avoidance of complications associated with them. The disadvantage of such an approach is prolonged bleeding which can last over several weeks. The products of conception may be retained leading to infection, and necessitating treatment with antibiotics and surgical evacuation eventually.
The advantage of medical Mx .is that the patient can avoid the risks associated with surgical evacuation and general anasthesia.Also the patient feels more in control of the situation. The disadvantage of this method is pain , abdominal cramps and bleeding which may continue for long, leading to haemodynamic instability and the eventual need for an emergency surgical evacuation.Also the side effects of the prostaglandins used in the medical management can be quite severe, i.e nausea, vomiting, diarrhoea, bronchospasm, chest pain, palpitations and rarely wholive farmyocardial infarction.Such an approach is not suitable for her if she lives far away from the hospital, lives on her own and has no access to a 24 hour emergency telephone service or emergency admission.
B)
In 99% of cases there is no cause found and the prognosis for such cases is excellent. The investigations include karyotyping of the woman and her partner to diagnose a balanced or translocation as a cause of miscarriage.Also karyotyping of products of conception should be done to rule out a chromosomal anomaly such as lethat X chromosome mutation. In case of a posotive finding, referral to a clinical geneticist is done to offer councelling and management of future pregnancy in the form of preimplantation genetic diagnosis, CVS or amniocentesis or referral for IVF depending on the situation.A pelvic ultrasound should be carried out to identify uterine abnormalitis like bicornuate uterus, subseptate uterus or submucous fibroids. these can be treated with hysteroscopic resection; although the efficacy of such a treatment for recurrent miscarriages remain uncertain.It is important to rule out antiphospholipid syndrome as a cause of recurrent miscarriage.It is done by testiong the blood for anticardiolipin antibody and lupus anticoagulant. It is tratable with co therapy with heparin and aspirin during future pregnancies. The investigation for other thrombophilias such as protein c and s deficiency, factor five leiden deficiency and prothrombin gene variant is also carried out. The efficacy of treatment with aspirin and heparin of these however remain uncertain.
Posted by ASB -.
ASB
(a) Medical managment is an alternative to surgical managment in clinically stable patients . It is performed using prostaglandins analouges ( gemeprost or misoprostol ) with or without antiprogesterone priming ( mifiprestone) . The most ommonly used drug is misoprostol which is cheap , highly effective and active vaginally and orally . Advantage of medical managment is that it is cost saving with average saving of 50 pounds /case compared to surgical treatment . In addition , it avoids risks of anaethesia and surgery , can be performed on outpatient basis and assosiated with lower risk of pelvic infection compared to surgical managment . Disadvantage of medical managment include increased pain and bleeding can persist for up to 3 weeks . surgical evacuation may be needed after medical teatment . It should only be offered in units where 24 hour access to telephone cantact and access to emergency admission should be available . Also success rate is variable depending on type of miscarriage , dose and duration of therapy.

Expectant managment is another option in vitally stable patients . careful counselling regarding long duration and lower efficacy is needed . Advantage include avoidance of risks of anaethesia and syrgery . Anti -D immunoglobulin is avoided unless bleeding is heavy . It requires no drugs and so cost is less than that of other modalities of treatment . Risk of pelvic infection is less compared to surgical managment . Disadvantages include prolonged duration of treatment: majority of expusions occur in 2 weeks , however 3-4 weeks may be needed . Also, success rate is variable . It should only be offered in units where 24 hour telephone contact and access to emergency admission is available .

(b) This is a case of recurrent miscarriage ( RM ) because she has 3 consecutive miscarriages . Because genetic abnormality is found in 3-5% of parents with RM , karyotyping for both parents should be offered with referal to clinical geneticist for genetic counselling if karyotyping is abnormal . Karyotyping of product of conception because fetal chromosomal abnormalities are common cause of miscarriage . Pelvic ultrasound is required for detection of uterine structural defects . Measurment of lupus anticoagulant and anticardilipin antibodies with repeated testing 12 weeks later if results are positive in medium to high titre to diagnose antiphospholipid syndrome . screening for inherited thrombophilia particularly factor five leiden mutation l
Posted by Ida I.
a)
Non surgical options would include medical and expectant management, which are effective alternatives to surgical evacuation. In order to have an effective management of the patients undergoing medical and expectant management, the hospital should have protocols that would include stringent patient selection criteria, therapeutic regiments and follow up plans for the patients.

Medical management uses a prostaglandin analogue ( Gameprost or Misoprostol), that could be used together with and antiprogesterone priming agent, Mifeprostone. Misoprostol is cheap, highly effective and can be used as an outpatient management. This method can avoid the patients from undergoing general anaesthesia, and reduces the risk of pelvic infection that comes with surgical evacuation. Misoprostol comes in both oral and vaginal preparations and are found to be effective in both modes of administration. However, the patients need to be counselled that medical evacuation involves a longer period of bleeding that could last for 14 to 21 days, and is also associated with a higher level of pain. Patients with a missed miscarriage may need a higher dose of Misoprostol, and priming with antiprogesterone agent, Mifepristone.

Expectant management involves the product of conception being naturally expelled by the body, which could lead to incomplete or complete miscarriages. Expectant management is often followed by minimal bleeding, and any residual tissue will undergo resorption. Patients opting for expectant management need to be informed that resorption may take weeks, and that they may wish to consider having a medical or surgical evacuation later. They can be followed up with serial transvaginal ultrasound scans to assess the thickness of the uterine cavity or serial serum progesterone. Any reduction in thickness of the uterine cavity or serum progesterone levels could indicate resorption of the pregnancy.

b)
In view of her vaginal discharge, she would need a high vaginal swab to exclude bacterial vaginosis, which is one of the causes of miscarriages. She also needs a Chlamydial screen, in case she opts for a surgical intervention later.
Karyotyping needs to be
Posted by Ida I.
a)
Non surgical options would include medical and expectant management, which are effective alternatives to surgical evacuation. In order to have an effective management of the patients undergoing medical and expectant management, the hospital should have protocols that would include stringent patient selection criteria, therapeutic regiments and follow up plans for the patients.

Medical management uses a prostaglandin analogue ( Gameprost or Misoprostol), that could be used together with and antiprogesterone priming agent, Mifeprostone. Misoprostol is cheap, highly effective and can be used as an outpatient management. This method can avoid the patients from undergoing general anaesthesia, and reduces the risk of pelvic infection that comes with surgical evacuation. Misoprostol comes in both oral and vaginal preparations and are found to be effective in both modes of administration. However, the patients need to be counselled that medical evacuation involves a longer period of bleeding that could last for 14 to 21 days, and is also associated with a higher level of pain. Patients with a missed miscarriage may need a higher dose of Misoprostol, and priming with antiprogesterone agent, Mifepristone.

Expectant management involves the product of conception being naturally expelled by the body, which could lead to incomplete or complete miscarriages. Expectant management is often followed by minimal bleeding, and any residual tissue will undergo resorption. Patients opting for expectant management need to be informed that resorption may take weeks, and that they may wish to consider having a medical or surgical evacuation later. They can be followed up with serial transvaginal ultrasound scans to assess the thickness of the uterine cavity or serial serum progesterone. Any reduction in thickness of the uterine cavity or serum progesterone levels could indicate resorption of the pregnancy.

b)
In view of her vaginal discharge, she would need a high vaginal swab to exclude bacterial vaginosis, which is one of the causes of miscarriages. She also needs a Chlamydial screen, in case she opts for a surgical intervention later.

Karyotyping needs to be done as 3-5% of couples with recurrent miscarriages has a partner that carries a balanced structural chromosomal abnormality, commonly the RObertsonian translocations. Any couple that has been found with this abnormality needs to be referred to the clinical genetist for genetic counselling.

Some of the miscarriages are also due to an abnormal product of conception, thus karyotyping of the conceptus can be done to ascertain the cause of miscarriage. However, this can be expensive, and not every patient can afford the investigation.

She also needs a glucose tolerance test to exclude underlying diabetes, or a HbA1c if she has underlying diabetes, which is one of the causes for first trimester miscarriages. If she is found to have diabetes, she needs to have proper pre-pregnancy counselling, and probably has to be referred to the dietician for optimal diet control. High HbA1c levels are associated with miscarriages and fetal anomalies. A thyroid function test needs to be done to exclude any derangement of her thyroid function, that is also associated with miscarriages.

She also needs to be screened for antiphospholipid antibodies and inherited thrombophilia defects ( protein C and protein S deficiency or Factor V Leiden mutations) which are also associated with first trimester miscarriages. If she is positive for and of the antibodies, she would need aspirin or low molecular weight heparin in her next pregnancy.

She may need a hysterosalphingogram to exclude any structural uterine anomalies that could be the cause of her miscarriage. This can be uncomfortable for the patient, and carries a higher risk of pelvic infection due to catheter insertion into the uterine cavity. Some patients may also develop anaphylaxis from the contrast given.



Posted by Mohammad A.
(MA)

a) Non surgical options in treatment of missed miscarriages includes expectant management and medical management. General advantages of non surgical managemnet includes avoidance of hazards f general anaethesia. Also, it will avoid the complications of uterine trauma which may increase the rate of cervical trauma and incomptency. Increase incidence of uterine infection, endometritis and pelvic infection. There is increase in uterine synyaechiae (Asherman syndrome). Surgical option is costly procedure which can be avoided with non surgical option. Repeated miscarriages may be a reason of psychological upset, patient may ask for quick solution with proper investigations, this includes hitopathology and karyotyping of the products f conceptus. The tissue may be missed with non surgical management. Non surgical option may be finished by surgical procedure in case of persistent bleeding with retained products. Non surgical optin may needs to wait for some weeks till the uterus expelled its contents.

b) Repeated miscarriages can be identified in case of 3 or more early trimester miscarriages. For this case should offer the required investigations according to the possible etiology. Antiphospholipid syndrome is one of the leading causes. This may be effectively treated during pregnancy using baby aspirin and low molecular weight heparin. Anticardiolopins, lupus anticoagulant and antinucleus antibody and ante RO SE antibodies can be evaluated. Karyotyping of the products of conceptus can be offered, this may rule out chromosomal abnormalities. Preimplantation genetic diagnosis and IVF can be offered for those with known mutation. However, it is a costly and invasive procedure. Also, it is available only in few centers. Ploycystic ovarian syndrome (PCOS) is another cause of repeated first trimester miscarriages, so hormonal essay in form of LH/FSH can be requested, also, transvaginal ultrasound features of polycysic ovaries can be seen. However, ovarian suppression using GnRh analogue and progesterone support are not justified for case of PCOS. Uterine anomaly and submucous fibroid may be a local cause of miscarriage. Transvaginal scan, sono hysteroscopy and hysteroscopy are different diagnostic tools. Infectious screen TORCH and thyroid profile are not required for cases with repeated miscarriages.
Posted by Lilantha W.
(a) Non-surgical options available for this patient are expectant and medical management. The expectant management includes careful waiting until the products of conception (POC) expelled naturally and spontaneous resolution occurs. Patient is provided with advice and support. She is managed outpatient in a unit which has access to 24h emergency care as emergency surgical evacuation might be required in some cases. The advantages are it avoids surgical (accidental trauma to the cervix, uterus, bladder & bowel, in particular), and (general) anaesthetic risks, if the expectant management was successful. Patient would feel more in control which may be an advantage for her. Anti-D injection is not indicated as it is <12 weeks unless pain and bleeding severe. Patient can be managed at home/community which can be cost effective as well as more acceptable for her. There is no increased risk of uterine infection. Antibiotic prophylaxis might be avoided, which is essential in the surgical treatment. Need of strong analgesia may be less. Outpatient management minimises risks of hospital acquired infections.

The limitations of expectant management are the efficacy could be low as 50%. It might take up to 6 weeks for natural resolution to occur, during which she might experience vaginal spotting. Vaginal bleeding is unpredictable and there is a risk of emergency surgical evacuation of POC if heavy bleeding and/or pain occur which can cause significant anxiety and stress. A blood transfusion may be indicated if heavy bleeding encounters. Bleeding can last for 3 weeks even after expelling the POC. POC may not be collected for further cytogenetic or pathological testing which is useful in establishing the aetiology.

The medical management includes priming of the uterus with an anti-progestogen (mifepristone 200mg orally) followed by administration of vaginal prostaglandin (misoprostol 800mcg) 36-48h later. Prostaglandin dose might have to be repeated, orally, up to 3 doses. Antibiotics, analgesia, anti-D are given as indicated. Patients can be managed both inpatient as well as outpatient. Complete expulsion of POC occurs about 80-90%. Advantages of the medical management are it potentially avoids surgical and anesthetic risks if successful. Its efficacy is high, 80-90%. Complete miscarriage results in expected time interval in majority of patients (nearly 80% within 24h) Risk of pelvic infection is less than the surgical treatment.

The limitations of the medical management are 10-20% patients might end up with surgical treatment as a result of incomplete/failed procedure. Patients would experience side effects of mifepristone (cramping, heavy bleeding, nausea, vomiting) and misoprostol (bleeding, nausea, vomiting, diarrhoea, chills, pyrexia). Patients would require sring analgesia and anti-ematics. Patients who are allergic to these medications or contraindicated due to medical conditions e.g. active liver disease, renal failure, heavy smoking are not suitable for this method. Occasionally, the POC may not be collected for investigations. Vaginal bleeding and spotting may last for 3 weeks even after expelling the POC.

(b) Cytogenic testing (foetal karyotype) and histopathology (molar pregnancy) of the POC are useful to establish the cause of the recurrent and current pregnancy loss. Foetal karyotype would reveal possibility of numerical chromosomal defect, if found, would indicate better prognosis for next pregnancy. Appropriate genetic counselling can be offered.

Parental karyotyping is important that the cause of 3-5% recurrent miscarriages is due to balanced structural chromosomal anomaly such as Robertsonian translocation. A positive genetic defect would prompt referral to a clinical geneticist for counselling. This might lead to IVF/ICSI pregnancy and pre-natal testing with consequent improved live birth rates.

Inherited and acquired thrombophilias are commonly associated with recurrent pregnancy losses; however, they are treatable conditions upon which the live birth rates are good. Antiphospholipid syndrome can be confirmed with the presence of moderate to high titres of lupus anticoagulant and anti-cardiolipin antibodies when tested 6 weeks apart. Although the chance of spontaneous delivery at term with untreated antiphospholipid syndrome is low, with treatment of low-dose aspirin and LMWH, a full term delivery can be improved up to 70%.

Similarly, inherited thrombophilias can be treated if the screening tests found positive, with low-dose aspirin and LMWH with consequent better live birth rates. Screening includes antithrombin III deficiency, factor V Leiden gene mutation, prothrombin gene defect, homocystinaemia, protein s deficiency, protein c deficiency; screening also includes PT, APTT, FBC and clotting factors.

A pelvic ultrasound scan is necessary to exclude uterine anomalies. Polycystic ovarian syndrome is associated with early pregnancy loss. If found, appropriate treatment and surveillance can be offered.

Routine screening for hypothyroidism, diabetes and ToRCH screening has little value in screening for recurrent miscarriages.

Posted by sutha  C.
SC

a) Medical and expectant management would be the available options for treatment. Expectant management involves spontaneous resolution of the products of conception. Patient counseling is very important as this method has a high failure rate. Complete resolution may take several weeks and she may have persistent brownish discharge till then. She may also eventually need to have a surgical evacuation to complete the procedure of miscarriage. The advantage of this method is the patient is in control of her decision and does not need to stay in the hospital as it can be performed as an outpatient treatment.

Medical management involves the use of prostaglandin analog like gameprost or misoprostol with or without cervical priming prior to the procedure. The advantage of this method is the patient feels in control and there is avoidance of general anesthesia. This method is highly effective and cheap as compared to surgical evacuation. The limitation of the method is pain and bleeding which may sometime continue for 2 weeks.

b) Recurrent miscarriage has an incidence of 1%. In most cases the cause is unexplained. Blood investigation is sent for karyotype for both the patient and her partner. This is to detect for balanced structural chromosomal anomaly in either of the parents. If either one of them are positive, they should be referred to a geneticist who can explain to them the prognosis for future pregnancies and give counseling.

Acquired and inherited thrombophilia is also screened for. Inherited thrombophilia like deficiency in Protein C, Protein S and anti Thrombin III can cause thrombosis during pregnancy leading to miscarriage. The use of thromboprophylaxis may be beneficial in future pregnancy to achieve a live baby. Acquired thrombophilia is the anti phospholipids syndrome (APS). If the patient is tested positive with moderately high titre, a repeat test is performed again after 6 weeks. If the results is still positive, she has APS. In her next pregnancy she should be started on heparin and asprin with good outcomes of the pregnancy.

Ultrasound of the uterus and ovaries are also performed looking for any structural anomalies. If all investigations done is negative, the patient should be reassured that in majority of the patient with unexplained recurrent miscarriage, they have excellent prognosis for future pregnancy outcome if offered supportive care in a dedicated early pregnancy assessment unit.
Posted by SUNDAY A.
SOS answers.
a) The options for the management of this patient include a conservative management which involves no intervention but follow up with scan and Bhcg may be required. The advantage is that it allows natural resolution of the miscarriage with patient having a sense of been in control. Up to 95% success rate can be achieved in properly selected patient. The risk of anaesthesia and surgery is avoided including uterine perforation, infection, drug reaction. The limitation includes a long time for natural resolution of miscarriage with bleeding which may last up to 3 weeks and prolonged follow up in EPAU. Surgical evacuation may still be required in about 10-25% of patient particularly if evidence of infection. There is also reduced success rated if gestation sac intact on scan. The second option is medical management of miscarriage which involves the use of mifepristone (200mg or 600mg) and misoprostol ( 800mcg or 400mcg)given per vagina (pv) or orally 36-48hrs after. Dosage may vary according to the unit protocol. The advantage include achieving a success rate of between 80-90% with little intervention. It achieves quicker resolution of miscarriage while avoiding the risk and complication of anaesthesia and surgery as highlighted above. The limitation include an increased risk of pain and bleeding. The failure rate is about 10-20% with those patient requiring surgical intervention. There is risk of reaction to the medication used and mifepristone should be avoided in poorly controlled or severe asthmatics.
B) The investigation required would include karyotype of the patient and partner to exclude balanced or robertsonian translocation which is implicated in early miscarriages. The products of conception should also be sent for Karyotyping to exclude chromosomal anomalies. The prognosis for the patient is better if karyotype is normal. Other investigation would include bloods for antiphospholipid syndrome. This involves checking for a medium or rising titre of anticardiolipin or lupus anticoagulant antibodies IgM /IgG done 6 weeks apart. The presence of these antibodies is implicated in 15% of women with recurrent miscarriages and commencing heparin and aspirin in the next pregnancy can improve life birth rate . Thrombophilia screen to check for the presence of inherited thrombophilia such as factor V Leiden gene mutation, antithrombin III deficiency , protein and S deficiency is important as the presence of these are associated with miscarriage and thromboprophylaxis with heparin may improve live birth rate. Pelvic scan can also be done to exclude uterine anomaly such as septate uterus which implicated in miscarriages, there is however no role for hysterosalpingogram in investigation of this patient. There is also no role for TORCH screen, thyroid function test and HbA1c , FSH/ LH assay if the patient has no underlying medical or endocrine problem as they add no value in establishing the aetiology. Bacterial vaginosis (BV) screening can be done as BV is implicated in 2nd trimester miscarriage and preterm delivery.
Posted by AFSHEEN M.
A 25 year old nulliparous woman with two previous first trimester miscarriages is referred to the emergency gynaecology clinic with a 24 hour history of brown vaginal discharge at 10 weeks gestation. Ultrasound scan shows an 8 weeks size missed miscarriage. (a) Discuss the non-surgical options for her management, indicating the advantages and limitations of these options [10 marks]. (b) Discuss and justify the investigations that you will undertake to identify the cause of her miscarriages [10 marks.


I will discuss the non surgical options with her in a supportive and sympathetic way,as she has now had three recurrent miscarriages.Non surgical options include medical or expectant methods.
Advantages of medical mangement include cost effectiveness, great degree of patient satisfaction and acceptance as well as patient control to some extent. It avoids risks associated with general anesthesia and complications related to surgical evacuation of products.

However, the main disadvantage of medical method is variable efficacy from 15-96%; and is dependent upon several factors. Efficacy is increased with incomplete miscarriages and decreased with missed miscarriages, intact gestational sac and gestation more than 8 weeks.There are also risks associated with emergency evauation, in case of heavy bleeding or retained products.There may be prolonged bleeding upto 3 weeks after the procedure; as well as greater short term pain.

Advantages of expectant method include good patient control, great patient acceptability and avoidance of risks associated with drugs for medical management. It also avoids risks of general anesthesia and complications of surgical evacuation including uterine perforation.Also, it is cost effective.

Disadvantages of expectant method include its variable efficacy, which is increased with incomplete miscarriages or gestation less than 8 weeks.It may associated with prolonged waiting time and patient anxiety; also risk of pain and prolonged bleeding and complications associated with emergency evacuation procedure.


b) I will approach and discuss further investigations in a supportive,honest and sympathetic way. I will exclude genetic causes by offering parental karyotyping and cytogentic analysis of products of conception.Approximatelt 3-5% couples may have balanced structural chromosomal abnormality; commonest being Robertsonian or reciprocal translocations. If positive, I will refer the couple for gentic counselling who will explain prognosis of future pregnnacies, familial chromosome studiea and pre natal diagnosis of further pregnancies.Cytogentic analysis of products of conception is expensive and should be offered if further miscarriage occurs.

I will also organise pelvic ultrasound scan to view pelvic anatomy, morphologyand to exclude uterine anomalies. Uterine anomalies are typically associated with late miscarriages, which may be due to cervical incompetence, which in turn, may be associated with uterine anomalies.Hystersosalpingography is not routinely recommended and 2D USS can give valuable information.

I will arrange tests for diabetes mellitus, thyroid disease, anti thyroid antibodies and hyperprolactinemia,if the patient has got relevant symptoms. Otherwise, there is no indication to performs these investigation sin asymptomatic patients.

In order to exclude underlying autoimmune disorder,I will offer thrombophilia screen for her, including testing for anti cardiolipin antibodies and lupus anticoagulant. The bloods must be positive twice at least 6 weeks apart, with IgM antibosies present in medium/ high titre. If positive results, I will counsel her about poor outcome if no treatment given.Chances of a livebirth are less than 10% if no treatment; 40% with aspirin alone and upto 70% with heparin and aspirin.

I will also take history of any other medical disorder and screen appropriately.



Posted by R S.
R S

a.Non surgical options are expectant and medical management. Expectant management allows time for spontaneous expulsion of gestational sac and avoiding surgical intervention, it ca be successful in up to 50-60% of cases. However, it may takes days or weeks till complete expulsion and can be associated with heavy vaginal bleeding or retained products of gestation that will require further surgical evacuation. The patient will be provided with contact details if she needs any help as she may need admission at any time.

Medical management is more successful (70-80%) of cases, it takes less time. Prostaglandin can be administered orally or vaginally as tablets, suppositories or gel. Mifepristone (antiprogesteron) is given if the cervix is unripe, it can also enhance uterine sensitivity to prostaglandin.
Occasionally the patient may get heavy bleeding and surgical evacuation is needed.
Both expectant and medical management is safe provided that the patient is management in hospital with 24 hors services. There is minimal risk of cervical injury. Antibiotic is prescribed to protect against infection. Analgesia will be needed especially if medical treatment employed. Gestational products can be lost in both methods that hinder investigations.

b. Karyotyping of parental peripheral blood can detect chromosomal or genetic factors that are responsible for the recurrent miscarriage particularly that all the miscarriages occurred in the first trimester. Cytogenic analysis of the conceptus can also detect an underlying cause. Other tests include anti cardiolipin antibodies and / or lupus anticoagulant antibodies; IgM or IgG to detect antiphospholipid syndrome (acquired thrombophilia), two tests will be required 6 weeks apart as these can be fluctuating. Diluted Russell viper venom is more sensitive and specific , also activated partial thromboplastin time.
Tests of congenital thrombophilia may reveal factor V laiden mutation, antithrombin III deficiency, protein C&S deficiency or homocystinaemia. Thrombophilia regarded as a major cause of recurrent consecutive miscarriages.
Thyroid function test and oral glucose tolerance test are not recommended in asymptomatic women , also screening for congenital infection ( TORCH) as they can cause sporadic miscarriage during the vireamic or parasiteamic phase but not recurrent miscarriages.

Polycystic ovaries is another cause, it’s diagnosed by Roterdam criteria. Serum testosterone or free androgen index can reveal hyperandrogenisim. US examination may shows the pearle ring sign or ovarian volume equal to 10 cubic CM or more which is diagnostic. Anovulation can be detected by US follicle tracing or measuring serum progesterone in the mid-luteal phase.
Two dimensions US can shows uterine congenital anomaly, but usually it may cause second trimester miscarriage.
Many cases remain unexplained or idiopathic and all the tests available are negative. Immunological tests are also unhelpful as the theory of immunological rejection of the fetus has been rejected.
Posted by Atashi S.
(A)
Non surgical options are expectant management and medical management.These method should only be offerrd in units where women can access 24 hrs telephone advice and emergency addmission if required.Advantage of expectant managementshould often followed by minimum bleeding.as any retained tissue will usually undergo resorption.Another advantages are reduction in clinical pelvic infection and no adverse effect on future fertility.Expectant management is effective method to use in selected cases of confirmed first trimester miscarriage.Patient counselling is important to adopt the method as it has some limitation.Complete resulation may take several weeks. Over all efficacy rate are lowercomplete evacuation rate for expectant verses surgical managementare 28%and 81%.Option for surgical evacuation at a later date may required.Tissue for histopathological examination may not be available.Unexpected hevy bleeding and pain may arise and patient may need emergency admission.Medical method using prostaglandin analogue is another option. Protocolshould bedevoloped locally with selection criteria,therapeuticregimensand arrangement for follow up.Misoprostol or gemeprost vaginal or oral with or without prime with mifipriston can be used.High dose misoprostol(1200to1400microgram)vaginaly and clinical follow up without routine USG success rate is about 70 to 96%. Advantages of this method it avoid the risk of anesthesea,reduce risk of infection and reduce the conventional risk of surgical evacuation.Medical evacuation has potential economic benifits for NHS with an average cost saving of lb50/case. Limitation include efficacy vary 13% to 96% which is influence by many factors.These include sac size,followup whether clinical or involve USG, total dose & durationof use of prostaglandin analoge and route of administration.Unexpected heavy blleding and pain may occur and pt may need emergency admission.Tissue for histopathological examination may not be available.
(B )Histopahological examination of the product of conception to confirm miscarriage, to exclude ectopic pregnancy, to diagnose unexpected tropoblastic disease.Karyotyping of the product of conception to detect chromosomal abnormality.Karyotyping of both parent is to be done to detect any carrier of balanced translocation.Pelvic USG is to be done to detect ovarian morphology to rule out polycystic ovary which is one of the cause of recurrent miscarriage and to detect congenital uterine anomaly.Thrombophillia screening is to be done.Activated proteinC , proteinS resistance, anti thrombin lll deficiency , factor v laden mutation is to be screen for inherited thrombophillia.Anti phospholipid antibody is to be checked for detection of aquired thrombophillia .Thyroid function test , screening of diabetes mellitus, screening of TORCHES infection not to be done unless clinically indicated.
Posted by M E.
SAM
a) The non surgical options in the management of a missed miscarriage are conservative management and medical management. Conservative management involves allowing spontaneous miscarriage to occur . It has the advantage that it avoids the side effects of medication and general anaesthesia.There is a lower risk of infection than surgical management.It does not involve hospital admission and is more cost effective than surgical management.
The limitations of conservative management is that spontaneus miscarriage make take up to 6-8 weeks to occur. Repeat ultrasounds every two weeks may be required until complete miscarriage is achieved. Also if signs of infection are present such as pyrexia, abdominal pain, excessive bleeding surgical evacuation will be required. Patients need to have easy access the the hospital and can only be offered by units with 24hour telephone contact and 24hour emergency services. No products of conception are sent for histology to confirm a miscarrige.

Medical management involves oral pretreatment with mifopristone, followed by admission 36- 48 hours later for vaginal insertion of misoprostol. The patient is allowed home after a few hours. It has the advantage of being offered to patients who are unwilling to wait as long for nature to take its course. This also has a lower incidence of infection than surgical management. It also avoids the need for anaesthesia if successful.

Limitations with medical management include a higher incidence of unplanned admission and surgical management if heavy vaginal bleeding or infection occur. Surgical management would also be require if medical management fails. Vaginal bleeding may persist for weeks after administation of drugs. If an IUCD is insitu it should be removed prior to administration of mifopristone. It can only be offered in units with 24hour telephone service.

b) Products of conception should be sent for cytogenetic testing. This may detect the presence of a chromosomal abnormality or structural defect.If the karyotype os abnormal there is a better prognosis in the next pregnancy as the risk of recurrence is small.

She and her partner should have peripheral blood karyotyping done. This may identify balanced reciprocal or Robersonian translocations. Identification of abnormal parental karyotyping requires referral to a clinical genetesist.

A pelvic ultrasound with or without sonohysterography to assess the uterine cavity and detect uterine abnormalities should be peformed. Prevalence of uterine abnormalities in patient with recurrent mioscarriages is between 2 - 38% and associated with cervical weakness.

Titres should be measured for lupus anticoagulant or anticardiolipin antibodies of IgG and IgM. Two positive test six weeks apart is diagnostic for antiphospholipid syndrome (APS). APS is present in 15% of patients with recurrent miscarriages. Combination of aspirin and heparin in patients with APS improves the live birth rate.

Screening for inherited thromophilias, such as activated protein C resistance due to factor V leiden mutation should be performed.