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

MRCOG PART 2 SBAs and EMQs

Course PAID
notes	336
EMQ	1502
SBA	2115

Do you realy want to delete this discussion?

Forum >>

ESSAY 178 - MISCARRIAGE

Page 1 of 1 [1]
		Posted by BAHAA-Uddin BOR B. Thu Jan 19, 2006 08:04 pm
e of recurrent miscarriage 1% and the theoretical risk of three consecutive pregnancy losses is 0.34%. Miscarriage may be associated with a significant psychological sequelae,sadness,depression and grief.,so un appropriate multidisciplinary counseling involving psychological counselor ,support group can result significant positive psychological gain.,Many of the specific issues which woman feels are important to be discussed to help in reducing in overall emotional disturbance. The woman will require continued counseling and support ,so we provide further appointment in presence of partner for more explanation ,genetic counselling for prognosis of future pregnancy,familial chromosomal studies,counselling and appropriate prenatal diagnosis. Detailed past reproductive,obstetric historyis most important indicator for future pregnancy loss.,risk of miscarriage also increases with maternal age.Menstural pattern and Medical history . I have to reassure the woman that the majority of women with recurrent miscarriage,subsequent pregnancy is associated with alive birth even without any treatment. Physical examination including weight , height, BMI,BP and identifying clues to endocrine abnormalities. Information booklets that explain the proposed investigations, a brief summary of the causes of recurrent miscarriage and future prognosis should be available.Current evidence-based investigations : as : karyotyping both partners-3-5% of chromosomal abnormality.,which prompt referral to clinical geneticist. Cytogentic analysis of products of conception after TOP.Screen for anti-phospholipid antibodies-lupus anticoagulant and anti-cardiolipin antibodies positive in 15%.Two separate measurements 6 weeks apart of prolonged dRVVT ( dilute Russel viper venom test ) is diagnostic. Screening for thrombophilia : Protein C & S and anti-thrombin III deficiency, Factor V leiden mutation and hyperhomocystienaemia 12-21%reported . Pelvic U/S SCAN-ovarian morphology (PCOS )and uterine anomalies-no proven treatment for PCOS and hysteroscopic resection of septa is promisiming,but studies are lacking.The tests for metabolic disease such as diabetes and thyroid disease are not necessary as primary tests., Similarly tests for infection such as CMV ,toxoplasmosis and Listeria are unnecessary.Offer opportunistic screening should be offered-rubella,HIV,cervical cytology. Unexplained recurrent miscarriage indicates attendance at dedicated Earl Pregnancy Assessment Unit clinic with supportive care improves outcome.All these leaflet informations given to the couple ,taking account of maternal wishes .and following RCOG recommendations. The second issue in the counselling is TOP: The full range of therapeutic options ( expectant ,medical and surgical) should be available to the woman.,and apart from certain specific clinical circumstances patient should be able to choose her preferred method of management .The woman should be offered screening for genital tract infection : Chlamydia trachomatis.,if surgical method is the patient \'s choice,FBC .,cross-matching.,Antibiotic prophylaxis should be given based on the individual clinical indications.Informed consent should be taken in advance after accurate impartial printed information. If she opts medical TOP ,mifepristone ( 200mg) orally followed by prostaglandin ( gemprost 1 mg vaginally or misoprostol 800microgram vaginally ) 36-48 hrs later is given.Misoprostol is unlicensed for TOP procedure,but can be administered if the patient informed properly and her consent obtained.Post-operative information and follow-up and access to formal counselling .FOLLOW-UP can involve any number of the Multidisciplinary team based in Hospital or Community .Support group: The Miscarriage Association.The incidenc.It is important that towards the end of the counsellimg :an opportunity should be made for the patient to ask questions., A follo-up appointment is always given. The woman after had been adequately counseled ,on an ongoing basis,about possible management outcomes. Once pregnancy is embarked upon,she should be carefully monitored and follow-up the woman and the foetus.
		Posted by adnan S. Thu Jan 19, 2006 08:41 pm
Previous two miscarriages followed by again a miscarriage associated with psychological upset ,hence approach should be sensitive and supportive.I will reassure her majority of women with recurrent miscarriage subsequent pregnancy is associated with a live birth even with any treatment. Detailed history is taken about previous pregnancies ,any successful pregnancy, gestational age at miscarriage .was the pregnancy confirmed by pregnancy test or scan, fetus with out cardiac activity with CRL measurement or a gestational sac with no embriyonic structures noted in the scan,change in the partner should be enquired .On examination weight and height checked to calculate BMI, any thyroid enlargement is noted . Following.investigations requested ,maternal and paternal kariyotyping should be done if one of the partner carries a balanced structural chromosomal anomaly genetic councelling is offerd .Screening for anti phospholipid antibodies,lupus anticoagulant,and anti-cardiolipin antibodies is done,if positive it should be reapeated after 6 wksTreatment with aspirin 75 mg when pregnancy test positie and sc heparin once fetal heart is positive associated with 70%live birth 10% without treatment..Thrombopheliascreening like protein C&S andante-thrombin III deficiency,Factor V Leiden mutation and hyperhomocystienemia are reported to more common in recurrent miscarriages but efficacy of treatment is not established .Pelvic ultrasound scan is done for PCOS and uterine anomalies,but no proven treatment for PCOS associated with recurrent miscarriages and value of uterine surgery for anomalies is not proven.Routine screeninig for occult diabetes and thyroid disease is uninformative.TORCH screening is also not helpful. Unexplained recurrent miscarriage have an excellent prognosis without any treatment if offerd supportive care alone in a dedicated early pregnancy assessment unit. The available treatment options are expectant,medical,&surgical management.Womens wishes should be taken into consideration during decision making.Expectant management associated with low risk of infection and no adverse effect on future fertility,but no tissue for histological examination,bleeding is un predictable may need surgical evacuation.Medical management with prostaglandins with or without anti progestogens ,cost effective ,lower risk of clinical infection compare to surgical evacuation,and pationts acceptability.Surgical evacuation under GA or local aneasthesia,tissue is send for histological confermation of pregnanc.AntiD IgG is given if Rh negative. Verbal counseling supported by written information is documented.Iwill provide information on support groups like The Miscarriage Association ,with telephone contact no and followup appointment is given.
		Posted by Aroosha B. Thu Jan 19, 2006 08:45 pm
Thefinding of missed miscarriage in a woman who has already two miscarriage may lead to considerable distress and even psychological morbidity .The diagnosis should be explained to the patient in a sympathetic and caring way avoiding the term abortion as it may contribute to the development of negative self perception who may already be feeling a sense of failure. The patient should be informed that there is no need of immediate admission to the hospital. Another ultrasonography is not nessasary to confirm the diagnosis at 10 weeks and neither an pelvic examination is requiredin the absence of symptoms. The various possible methods of management should be informed to the patient along with theiradvanteges and risks. The various possible methods are expectant ,medical and surgical. The expectant method has the advantage that it avoids hospital admission and hazards of anaesthesia.The patient should be informed of symptoms and sighns and possibility of heavy bleeding. She should have all telephone no in case of emergency admission and directaccess to ward staff for advice and support via telephone. Ther disadvantage of expectant management is that tissue is lost for histopathological examination. Medicaml method is by giving an anti progesterone like mifipristone 600mg or 200 mg orally. It has same efficacy although not lisenced in this dose .It is followed by vaginal prostaglandin analogue like gameprost or misoprostol .The patient may experience leg cramps and pain when the products are passed She may also suffer heavy bleeding and should be advised to have direct access by telephone if she needs.As she is 10 weeks pregnant the incidence of incomplete miscarriage is high. The surgical method of management is done on a day case basis under general anaesthesia by suction evacuation as it requires less time and less risk of complication such as need or reevacuation1.1?2.1infectious morbidity 1?2.3 and uterine perforation >1% As no method has been proved to be superior to each other the patient should be given a choice of method. Miscarriage may lead to considerable negative impact so plan for follow up should be clearly given and when needed appropriate support groups and councelling services should be involved
		Posted by Zaibunnisa khan K. Fri Jan 20, 2006 12:42 am
Missed miscarriage is a failure of expulsion of products of conception after the death of the fetus or embryo.There may be an episode of vaginal spotting or brownish vaginal loss and / or history of regression of early pregnancy sign and symptoms. She should be counseled with sympathy in a specialized clinic and adequate time should be provided. .Before councelling the patient detailed information should be obtained regarding current pregnancy and her past obstetrics performance.Her last menstrual period should should be confirmed. Regarding her current pregnancy her detailed history of vaginal bleeding and or discharge or abdominal pain should be obtained .Her previous obstetric history and their outcome should be asked.Detail of previous miscarriages regarding biochemical or histological confirmation,viability confirmatiom by ultrasound and their subsequent management . Her medical , surgical history and drug history should be obtained as it will effect her subsequent management Family history of chronic medical disorders and congenital malformation should be obtained . She should be discussed option of repeat scan in 1-2 weeks for confirmation and reassurance.Different management options should be discussed with their pros and cons Active management may be medical or surgical .She should be informed that medical management involve two visits to the hospital .At firist visit oral antiprogestoogen mifepristone 200 mg will be given to her and she will be observed for one hour .She will be informed that she will experience period like pain and vaginal bleeding before the next visit .It will be followed by vaginal prostaglandin analogue Gemeprostor Misoprostol(oral or vaginal)36 to 48 after mifepristone. She may experience loose motion vomiting ,dizziness and chills.She will be provided will analgesic.She will passed the complete products of conception in next 4-6 hours .Minimal vaginal bleeding will confirm that miscarriage is complete .Some cases may require evacuation. Surgical management consists of suction evacuation often with pre operative ripening of the cervix with prostaglandin analogue (Misoprostal or Gemiproste).She should be explained that surgical evacuation has advantage of low rate of complications such as need for readmission(1 -1.2%),infection morbidity ( 1-2%) ,and uterine perforation (< 1%) and obtained tissue will be send for histopathological eximiantion but she will need admission to the hospital as a day case and pre operative blood test and anaesthestist fitness. She should be informed she will have anti D prophylaxis in case she is rhesus negative unsensitized .She should be councelled about the need for cytogenetics analysis of the products of conception. Conserative approach consists of watchful observation and in few days she will pass the products spontaneously Its safety and efficacy has been confirmed by the evidence . She should be informed about the sign and symptoms which she will experience during the passage of products of conception such as severe abdominal pain and vaginal bleeding.Later she will need an ultrasound to confirm the complition of miscarriage . She will be provided with contact telephone numbers and follow up regularly till the management will completeShe should be informed that disadvantages of conservative approach are long waitng time and loss of availability of products of conceptions for histopathology and rare possibility of missing a vesicular mole and sometime need for surgical evacuation. During counclling it should be emphasized that to determine the cause leading to recurrent miscarrisge is more important before doing something about it .She should be discussed regarding her future management plan which should include prepregnancy councelling of the couple in recurrent miscarriage clinic after the managemaent of current preganacy.She should be provided with accurate information so they can make their own decision in the light of this informatiom. She should be provided with written information along with verbal discussion.
		Posted by Raja kumar S. Fri Jan 20, 2006 02:01 am
Such information should be provided in a private setting,idealy in the presence of her partner.Be sympathetic and allow time for her to realise this information.subsequent to this counsel and provide information regarding further management. primarily patient may be anxious, worried and dejected in carrying a pregnancy that has lost its purpose.Provide options concerning removal of products of conceptions:either conservative, medical or surgical options and its risks and benefits ,obtain informed consent for any such procedure she may choose. subsequently explain regarding the need to investigate ,to look into the possible causes of her recurrent miscarriage.(pending it has been not investigated before)Explain the causes and the investigations, In more than a third of cases no discernible cause could be found ,and in such instances the chances of a successful future pregnancy is >75%,provided she has good support and attends a dedicated early pregnancy clinic. In nearly 30% of cases the cause is attributed to an abnormal fetus (chrosomal anomaly/lethel congenital malformation)THUS need to do a cytogenetic study of the products of conception and karyotyping of peripheral blood ofboth parents . if abnormality found explain need for specialist genetic counselling -for assessment of prognosis of future pregnancies ,familial genetic counselling and prenatal diagnosis. Uterine anomalies are associated in <5% as a cause of recurrent miscarriage. An ultrasound can in most instances delineate such anomalies.But the value of correcting such pathology is questionable ,Furthermore uterine surgery is associated with infetility and risk of scar rupture in pregnancy.thou hysteroscopic surgery has less such risks compared to open surgery. An association with APS can be found in nearly 15% of recurrent miscarriages.,and if such an association is found , (two positive titres of anticardiolipin antibodies and lupus anti coagulant 6 weeks apart) .and treatment with aspirin and /or heparin might improve their chances of a live birth to 70%.thou other complications like preeclampsia,iugr,pre term birth might be increased. other possible associations like infection ,endocrine disorders like diabetes,thyroid disease,hyperprolactinemia,no beneficial value to screen in asymptomatic persons. regarding treatmaent , value of progestrone /hcg support during early pregnancy is still inconclusive and thus cannot be adviced.Immunotherapy -paternal cell immunuzation,donor cell leucocytes and IVIG does not seem to improve live birth. also note that risk of miscarriage increase with maternal aging.smoking and previous miscarriage. advice regarding folate supplements and anti D prophylaxis as appropriate. In the event that no discernible abnormalities found as a cause for recurrent miscarriage .reassure her that she has a 75%chance of a succesful next pregnancy.
		Posted by Vaani M. Fri Jan 20, 2006 04:32 am
This woman has had previous 2 miscarriages and the news of another missed abortion would be very much upsetting to her. So a sensitive and sympathetic counselling should be done, if she prefers she could be counselled in the presence of a relative, a friend or a partner. A detailed history of her LMP( for possible wrong dates or irregular cycles) needs to be taken. Her obstetric history of any previous live childbirth should be considered. Her options for the current pregnancy would be termination of pregnancy by a medical or surgical means. Medical termination would be more likely to fail in a missed miscarriage than a spontaneous miscarriage. She could opt for a either method after going home and discussing with anyone else she wishes to discuss the matter with and then be planned for the termination with an appropriate informed consent. Since she has had a third abortion she would be chatergorised a woman with recurrent miscarriage. She would thus require some specific investigations for this. A karyotyping of both parents to detect a genetic balanced translocation is to be offered. If an abnormality is detected they would be considered for genetic counselling. A screening for anti-phospholipid antibody syndrome with tests for lupus anticoagulant and anti-cardiolipin antibody would be considered, if positive they need to be repeated after 6 weeks. A positive test with this history would be considered for treatment with aspirin and heparin in the next pregnancy to reduce her chances of another miscarriage. In case she has a history of venous thromboembolism either personal or in her family, she would be considered for thrombophilia screen, especially the factor V Leiden mutation which is a treatable cause of miscarriage. A karyotype of the products of conception could be done although it would be more appropriate if she has one more abortion. A screening for TORCH infections is not indicated. A screen for diabetes mellitus or thyroid dysfunction would only be done if she is symptomatic. The woman should also be explained that many of the recurrent miscarriage cause is still unknown and would be categorised as being unexplained. There is no need to be alarmed by this as unexplained miscarriage also result in a 75% chance of having a livebirth in her next pregnancy without any treatment. Supportive care in the next pregnancy is required. An early referral to early pregnancy assessment unit and appropriate treatment of an identifiable cause is to be done. The outcome for a livebirth in her next pregnancy would be high and she should be very much reassured of this whatever be the cause identified or not.
		Posted by Srivas P. Fri Jan 20, 2006 08:57 am
This woman has recurrent miscarriage which is defined as three or more consecutive pregnancy losses. This is likely to be very distressing for the woman and her partner and naturally she will be anxious to know the reasons for this, any treatment options and her chances of a successful pregnancy in the future. History and investigations may help find a cause so that she can be counseled appropriately and a treatment plan can be formulated. The history should include details of previous miscarriages, gestational age at miscarriage, spontaneous or medical termination of miscarriage, curettage if done, histopathological report of products of conception if available etc. Recurrent miscarriage affects 1 % of the population and all couples with a history of recurrent miscarriage should have peripheral blood Karyotyping done as in 3?5% of these couples, one of the partners carries a balanced structural chromosomal anomaly. Most common parental chromosomal anomaly found is balanced and Robertsonian translocations and presence of abnormal parental Karyotype requires referral to a clinical geneticist for detailed genetic counseling. Chorionic Villus sampling, Pre implantation genetic diagnosis and IVF are treatment options for her in next pregnancy but are tedious and costly procedures with low fertility rates following an IVF. She should be told about 40?50% chance of a healthy live birth even in future untreated pregnancies, following natural conception. The couple should also be counseled about the value of cytogenetic analysis of products of conception once she aborts now. Anatomical abnormalities of the genital tract mostly cause second trimester miscarriages but uterine septae, Intra uterine myomas, intra uterine Synechiae following curettage may be likely causes for 1st trimester abortions. Ultrasonography helps in diagnosis but a Hystreoscopy done based on USG findings helps confirmation and concomitant surgical removal of myoma or breakage of intra uterine adhesions, allows uneventful pregnancies in the future. HSG is not necessary due to 1 % risk of genital tract infection with no diagnostic advantages. Couple should be informed about risks associated with hysteroscopic procedures. Opportunistic testing for Chlamydia must be done before intrauterine procedures. Ultrasonography may detect features of polycystic ovaries which are prevalent in women with recurrent miscarriage (50%) though PCO disease itself is not a cause for recurrent miscarriage once she conceives and needs no treatment if she is ovulating spontaneously. Routine screening for anti-thyroid antibodies, Prolactin and Diabetes is not recommended but if she has family history of diabetes test for Glycosylated Hb A1C may pinpoint a cause for recurrent abortion. She must be investigated for Anti-phospholipid antibodies as Lupus anticoagulant and anti-cardiolipin antibodies, IgG or IgM are present in 15% of women with recurrent miscarriage (<2% general population) She should have dRVVT(Dilute Russel Viper Venom test) which is more sensitive and specific than aPTT or the kaolin clotting time to detect Lupus anti coagulant and ELISA test to detect Anti Cardiolipin antibodies. She should be told that she has 10 % pregnancy rate without treatment. Corticosteroids do not improve pregnancy outcome but Low dose aspirin if started soon after pregnancy test positive in next pregnancy can improve live birth rate to 40% with a further significant improvement to 70% if heparin is added when FH detected on scan. But her pregnancies will remain at high risk of miscarriage, pre-eclampsia, IUGR and pre-term delivery. She should be screened for Congenital Thrombophilia which includes Levels of Proteins C/S, antithrombin III deficiency,activated proteinC resistance, hyperhomocystinaemia and prothrombin gene mutation. These are costly but are relevant with a positive family and personal history of DVT and Low Molecular weight heparin treatment during next pregnancy can improve pregnancy outcome. No evidence that genital tract bacterial / viral infections cause recurrent miscarriage and TORCH studies are not recommended routinely for recurrent miscarriages though they do cause isolated miscarriages. If no cause can be found on investigations the couple should be comforted that they still have 75% chance of a successful outcome in next pregnancy with supportive care and attendance at early pregnancy assessment clinic She would need to be counseled about termination of the present missed miscarriage. At less than 13 weeks gestation surgical curettage may not be necessary with spontaneous resolution occurs in 30 % patients. She may be offered expectant management if she is asymptomatic and she and her partner are willing for it. She would need follow up with USG to confirm resolution. If the patient is not willing to wait or is bleeding, Surgical termination by Suction evacuation should be done and she should be given anti RhD prophylaxis if she is Rh Negative. The couple should be given further appointment after discharge to review histopathology reports and answer further questions and doubts the couple may still have and give reassurance of improved care in next pregnancy in Early Pregnancy Assessment units under consultant for optimal care.
		Posted by BAHAA-Uddin BOR B. Fri Jan 20, 2006 04:16 pm
The incidence of recurrent miscarriage 1% and the theoretical risk of three consecutive pregnancy losses is 0.34%. Miscarriage may be associated with a significant psychological sequelae,sadness,depression and grief.,so un appropriate multidisciplinary counseling involving psychological counselor ,support group can result significant positive psychological gain.,Many of the specific issues which woman feels are important to be discussed to help in reducing in overall emotional disturbance. The woman will require continued counseling and support ,so we provide further appointment in presence of partner for more explanation ,genetic counselling for prognosis of future pregnancy,familial chromosomal studies,counselling and appropriate prenatal diagnosis. Detailed past reproductive,obstetric historyis most important indicator for future pregnancy loss.,risk of miscarriage also increases with maternal age.Menstural pattern and Medical history . I have to reassure the woman that the majority of women with recurrent miscarriage,subsequent pregnancy is associated with alive birth even without any treatment. Physical examination including weight , height, BMI,BP and identifying clues to endocrine abnormalities. Information booklets that explain the proposed investigations, a brief summary of the causes of recurrent miscarriage and future prognosis should be available.Current evidence-based investigations : as : karyotyping both partners-3-5% of chromosomal abnormality.,which prompt referral to clinical geneticist. Cytogentic analysis of products of conception after TOP.Screen for anti-phospholipid antibodies-lupus anticoagulant and anti-cardiolipin antibodies positive in 15%.Two separate measurements 6 weeks apart of prolonged dRVVT ( dilute Russel viper venom test ) is diagnostic. Screening for thrombophilia : Protein C & S and anti-thrombin III deficiency, Factor V leiden mutation and hyperhomocystienaemia 12-21%reported . Pelvic U/S SCAN-ovarian morphology (PCOS )and uterine anomalies-no proven treatment for PCOS and hysteroscopic resection of septa is promisiming,but studies are lacking.The tests for metabolic disease such as diabetes and thyroid disease are not necessary as primary tests., Similarly tests for infection such as CMV ,toxoplasmosis and Listeria are unnecessary.Offer opportunistic screening should be offered-rubella,HIV,cervical cytology. Unexplained recurrent miscarriage indicates attendance at dedicated Earl Pregnancy Assessment Unit clinic with supportive care improves outcome.All these leaflet informations given to the couple ,taking account of maternal wishes .and following RCOG recommendations. The second issue in the counselling is TOP: The full range of therapeutic options ( expectant ,medical and surgical) should be available to the woman.,and apart from certain specific clinical circumstances patient should be able to choose her preferred method of management .The woman should be offered screening for genital tract infection : Chlamydia trachomatis.,if surgical method is the patient \'s choice,FBC .,cross-matching.,Antibiotic prophylaxis should be given based on the individual clinical indications.Informed consent should be taken in advance after accurate impartial printed information. If she opts medical TOP ,mifepristone ( 200mg) orally followed by prostaglandin ( gemprost 1 mg vaginally or misoprostol 800microgram vaginally ) 36-48 hrs later is given.Misoprostol is unlicensed for TOP procedure,but can be administered if the patient informed properly and her consent obtained.Post-operative information and follow-up and access to formal counselling .FOLLOW-UP can involve any number of the Multidisciplinary team based in Hospital or Community .Support group: The Miscarriage Association. .It is important that towards the end of the counsellimg :an opportunity should be made for the patient to ask questions., A follo-up appointment is always given. The woman after had been adequately counseled ,on an ongoing basis,about possible management outcomes. Once pregnancy is embarked upon,she should be carefully monitored and follow-up the woman and the foetus.
		Posted by hala M. Sat Jan 21, 2006 08:54 am
Mr. Paul, please correct my essay on the miscarriage. This is a very upsetting and distressing situation and the breaking of the bad news needs an uninterrupted, dedicated and suitable time. A great care needs to be exercised during the consultation of this sensitive matter and it is necessary to use a suitable terminology when referring to the failed pregnancy. A silent miscarriage is a preferred term. The presence of a partner or family member is helpful. I would tell her that she still has a good chance of having a live birth and that this chance is even higher if she had a previous successful pregnancy. I need to counsel her about the options available for the management of this pregnancy, explaining the methods, pros and cons of each of them. She does not need to be admitted urgently and she can go home and think about what she would like to do. The options I need to tell her about are medical, surgical and expectant option. The medical option is to give her anal tablets and vaginal pessaries which would be followed by bleeding and some pain. This is good in avoiding general anaesthesia and has good success, but she might still need to have surgical evaluation in case of heavy bleeding. There is no risk of infection. The surgical option is quick and successful and good in that the whole products can be sent in an ideal situation to the lab for cytology studies. Screening and/or treatment for infection is necessary. The patient might prefer to do nothing (expectant) and to wait for the spontaneous events to happen and this is totally acceptable. This will give her the chance to feel that she is more in control of the situation, but we need to stress the importance of attending as soon as possible in case of heavy bleeding. As this is considered now as recurrent miscarriage (RM), I need to tell her about the causes of RM and the possible investigations needed and the possible management. I would discuss this with her briefly and in more detail in her subsequent follow up appointment when histology results are back in a few weeks time. Balanced translocation with one couple can be identified on peripheral blood sample karyotyping and a referral to a geneticist is made in case of abnormalities. After pregnancy a blood test for antiphospholipid antibody syndrome APS (Acquired and Congenital) can be done, and the use of low dose aspirin LDA and low molecular weight heparin (LMWH) is the treatment of choice for the next pregnancy in case of confirmed APS. Polycystic Ovary (PCO) might cause RM, so after the miscarriage a blood test and ultrasound scan (USS) need to be arranged. Unfortunately there is no effective treatment for RM in PLO. Continuous counselling and support is very important in this case and putting the patient on line with support groups and associations will help.
		Posted by Sarwat F. Sun Jan 22, 2006 05:05 am
A woman who presents with a diagnosis of missed miscarriage needs counseling regarding management of miscarriage and future pregnancies. Management options available to her include conservative management or evacuation of uterus. She will be counseled that 80 to 90% women miscarry in 3 to 4 weeks time if no intervention is done. There is a very remote risk of coagulopathy. However woman may not feel good to carry dead tissue and option in this case is admission followed by evacuation of uterus. She will be given prostaglandin E2 prior to evacuation to minimize damage to cervix during evacuation. Swabs for Chlamydia and gonorrohea will be done before starting evacuation to detect any subclinical infection. She will be explained about need for examination of embryonic tissues and appropriate consent will be taken. Information will be provided regarding burial of tissues and cremation. She will be told that blood will be crossmatched before starting the procedure. She will be told that she will most likely be discharged the same day if every thing goes fine. However there are some complications of the procedure which include hemorrhage, uterine perforation, damage to adjacent structures including bowel and omentum, infection and retained tissue. Sympathetic approach is needed as it is difficult time for woman and her partner. Anti D will be given if rhesus negative. She will be given information leaflets regarding miscarriage and information regarding support groups. A follow up appointment is arranged to discuss future pregnancy management and to answer questions if woman wants. For future pregnancies woman will be evaluated by taking proper history, examination and investigations. Any preexisting medical conditions are asked. Obstetric history is takenand her parity, details of pregnancies and mode of delivery are asked. If she had two consecutive miscarriages she may need investigations regaring recurrent miscarriage which include pelvic ultrasound, hysterosalpingogram, midfollicular serum LH and FSH, lupus anticoagulant, anticardiolipin antibodies, activated protein C resistance and high vaginal swab. Various causes of miscarriage include uterine abnormalities like bicornuate uterus, chromosomal abnormalities, autoimmune diseases like SLE and polycystic ovary syndrome. She will be told that if no cause is found prognosis is good around 70 to 80%. For the diagnosis of antiphospholipid antibody syndrome two consecutive tests 6 weeks apart are done. Dilute russel viper venom test more reliable than direct testing. If anticardiolipin antibodies are found she will need aspirin and heparin when she is planning for pregnancy. For polycystic ovaries, metformin has been advocated to improve outcome although it is not recommended for this purpose. Correction of anatomical abnormalities may improve outcome but are associated with pregnancy complications and scar rupture. She will be advised that she will need early booking in next pregnancy and preferably hospital based care. She will need more frequent visits during antenatal period. Role of progesterone or HCG supplementation is not proven to prevent early pregnancy complications. There is no role of bed rest in preventing miscarriage.
		Posted by M H. Tue Jan 24, 2006 01:53 am
Recurrent miscarriage is defined as 3 or more consecutive miscarriages and affects about 1% of women. Couselling of this lady should be carried out in with her partner in attendance if possible by and experienced person in a non directed way. The couple should be allowed time to grieve, to ask questions and if necessary, reschedule the counselling session. To exclude a genetic cause of recurrent miscarriage karyotyping should be offered to the couple. 3-5% of recurrent miscarriages is a result of a balanced translocation of one parent. Mosaicism is also common. They should also be referred onto a geneticist to be counselled further should they choose to be tested. If an abnormality is detected, there should be further consultation with the genetic team and discussion about familial testing, preimplantation and prenatal diagnosis be discussed. To diagnose antiphospholipid syndrome, tests for antiphospholipid antibodies (lupus anticoagulant or anticardiolipin antibodies) must be positive in 2 occasions, at least 6 weeks apart. In a woman with this condition, aspirin 75mg should be offered from the time pregnancy is diagnosed (pregnancy test positive) till about 34W gestation. These pregnancies remain high risk pregnancies (high risk of miscarriage, pre-eclampsia) and would require close antenatal follow up. A pelvic examination and ultrasound to exclude uterine structural anomalies should be offered. The prevalence of uterine structural anomaly is about 2-40%. There is however, little evidence to suggest that pregnancy rates improve with surgery. This lady should also be counselled that following the termination of this current pregnancy, it is recommended that the conceptus be sent for karyotyping. If a chromosomal abnormality is detected, the prognosis for the next pregnancy is better. If no cause can be found for her recurrent miscarriages, the couple should be reassured that in 75% of couples, there will be a successful pregnancy. The couple should be adviced to present early in the next pregnancy and referred to a dedicated early pregnancy support unit. All advice should be supplemented by information leaflets and referral to appropriate support group offered. She should also be counselled to take folic acid supplementation, check her rubella status and abstain from alcohol and smoking prior to embarking on her next pregnancy.
		Posted by ah A. Thu Jan 26, 2006 05:44 am
Informing this unfortunate lady about this third miscarriage would be distressing to her & her partner. So breaking this news to her must be done in a sympathetic &sensitive manner at an appropriate place preferably at a dedicated recurrent miscarriage clinic with comfortable seating in the presence of her partner/relative according to her wish. Anxiety about the causes of these losses (especially if they are consecutive) and the chances of having a successful pregnancy are expected to be brought about by her amongst other queries that might arise during the consultation, as such an adequate time should be allocated to address all concerns of this lady, several visits might be needed for investigations . Of immediate management would be to evacuate the conceptus which might be done in several ways. Conservatively wait and see as an option might be opted for if there are any symptoms& signs of threatened miscarriage like PV bleeding associated with lower abdominal cramps or cervical dilatation, in the absence of these symptoms & signs the conservative option might take an unacceptable period of time. Medical evacuation is another option which involves oral/vaginal prostaglandins with or without mefipristone; medical evacuation has the advantage of less infection avoidance of anesthesia and patient acceptability. the third option is the surgical evacuation under general or local anesthetic is advantages by obtaining tissues for histology or karyotyping if facilities permit ANTI D would be required in case of surgical evacuation if the lady is rh(-ve). A meticulous history taking is essential to direct future investigation. Obstetric history is obtained especially about the nature & type of the previous miscarriages and whether they are consecutive or not. History of life pregnancies & whether these pregnancies were complicated by PET, IUGR or congenital abnormalities. Family history of recurrent miscarriages or thromboses is obtained. If the miscarriages are consecutive THEN an appropriate workup is carried out for first trimester RM. Paternal peripheral blood karyotyping looking for translocations or structural chromosomal abnormalities might be present in 3-5 % of couples of RM; these need the involvement of a medical genetics team. The prognosis depend on the type of translocation And may require pre implantation genetic diagnosis and/or prenatal diagnosis (CVS, amniocentesis). She should be informed of the low implantation rate in the case they opted for pre implantation diagnosis which necessitates IVF to produce embryos. the loss rate associated with cvs &the limitation of amniocentesis are mentioned to the lady as well as making her aware of the chance of around 40 -50 % of having a healthy child in untreated natural conception. Serological investigation for acquired thrombophilia like antiphospholipids syndrome is carried out looking for high titers of anticardiolipin antibodies which should be confirmed 6 weeks later. in such situation treatment in the form of low dose aspirin &heparin is advised for next pregnancy. Informing the lady of the osteopenia associated with long term heparin. Inherited thrombophilic defects like activated protein c resistance due to factor v lei den mutation, protein c/s & antithrombin 3 deficiencies are looked for as there is possibility that inheriting one of these mutation is associated with adverse pregnancy outcome including RM. thromboprophylaxis might improve the live birth for these women but the lady should be aware of late trimester complications like PET, IUGR. There is 50 % chance that the investigations may not reach a cause so in this case the condition would be called idiopathic. Idiopathic RM carries a good prognosis and in this lady\'s case would be around 70% chance of getting successful pregnancy. Supportive therapy with regular ultrasound scanning at a dedicated early pregnancy clinic is the best management for idiopathic RM. Finally it is important to support these prognostic &management modalities with written information and leaflets .directing this lady to appropriate support groups is helpful.