TEALE FENNING

shachi · Joined: 10 Jun 2008 Posts: 16

Here's an easy one: Wink

A 35 yr old is referred to the gynaecology clinic because of 3 successive miscarriages.
What are the relevant points in her history that you would ask her?(6)
How will you investigate her? (8marks)
What advice will you give her about the available treatment options and the management of future pregnancies? (8marks)

shachi · Joined: 10 Jun 2008 Posts: 16

A 35 yr old is referred to the gynaecology clinic because of 3 successive miscarriages.
What are the relevant points in her history that you would ask her?(6)

I will get a detailed history of the events around the miscarriages, their number, timing, presentation and if the patient had surgical evacuation.
The risk of having a miscarriage increases with the woman’s age and the number of miscarriages she has already had.
Midtrimester miscarriages can be caused by cervical incompetence, syphilis, and associated with uterine anomaly and bacterial vaginosis. A history of painless dilatation of cervix, followed by miscarriage especially in a patient who has had previous surgery to cervix, like LLETZ or cone biopsy, is suggestive of cervical incompetence. A history of previous preterm spontaneous rupture of membranes followed by preterm delivery may indicate bacterial vaginosis.
A history of preterm delivery, early onset pre-eclampsia in previous pregnancies, intra-uterine death, previous personal history of thrombosis, cardiovascular disease, epilepsy and migraine, may prompt investigations for thrombophilias.
A gynaecological history of irregular periods with prolonged periods of amenorrhea, hirsuitism and acne, is suggestive of polycystic ovarian disease, which can be associated with recurrent miscarriage.
A medical history is important as any uncontrolled systemic disease like thyroid disease and diabetes can lead to miscarriage. Also a history of arthritis with malar rash, anemia and renal disease may point to a diagnosis of systemis lupus erythematosus which can cause recurrent miscarriages.
In general, smokers, cocaine users and women who consume excessive alcohol are at increased risk of miscarriage.

Xerxes I · Posted: Sat Jun 21, 2008 1:10 pm Post subject:

How will you investigate her? (8marks)

Karyotyping of the couple should be performed as there is a genetic factor in around 5% of the cases. If next pregnancy fails, the prodects should be set for karyotyping too; an abnormal karyotype of the prroducts carries a better prognosis.
Screening for diabetes mellitus and thyroid diseases should only be done if there is clinical suspicioun. A thrombophylia screening is justified in the presence of family o persoal history of thromboembolic disease. Antiphspholipid antibodieslupus screening should be performed as if diagnosed, effective treatment for recurrent miscarriage is available in presence of pntiphospholipid syndrome or lupus.
A pelvic ultrasound scan should be perfomed to diagnose or rule out structural uterine anomalies.

Xerxes I · Posted: Sat Jun 21, 2008 1:24 pm Post subject:

What advice will you give her about the available treatment options and the management of future pregnancies? (8marks)

If cervical weakness is thought to be the underlying cause of midtrimester miscarriages, cervical cerclage could be offered in carfully selected cases after discussion of the risks, including infection, rupture of mmbranes and preterm birth. Cervical weakness is usually overdiagnosed and there is no evidence that cerclage improves outcome. In most cases, serial measurement of cervical length can be performed and corticosteroid therapy should be considered.
If a genital infefction (e.g. bacterial vaginosis) is suspected o be the underlying cause, vaginal swabs and subsequent treatment maybe justified.
Underlying medical conditions should be treated sppropriately. Good glycaemic control in diabetic patients is likely to improve outcome and acheiving a euthyroid state in thyroid dysfunction will be beneficial.
If antiphospholipid antibody syndrome is diagnosed, combination of aspirin and heparin has shown to be effecive in treatment of recurrent miscarriage. Neither progesterone support nor HCG have been shown to be useful. Metformin has ben used with varying success to reduce incidence of recurrent miscarriage in patients with pcos. Immunotherapy with paternal lymphocyte has net been shown to be beneficial.
The patient should be advised that in case of idiopathic rcurrent miscarriage, there is a very good prognosis. leaflets, feely touchy, support groups, websites, psychological factvery improtant, specially in this case

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

hi guys,

between the 2 of you, you have RMC covered. won't change a thing with those answers.

r

p.s-- am still in sunny india, but could not resist loging in. Laughing

_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region

shachi · Joined: 10 Jun 2008 Posts: 16

I know.......u r a sad sad woman.

Miss u.........

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

hi guys,

based on the RCOG guidance, am just going to summarize the RCM points for a quick glance,.

Investigations --

To Do --

Genetic testing
USS
Screen for BV
Screen for APS Thrombophilia
Hormonal profile

Not Helpful / uncertain status --

GTT, TFT, Prolactin
Anti thyroid antobodies
HLA testing, leucocyte antibody testing, anti nuclear antibodies
TORCH

Treatments---

Helpful --
EPAU, Early scan, TLC
Growth scans, cervical length, cervical funnelling
Operate on uterine anomalies and cerclage.
Aspirin
Heparin
Optimise control of medical disorders pre pregnancy.

Not of Help/ uncertain status --
Progesterone support
HCG support
LH suppression in PCOS
Steroids in APLS
Immunotherapy

hope this helps.

r

p.s-- i must thank Anagha for this as it is from her RCM talk.
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region