Miscarriage Dr Mariem Gweder DHR MSc MRCOG DOGUS
Definition Miscarriage = Spontaneous abortion • Spontaneous loss of a fetus before the 24th week of pregnancy. • WHO definition: loss of an embryo or fetus weighing 500 grams or less, (20 to 22 weeks or less. (Pregnancy losses after the 20th week are called preterm deliveries.)
Incidence • Occurs in about 15% to 20% of all clinical pregnancies, • 60% to 70% occur during the first trimester. • Most miscarriages occur during the first 7 weeks of pregnancy. • The rate of miscarriage drops after the detection of fetal heart.
Classifications Clinical / ultrasonic • Threatened Miscarriage: bleeding seen, cervix closed, the fetus is viable. • Inevitable Miscarriage : the cervix has already dilated, but the fetus has yet to be expelled. This usually will progress to a complete miscarriage. • Complete Miscarriage: is when all products of conception have been expelled. Endometrium is less than 15mm thick on US. • Incomplete Miscarriage: part of conception is passed, cervical os is open, and the retained part is more than 15mm thick • Delayed or missed miscarriage: the embryo or fetus has died, but the os is closed. • Anembryonic pregnancy (blighted ovum) An empty gestational sac, the embryo is either absent or stopped growing
Complications • Septic miscarriage: missed or incomplete miscarrige becomes infected. • Recurrent pregnancy loss: three consecutive miscarriages.
Causes & Risk factors First trimester • Chromosomal abnormalities: majority of cases -Advanced maternal age: more likely to occur in older women highest after 40 -Woman suffering RPL, -H/O birth defects.
Causes & Risk factors • ??Progesterone deficiency may be another cause. No study has shown that first-trimester progesterone supplements reduce the risk • Polycystic ovary syndrome.: metformin significantly lowers the rate but insufficient evidence of safety, • Maternal disease: Hypothyroidism, autoimmune diseases, APL, uncontrolled diabetes • Infections,: TORCH, acute febrile illness, pylonephritis. • Smoking, Recreation drugs, Alcohol, Antidepressants • Physical trauma, exposure to environmental toxins, • Multiple pregnancy
Causes Second trimester (PTL) • Uterine malformation: Up to 15% • Uterine fibroids • Cervical problems (cervical incompetence)
Diagnosis • Symptoms • Examination • Ultrasound: confirmation • BHCG • Microscopically • Genetic for abnormal chromosomes
Symptoms • The most common symptom is vaginal bleeding with or without abdominal cramps Up to 30% of women will have first trimester bleeding or spotting • Low back pain or abdominal pain (dull, sharp, or cramping) • Tissue or clot-like material that passes from the vagina
Examination • General examination: vital signs • Abdominal examination : fundal level • Pelvic exam, cervical dilatation or effacement, blood clot, POC in the cervical os • Abdominal / vaginal ultrasound : gestational age, fetal heart, retained products.
Investigations • Blood type (if Rh-negative, anti-D immune globulin is needed. • Complete blood count (CBC): HB to determine blood loss, WBC and differential to rule out infection • HCG to confirm pregnancy • HCG (quantitative) to rule out ectopic pregnancy • HVS and Blood C/S if septic
Management If in shock or heavy bleeding act as emergency: A B C
No treatment -Threatened : bed rest has no proven benefit. -Complete Only • Counsel • Anti-D if needed • Follow up:(weekly)
Management options For - Incomplete abortion, - Anembryonic (empty sac) -Missed abortion “Early Pregnancy Assessment Unit” Options: • Expectant (Conservative) • Medical or • Surgical
Expectant (conservative) • No treatment • “wait & see” • (65–80%) will pass naturally within two to six weeks. • avoids the side effects and complications of medications and surgery • risk of mild bleeding, • need for unplanned surgical treatment, and incomplete miscarriage
Medical management • Mifepristone (anti-progesterone) oral, followed by (36-48h) • Misoprostol: vaginal or oral tabs: repeat in 4-6 hrs if required • Success rate 95% will complete within a few days. Indications: • Patient choice • Second trimester: Surgical evacuation is unsafe • First trimester : >10 weeks, before D&C & cervix is closed (Misoprostol 400 mcg to ripen the cervix 3-4 hrs prior to dilatation) • Contraindication to surgery or anaesthesia ,DIC Advantages: • Fewer risks and complications • Less cost • Greater patient satisfaction
Surgical treatment Vacuum aspiration or Traditional (D&C or E&C) • Fast • Less bleeding, • Less pain • Convenient for karyotype analysis (cytogenetic or molecular), • The patient is febrile (>37.50 C) • After appropriate antimicrobial management • The patient or your health facilities are incapable of appropriate follow up Complications: • injury to the cervix (e.g. cervical incompetence) • perforation of the uterus, • Asherman's syndrome: scarring of the endometrium
Septic miscarriage • Occurs when the tissue from a missed or incomplete miscarrige becomes infected. • Unsafe abortion: gram negative, E.Coli Streptococci Staphylococci BacteroidesChlostridiumPerfringens • STIs: Niesseria Gonorrhea Chlamydia Trochomatis Presentation: • Prolonged or heavy vaginal bleedin • offensive vaginal discharge • Fever • hypotension • Hypothermia, oliguria • Septic shock may lead to kidney failure and disseminated intravascular coagulation(DIC). • chronic pain, PID, and infertility • Risk of septicaemia and maternal death.
Septic miscarriage management • Intravenous fluids • Broad-spectrum IV antibiotics should be given until the fever is gone. • D&C or misoprostol
Recurrent pregnancy loss(RPL) • Recurrent miscarriage (habitual abortion) three consecutive miscarriages. • 1% of miscarriages Causes • Chromosomal: balanced translocation or Robertsonian translocation in one of parents • Endocrinal • Thrombophilia, Antiphospholipid syndrome • Anatomical: cong anomalies, fibroids • Cervical incompetence Work up • Ultrasound: 2D, 3D, Sonohysterography • Hysterosalpingogram (HSG) • Hysteroscopy • Karyotyping Women with unexplained recurrent miscarriage have an excellent prognosis for Future pregnancy
After miscarriage • The tissue passed should be sent to histopathology to exclude molar pregnancy. • Possible to become pregnant immediately. However, it is recommended that women wait one normal menstrual cycle before trying to become pregnant again. • Anti-D for RH negative. • Counseling, support, explanation • Follow up
Summary • Miscarriage mostly occurs in first trimester • Majority of cases are due to chromosomal abnormalities • Classification is clinical and ultrasonic • Proper counseling is needed • Patient choice should be considered in management options.