Miscarriage Early Pregnancy Loss
Miscarriage Early Pregnancy Loss
Miscarriage Early Pregnancy Loss
geekymedics.com /miscarriage-early-pregnancy-loss/
Lucy 12/15/2015
Hempenstall
Miscarriage is the spontaneous loss of an intrauterine pregnancy before 20 weeks gestation (or weighing less than
400g depending on the jurisdiction). It occurs in approximately 10-20% of all clinical pregnancies. The risk of
miscarriage increases with increasing maternal age; miscarriage occurs in 21% of pregnancies between the age of
35-40 years old and increases to 41% above the age of 40 years old. Most miscarriages (~80%) are diagnosed
between 8-12 weeks, with the risk of miscarriage decreasing as gestational age increases.
Causes of miscarriage
In the first trimester the most common cause of miscarriage is chromosomal abnormality (50-60%):
Autosomal trisomy is the most common abnormality trisomy 16 is the most common trisomy in miscarriage
The most common single chromosomal anomaly is 45X karyotype
Maternal age is related to aneuploidy risk = increasing maternal age increases aneuploidy risk
Thrombophilia
Antiphospholipid syndrome
SLE
PCOS
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Poorly controlled diabetes mellitus
Thyroid dysfunction
Rubella
CMV
Herpes simplex virus
Listeria infection
Toxoplasmosis
Parvovirus B19
Iatrogenic causes:
Amniocentesis
Chorionic villus sampling
Social factors:
Tobacco
Alcohol
Cocaine
Definitions of miscarriage
Miscarriage can be classified according to stage.
Stages
1. Threatened miscarriage
The fetus is threatened (i.e. a miscarriage may happen). There is some vaginal bleeding BUT the cervical os is
CLOSED and ultrasound reveals a VIABLE intrauterine pregnancy.
IMPORTANT TO NOTE: 90% of threatened miscarriages will continue to grow to normal gestation.
2. Inevitable miscarriage
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The miscarriage is inevitable i.e. a miscarriage is going to happen. There is vaginal bleeding +/- cramping
abdominal pain AND the cervical os is OPEN but the products of conception have not yet passed.
3. Incomplete miscarriage
The miscarriage is incomplete, i.e. currently happening. There is heavy and increased vaginal bleeding, intense
lower abdominal pain and passage of some products of conception. On examination the cervical os is OPEN and
there are PRODUCTS OF CONCEPTION present in the canal.
4. Complete miscarriage
The miscarriage is complete. Products of conception have been passed. On examination the cervical os is
CLOSED. Ultrasound reveals an EMPTY uterine cavity.
Missed miscarriage
The miscarriage was missed i.e. a NONVIABLE INTRAUTERINE pregnancy has remained inside the uterus (the
fetus has not spontaneously aborted). The patient is amenorrhoeic but has not had any vaginal bleeding or
abdominal pain. On examination there is no passage of tissue and the cervical os is CLOSED. Ultrasound confirms
a non-viable intrauterine pregnancy.
Blighted ovum
Missed miscarriage in which embryonic development stopped before the embryonic pole was visible. The
gestational sac may continue to grow.
Septic miscarriage
Recurrent miscarriage
Occurrence of 3+ miscarriages.
Clinical assessment
History
Symptoms:
Amenorrhoea
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Vaginal bleeding (details regarding quantity and pattern) +/- syncope (indicating significant blood loss)
Cramping abdominal pain
Passage of any fetal tissue
Fever ?septic miscarriage
Family history
Medications / Allergies
Abdominal examination: benign in miscarriage (if rebound tenderness present consider ectopic pregnancy)
Speculum examination
Bimanual examination
Uterine size
Cervical motion tenderness (if present increases likelihood of ectopic pregnancy)
Adnexal mass ?ectopic pregnancy
Investigations
Blood tests
Quantitative b-hCG:
Transvaginal ultrasound
Ensure that the b-hCG level is above that of the discriminatory zone:
The discriminatory zone is the level of serum b-hCG above which the gestational sac is visible on USS
To confirm a pregnancy by transvaginal ultrasound the b-hCG must be above 1500.
This correlates with a gestational age of approximately 5 weeks gestation.
The discriminatory zone for an abdominal ultrasound is 6500.
Dating
Location: is the pregnancy intrauterine? = important to rule out ectopic pregnancy
Multiple pregnancy
Molar pregnancy = snowstorm appearance
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Nonviable pregnancy includes:
Look for retained products of conception (if from the history the miscarriage is incomplete or complete)
2) Ectopic pregnancy
3) Molar pregnancy
4) Implantation bleed
Management
Management considerations
Emergency
Surgical
Medical
Expectant
Psychological support
In every case:
The key points in this situation are to make an accurate assessment of the patient, initiate basic resuscitation
(ABCD) and inform seniors as soon as possible.
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Urgent O&G specialist input consultant / registrar input is essential.
This may stop the bleeding and restore blood pressure (POC in the cervical os causes cervical dilatation
which causes a vasovagal response)
Dilation and curettage (D&C) refers to the dilation (widening) of the cervix and surgical removal of part of the lining
of the uterus and/or contents of the uterus by scraping and scooping (curettage).
Haemodynamic instability
Excessive bleeding
Infected retained tissue
Suspected molar pregnancy
Unsuccessful expectant or medical management
Medical management
Medical management involves the use of a prostaglandin agent to induce uterine contractions and effacement of
the cervix (Misoprostol is commonly used).
Patient education its essential to inform the patient of the potential risks and explain the need to seek review
Expectant management
Expectant management involves waiting for spontaneous passage of the products of conception, without any
medical or surgical intervention.
Risks include:
Patient education its essential to inform the patient of the potential risks and explain the need to seek review
Follow-up review at 7-10 days with ultrasound if continued bleeding, pain or evidence of retained POC on
ultrasound discuss further management (suction curettage)
Psychological support
Offer referral to relevant healthcare professionals and support groups prior to discharge particularly for
counseling/psychological support.
Risk of recurrence
There is no increased risk of having another miscarriage after having one miscarriage (10-20% for the
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general population).
Recurrent miscarriages
3+ miscarriages, requires specialist review
Causes include:
Physical examinations should include general physical assessment, any signs of endocrinopathy and any pelvic
organ abnormalities.
Investigations:
Cytogenetic analysis performed on the products of conception of the third and any subsequent miscarriages
Parental karyotyping and genetic counseling
Female requires:
Pelvic ultrasound and MRI, sonohysterography, hysteroscopy for further structural evaluation
Thrombophilia screen
Antiphospholipid antibody screen, anticardiolipin antibodies and lupus anticoagulant
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Thyroid function: TSH, free T4, thyroid peroxidase antibodies
References
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