Miscarriage

Definition  - Pregnancy that ends spontaneously before fetus has reached a viable gestational age.(24 weeks)

It occurs in an estimated 10-20% of clinically recognized pregnancies.

75% of spontaneous abortions occur before the 16th week.

Etiology

1.     chromosomal abnormalities

2.     Endocrine abnormalities (10- 15%)

3.     Cervical incompetence (8-10%)

4.     Uterine anatomic abnormalities (1-3%)

5.     Immunological (5%)

6.     Infections (3-5%)

7.     Structural abnormalities

8.     Unknown reasons (< 5%)

Chromosomal abnormalities

·        Autosomal trisomy

·        Triploidy            

·        Monosomy X

·        Structural rearrangement;  

Uterine abnormalities

1.     Uterine malformations -  result from a failure of normal fusion of the Mullerian ducts, as: bicronuate uterus,   septate or subseptate, and uterus didelphys.

2.      Intra-uterine synechiae ( Asher man's syndrome) in which there is either partial or complete adhesion between walls of uterus leading to partial or complete obliteration of the uterine cavity.

            Usually occur as a result of intrauterine infections following; 

·        Retained parts of conception

·        post-abortal or postpartum curettage

·        repeated pregnancy loss

Cervical incompetence

It is a well-recognized cause of miscarriage in late second trimester.

Causes painless cervical dilatation

Causes

  Trauma to cervix is the main etiological factor

·        vigorous mechanical dilatation of cervix

·        trauma during delivery

·        cone biopsy

·        cervical amputation

  Congenital -  rare

Risk factors for spontaneous  miscarriage

·        Advanced maternal age* (>35 yrs)

·        Smoking

·        Alcohol use during pregnancy

·        Infections

Differential diagnoses /causes for early pregnancy bleeding

·        Miscarriage

·        Ectopic pregnancy

·        Molar pregnancy

·        Cervical or vaginal abnormality, e.g. infection,

·        polyp, trauma, malignancy

Investigations

1.Serum B-HCG   may be required to confirm pregnancy

2.Ultra-sound examination

Abdominal U/S  GS will be seen normally if SBHCG ≥ 3000mIU/ml

Trans-vaginal ;      more  accurate 

                                GS will be seen normally if SBHCG  ≥ 1000mIU/ml

If fetal heart seen on U/S examination, pregnancy will continue in 98%.

3.grouping and Rh- antiD immunoglobulin may be needed if patient is Rh negative .

Types of miscarriages

Types  of miscarriage	Clinical presentation	Ultrasound findings	Actions
Threaten miscarriage	Bleeding +/- pain	Intrauterine pregnancy, i.e. gestation sac with yolk sac +/- fetal pole and cardiac activity	Reassure. Follow up depending on symptoms
	Speculum / pelvic examination – Os closed
Inevitable miscarriage	Bleeding +/- pain	Intrauterine pregnancy, i.e. gestation sac with yolk sac +/- fetal pole and cardiac activity	Loss of pregnancy inevitable. Admit and discuss options
	Speculum / pelvic examination – Os open
Incomplete miscarriage	Bleeding +/- pain	Retained products of conception	Admit and discuss options
	Speculum / pelvic examination – Os open, +/- products at the Os
Complete miscarriage	Minimal bleeding +/- pain	Empty uterus or ultrasound appearances showing less than 15 mm in diameter of retained tissue	Reassure and GP follow. βhCG monitoring if ectopic not ruled out
	Speculum / pelvic examination – Os closed
Missed/ early fetal demise/ anembryonic pregnancy	Bleeding +/- pain	RCOG/ RCR criteria	Expectant/ medical/ surgical
		CRL > 6mm, no FHM Empty gestation sac with mean diameter > 20 mm

Management

Expectant

Medical

Surgical

Surgical 

Evacuation of products of conception (ERPC)

Complication

·        Cervical trauma and subsequent cervical incompetence

·        Uterine perforation

·        Intrauterine adhesion

·        Pelvic infection

·        Hamorrahge

Medical management

·        Prostaglandins are used in single or divided doses administrated orally or vaginally.

·        Progesterone antagonist can be added with prostaglandin

Most successful in pregnancies under 10 weeks or with a mean gestatinal sac diameter under 24mm.

Septic miscarriage

Occurs as a result of ascending infection following miscarriage.

If not treated, infection may spread throughout pelvis → septicemia and septic shock

Signs;

·        pyrexia

·        abdominal pain, and  tenderness

·        persistent vaginal bleeding

·        offensive vaginal discharge

Investigation 

Routine basic investigations as BL. Group, RH factor, CBC, BS, urea & electrolytes, etc.

Cervical swab/high vaginal swab

U/S examination for retained parts

Treatment

·        Iv. Broad spectrum antibiotic

·        IV fluids ± blood transfusion if needed

·        Analgesia

·        Evacuation of uterus

·        Anti D

Complication

·        Septicemia, and septic shock

·        Acute renal failure

·        Chronic pelvic infection

·        Infertility

Recurrent miscarriage

Definition- spontaneous loss of three or more consecutive pregnancies.

Affects 1 % of all women.

Etiology

1.Anatomic  (Sporadic)   

2.Endocrine                        

·        Luteal phase deficiency

·        Uncontrolled DM

·        Thyroid disorders

·        PCOS

3.Immunological               

       Anti phospholipid syndrome                      

4.Environmental

       Alcohol, Smoking

5.Genetic factors               

Management includes:

1-Careful history and examination

2- trans-vaginal U/S

3- HSG and/or hysteroscopy

4- karyotyping

5-blood tests for infections

6- antiphospholipid antibodies

Treatment according to the cause