Miscarriage

Andy Lim Yew Ann

Definition of Miscarriage
Pregnancy that ends spontaneously before the fetus has reached a viable gestational age. Legal definition of miscarriage in UK: Spontaneous loss of pregnancy at or before 24 weeks of gestation.

Clinical Forms of Miscarriage

Types of Miscarriage Definition Vaginal bleeding with a viable pregnancy Clinical Presentation Per vaginal bleeding and pain Speculum: Cervical os closed Per vaginal bleeding and pain Speculum: Cervical os open Pain and bleeding has resolved Speculum: Cervical os closed Per vaginal bleeding and pain Speculum: Cervical os open, products of conception located in cervical os With or without pain and bleeding Threatened Miscarriage

Inevitable Miscarriage

Bleeding with cervical dilation without passage of fetal tissue

Spontaneous passage of all products of conception

Complete Miscarriage

Incomplete Miscarriage

Retained products of conception Intrauterine fetal demise without passage of tissue

Missed Abortion

Causes of Miscarriage
Chromosomal Abnormalities (Maternal age>35 years old) Endocrine Disorders Abnormalities of the Uterus Infections Trisomies ( Downs syndrome), Triploidies and tetraploidies Monosomy X (Turners syndrome) Translocation and inversion Diabetes, hyperthyroidim, luteal phase deficiency, polycystic ovarian syndrome Uterine septa, endometrial adhesions(postcurettage or Ashermans sundrome) Salmonella typhi, malaria, cytomegalovirus, Brucella, toxoplasmosis, Mycoplasma hominis. Chlamydia trachomatis and Ureaplasma urealyticum

Chemical Agents

Tobacco, anaesthetic gases, arsenic, benzene, solvents, lead, mercury, pesticides, cadmium Antiphospholipid syndrome, thrombophilia (Hereditary)

Immunological Disorders

Signs and Symptoms of Miscarriage

Symptoms
Vaginal bleeding

Signs
Cervix may be dilated

Cramping abdominal pain

Fetal tissue may be felt at cervical os

Uterine size may be smaller than menstrual dating

Fading of pregnancy symptoms

No fetal movement

Ultrasonography Findings of Miscarriage

Transvaginal Ultrasound No heartbeat in an embryo larger than 5mm/ earlier ultrasound revealed fetal heartbeat, subsequent u/s no heartbeat detected

Gestational sac larger than 8mm and has no yolk sac

Gestational sac larger than 16mm and has no embryo

A: Gestational sac B: Crown lump length C: Amniotic sac D: Yolk sac

Definition of Recurrent Miscarriage

Three or more spontaneous consecutive pregnancy losses before week 20.

History & Physical examination

Questions to Ask
Uterine instrumentation ? Are the menstrual cycles regular ? Is there galactorrhea ? History of congenital abnormalities or karyotypic abnormalities ? Any exposure to environmental toxins ? Any history of venous or arterial thrombosis ?

Hirsutism ?

Uterine malformation ?

Cervical laceration ?

Investigation

Karyotyping

Sonohysterography

Hysterosalpingogram

Hysteroscopy

MRI

Other investigation
Anticardiolipin antibodies and lupus anticoagulant Thyroid function test and thyroid peroxidase (TPO) antibodies Culture and serology Hypercoagulable state Progesterone level Endometrial biopsy

Pathogenesis of Septic Abortion

Introduction of Foley Catheter To Vaginal Orifice

Infection of Uterine Lining

Septic Abortion (Abortion that is complicated by infection)

Circulatory System

Renal System

Gastro-Intestinal System

Respiratory System

Immune System

Positive hematoma (abnormal hematologic examination specifically hemoglobin and hematocrit)

Blood in urine Acidic (ph of 5.8) Difficulty and painful urination Possible renal failure

Loss of appetite Difficulty in swallowing

hemoglobin oxygen carrying capacity CO2 stimulation for breathing Hyperventilation

WBC

Loss of weight

Positive infection

Indications for Therapeutic Abortion

Maternal condition
History of dilated cardiomyopathy in previous pregnancies Myocarditis, Pericarditis, Heart Failure Hypercoagulability Marfan syndrome, when ascending aorta is wider than 5 cm Eisenmenger's Syndrome Pregnancy induced fatty liver History of esophageal varicosities hemorrhage Uncontrollable autoimmune hepatitis Renal failure Hypertension which is not controllable with permitted drugs during pregnancy Any of the pulmonary diseases that leads to pulmonary hypertension even to a mild degree (emphysema, fibrosis, diffuse bronchiectasis) Active uncontrollable SLE which has involved a major organ Vasculitis Pemphigus vulgaris and severe generalized psoriasis and advanced melanoma Multi-drug resistant epilepsies Multiple sclerorosis in which the patient is disabled Myasthenia gravis Some type of motor neuron diseases like amyotrophic lateral sclerosis (ALS) which is intensified following by pregnancy and will seriously endanger mother life

Fetal Condition
Osteogenesis imperfecta Osteochondrodysplasia Osteopetrosis and infantile neuroaxonal dystrophy Bilateral renal agenesis Polycystic kidney Multicystic dysplastic kidney Potter syndrome Congenital nephrotic syndrome and hydropsSevere bilateral hydronephrosis Alpha thalassemia and hydrops fetalis Thrombotic disorders Trisomy 13, 18, 3, 16, 8 Anencephaly Cat cry syndrome Holoprosencephaly Syringomyelia Cranioschisis Meningoencephalocele Meningohydroencephalocele Thanatophoric dysplasia Cyclopia with holoprosencephaly Ichthyosis congenita Schizencephaly

Counselling
Objectives of Counselling : To educate the patient about Recurrent Pregnancy Loss
What are the causes ? Who is at risk ? How to prevent / manage?

To provide care and support for the patient

Help the patient to cope with their emotional distress and prevent them from developing psychiatric disorder

Genetic causes Perform karyotype of parents with family or personal history of genetic abnormalities. Perform karyotype of the abortus in recurrent cases. Provide genetic counseling for families with recurrent loss or familial history of genetic disease. In patients with a high risk for recurrent, chromosomally abnormal conceptus, discuss the options of adoption, gamete donation, and PGD. Immunologic causes Perform APLA testing if indicated. If APLA levels are elevated, counseling with a hematologist and a specialist in maternal fetal medicine is recommended. Aspirin and heparin therapy may be given to patients who are diagnosed with APS. Anatomic causes Imaging may include HSG, hysteroscopy, ultrasonography, and/or MRI. Surgical correction may be required.

Infectious causes Cervical cultures should be obtained during the evaluation of infertility. Empiric antibiotics should be given before invasive testing, such as HSG.
Environmental causes Encourage life-style changes and counseling for preventable exposures. Endocrine factors Perform thyroid-stimulating hormone (TSH) screening in symptomatic patients. Thrombophilic disorders Aspirin and heparin therapy may be given for proven diagnoses.

Thank You =)