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Miscarriage (spontaneous abortion)

Definition: fetal loss before viability(20w-24), or (WHO) defines it as
extraction of an fetus weighing 500g or less.
Classified :
Early pregnancy loss *EPL*: loss within first trimester (1st 13w +6)
Early second trimester loss: loss within 14-20w
epidemiology :
-up to 30% of all pregnancies end in miscarriage (50%if you calculate clinical
and biochemical together)
-M.C occur as EPL 97%
RF :
1. ↑maternal age: age >35y *most significant risk factor (due to association
with chromosomal abnormalities in oocyte)
2. Prior miscarriage
medical conditions :
3. Infection
4. uncontrolled DM
5. Obesity -> due to chronic inflammation in blood
6. hypo or hyper-thyrodisim
7. Inherited thrombophilia : protein S,C F5 , Hyperhomocysteinaemia
causes of EPL *MC type* :
1-Chromosomal abn MCC-> monosomy or trisomies
2- malformations(especially of CNS)
3-uterine: submucosal fibroid, polyps, adhesions, or septa
4-Trauma

causes of ESTL :
1. Chorioamnionitis and viral infection.
2. Cervical insufficiency; first loss at 20w , 2nd at 19w , 3rd at 17w with painless
cervical dilation
3. Chromosomal abnormality
4. Uterine malformation
5. Fetal malformation : anencephaly, renal agenesis, or hydrops
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CLINICAL MANIFESTATIONS :
1-Asymptomatic or incidental *missed miscarriage* or
2-P.V bleeding before 20w either uncomplicated or complicated
(hemorrhage*heavy* and infection)
WHO classification of miscarriage :

Type Os US H/O other

Threatened closed Viable IUP Minimal vaginal pregnancy mostly

miscarriage bleeding*spotting will continue.

Inevitable open Viable IUP PV bleeding proceed to

miscarriage: Suuggest without passage incomplete or
invetbilty of product of complete
conception miscarriage
within hours to
days
Incomplete open Partially expled PV bleeding
miscarriage tissue with partial
passage of
product of
conception
Complete Closed No IUP (but there is PV bleeding
miscarriage: previous IUP) with complete
passage of
product of
conception
Missed miscarriage Closed Not Viable IUP Asymptomatic and usually is an
(early fetal demise) incidental finding.
Some recall a transient brownish
vaginal discharge, or a vague reduction
in symptoms of early pregnancy

. septic abortion: complicate missed and incomplete , have fever and tenderness and
uterine discharge , hge. , OS can be closed or open
Complication is SEPTIC : shock , emboli , pyelonephritis , t , DIC

Management :
1-History
2-Physical examination:
-bimanual examination estimate GA now, then compared with past known GA to
assess for discrepancy
-absence of fetal echo on Doppler in a pregnancy of 12 weeks or greater
3-investigation
-B-hCG: -> +? -> level
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-Ultrasound :
gestational sac is evident by TV.US : at 5thw or when B-HCG is 1500 or more
gestational sac is evident by TA.US: at 6 w or when B-HCG is 3500 or more
-If you find a sac by US no need to do serial HCG (only done in pregnancy of
unknown location)
progesterone: not usually use , used only in symptomatic with non conclusive
US findings, <6.0 ng/mL -> non-viable pregnancy
-CBC, blood group and RH type

-missed miscarriage is dx via TVUS with any of Following: fetal

ECHO(begging of fetal formation)
1-gestational sac ≥25 mm without yolk sac and embryo(no fetal ECHO)
2-presence of embryo(ECHO) with a CRL ≥7 mm without cardiac activity
3-gestational sac <25mm with a heartbeat & without a yolk sac and embryo -> repeat
US after 14d and confirm dx
4-gestational sac <25mm with a heartbeat & with a yolk sac & without embryo-> repeat
US after ≥11 days if there is no FH beat -> dx.

DXX OF PV bleeding before 20w:

obs :
-Normal pregnancy
-Ectopic pregnancy.
-molar pregnancy
-miscarriage
-Sub-chorionic hematoma .
non ob :
-Cervical pathology.
-Vulvar lesions or trauma .
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Management :
-Threatened abortion:
no evidence-based management but ? rest , no intercourse , 17-ohPC?
-Incomplete miscarriage management :
if pregnancy tissue visualized in vagina or cervical os ? remove it
if pregnancy tissue not visualized ?
either : conservative, medical (misoprostol), or D&C
-severe vaginal bleeding, or who continue to bleed after manual evacuation-> Give
misoprostol-> aid in complete emptying
Women with 1 or more : foul-smelling discharge, fever, chills, lower abdominal pain
preoperative antibiotics , followed by oral antibiotic.

-missed miscarriage :
- if asymptomatic -> Conservative management: for 2w
- misopristol: if vaginal bleeding is mild.
- Surgical management: if there is moderate to severe vaginal bleeding.

Recurrent pregnancy loss (miscarriage) :

2 or more consecutive pregnancies loss before 20w.
-after 3 consecutive unexplained miscarriages up to 75% of women are likely
to have a successful pregnancy
ETIOLOGY :
-Anatomical :
submucosal fibroid, Cervical insufficiency **
Acquired Thrombophilia *: Antiphospholipid syndrome
Endocrine factors:
Diabetes mellitus
Polycystic ovary syndrome.
Thyroid antibodies and disease.
Hyperprolactinemia
Luteal phase defect
Decreased ovarian reserve *FSH at 3rd day*
Ttt of RPL :
-treat the cause.
No intervention is advised in unexplained RPL , if she have a
cause , treat the cause.
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Anti-D immunoglobulin :
Rh-ve and un-sensitised ? ->RHO-GAM after surgical management of
miscarriage or within 72 hours if medical or expectant management is planned.

notes :highest oocyte concentration at 20w of gestation , and with inc age it dec in
Quantity &Qulaity
-biochemical pregnancy : conception has occurred, but spontaneous loss of
gestation takes place without prolongation of menstrual cycle (presence of hCG 7
to 10 days after ovulation)
Infection will never cause recurrent pregnancy loss , only
sporadic
Antiphospholipid syndrome criteria :
presence of at least one clinical and one laboratorian criterion, with no interval limits
between clinical event and laboratories finding

Mang : asprin low dose 12 tll 36w and celxan

-Painless cervical dilation is indication of cerclage in next pregnancy or progesterone

caproate pt can chose what chose what she want.

CC done at 13-16w and removed 36w