MISCARRIAGE

AND ITS TYPES

Farhad Ali

15|177

3rd Year MBBS

MISCARRIAGE / ABORTION

Definition: Termination of pregnancy before viability Or

expulsion of a fetus embryo weighing 500 gm or less
Incidence
o 15 - 20% of pregnancies total reproductive losses are much higher if one considers losses
that occur prior to clinical recognition.
Classification
1. spontaneous: occurs without medical or mechanical means
2. induced abortion
Miscarriage: Why Does It Matter?

• It is the most prevalent complication in pregnancy, affecting 1 in 4 pregnancies

• Psychological Morbidity
o Level of distress has been shown to be equivalent to stillbirth at term
o After a miscarriage 30%–50% of women experience anxiety symptoms and 10%– 15% experience depressive
symptoms, which commonly persist up to 4 months
• Physical Complications
o Vaginal bleed
o Infection
o Surgical or medical evacuation and its associated morbidities
• Mortality
• Socio-economic effect
PATHOPHYSIOLOGY

o Hemorrhage into the decidua basalis

o Necrotic changes in the tissue adjacent to the bleeding
o Detachment of the conceptus
o The above will stimulate uterine contractions resulting In expulsion
RISK FACTORS

o Maternal age - more than 35years

o Increased gravidity
o Previous history of miscarriage
o Multiple pregnancy
CAUSES OF MISCARRIAGE

• Fetal Causes
o Abnormal conceptus:
o Chromosomal e.g. Trisomy.
o Structural e.g. Neural tube defect.
o Genetic e.g. X- Linked diseases.
• Maternal Causes
o 1. Immunological:
o Alloimmune response: failure of a normal immune response in the mother to accept the fetus for a duration of
a normal pregnancy.
o Autoimmune disease: antiphospholipid antibodies especially lupus anticoagulant (LA) and the anticardiolipin
antibodies (ACL)
o 2. Uterine abnormality:
• congenital: septate uterus → recurrent abortion.
• Cervical incompetence:
o congenital or acquired e.g. second trimester abortions.
• fibroids :
o disruption of implantation and development of the fetal blood supply.
o rapid growth and degeneration with release of cytokines
o occupation of space for the fetus to grow.
o 3. Endocrine : -Poorly controlled diabetes (type 1/type 2). - hypothyroidism and hyperthyroidism. - Luteal
phase Deficiency : Decreased level of progesterone which secreted by corpus luteum so endometrium is
poorly or improperly hormonally prepared for implantation and is therefore inhospitable for implantation.
o 4. Infections (maternal/fetal): such as TORCH infections, Ureaplasma urealyticum, listeria
monocytogenes infection
o 5. Environmental toxins: alcohol, smoking, drug abuse, ionizing radiation.
 TYPES OF MISCARRIAGE

• Threatened miscarriage
• Inevitable miscarriage
• Incomplete miscarriage
• Complete miscarriage
• Missed miscarriage
o Septic miscarriage
o Recurrent miscarriage
Threatened Miscarriage

Clinical features
• Short period of amenorrhea
• Uterus corresponding to the duration
• Mild bleeding (spotting)
• Mild pain
• Pregnancy test (hCG): + ve
• US: viable intra uterine fetus
Management
• Reassurance
• Rest
• Repeated U/S
Inevitabtable Miscarriage

Clinical features
• Period of amenorrhea
• Heavy bleeding accompanied by clots (may lead to shock)
• Severe lower abdominal pain
• Examination-opened cervical OS + product inside the cervical canal
Management
• IV fluids
• Blood if need
• Ergometrine and syntocinon
• Evacuation of the uterus (medical/surgical)
Incomplete Miscarriage

 Clinical feature
• Partial expulsion of products
• Bleeding and colicky pain continue
• Examination-opened cervix, retained products may be felt through it
• US: retained products of conception.
Management
• Surgical evacuation (if the size of the uterus less than 12wks)
• Medical evacuation (if the size of the uterus more than 12wks), prostaglandins
Complete Miscarriage

Clinical features
• Expulsion of all products of conception
• Cessation of bleeding and abdominal pain
• Examination-closed cervix
• US: empty uterus
Treatment
• Antibiotics
• Analgesics
Missed Miscarriage

Clinical features
• Gradual disappearance of pregnancy sign and symptoms
• Brownish vaginal discharge
• Pregnancy test: negative but it may be + ve for 3-4 weeks after the death of the fetus
• US: absent fetal heart pulsations
Management
• Wait for spontaneous expulsion
• ERPOC ie. Dilation and Curettage
Management
• Wait 4 weeks for spontaneous expulsion
• evacuate if: Spontaneous expulsion does not occur after 4 weeks,
• Infection or
• DIC
• Manage according to size of uterus
• Uterus < 12 weeks : dilatation and evacuation
• Uterus > 12 weeks : try Oxytocin or PGs
Recurrent Miscarriage

Definition: Three or more consecutive miscarriages

Causes
1. Chromosomal abnormality
2. Immunological factors- antiphospholipids antibodies
3. Cervical incompetence: 2nd trimester miscarriage
a) Congenital
b)Acquired (cervical injury)
Diagnosis Of Recurrent Miscarriage

From the history :

• Usually painless with decreased gestational age
Investigation
• Hegar dilator(No.8) and HSG
• During pregnancy: Funnel shape, short cervix
Management
• Cervical cerclage
• also known as a cervical stitch, is a treatment for cervical incompetence or insufficiency, when the cervix
starts to shorten and open too early during a pregnancy causing either a late miscarriage or preterm birth.
Usually the treatment is done in the first or second trimester of pregnancy, for a woman who has had one
or more late miscarriages in the past.
Septic Miscarriage

Definition: Following an incomplete miscarriage due to ascending infection.

Clinical features
• Offensive bloody vaginal discharge
• Increased body temperature
• Lower abdominal pain (pelvic peritonitis) generalized peritonitis
• Increased pulse rate, dehydration, toxicity
Investigation
• High vaginal swab for c/s + CBC
Management
• Antibiotic, IV fluids,blood transfusion
• Evacuation of retained product
• In all form of miscarriages
• general clinical assessment should be made: vital signs, abdominal examination, vaginal
examination
• All needed investigations + / - u/s Management should be according to clinical Type &
gestational age
Counselling

• Patients who have suffered miscarriages should be offered counseling to ensure that they
understand that most miscarriages are non recurrent.
• They should also be provided with the necessary psychological support where necessary.