MISCARRIAGES

PRESENTERS : 1) Bhavitthrai
2) Noornadia
3) Syawaluddin
 DEFINITION
The World Health Organization –defines miscarriage as spontaneous
expulsion of embryo or fetus weighing 500 g or less.
↓ in which
 This corresponds to a gestational age of 22weeks or less.

Incidence : approximately 8 – 20 %

 80% of this miscarriages occurs in the first 12 weeks .

The half of these early miscarriages occurs due to chromosomal

anomalies.
Recommended revised nomenclature for use in early pregnancy loss as explained
by the European Society for Human Reproduction Special Interest Group

TERM DEFINITION

Biochemical pregnancy loss Pregnancy not located on scan

Empty scan Sac with absent or minimal

Early pregnancy loss
(Delayed misscarriage)
Pregnancy of unknown location
structures
Confirmed empty sac or sac with
fetus but no FHA < 12 weeks
No identifiable pregnancy on scan
with positive hCG
 PREDISPOSING FACTORS
• The risk factors associated with an increased risk of pregnancy loss are as follows :

1) Age

• Advancing maternal age

2) Previous spontaneous miscarriage

• Past obstetric history

• The risk of miscarriage in future pregnancy is about 20 % after one miscarriage

• 28% after two consecutive miscarriages

• 43% after three or more consecutive miscarriages.

3) Smoking
• Heavy smoking
• Smoking by the partner may also increase pregnancy loss due to passive smoking.

4) Alcohol
• Moderate to high alcohol consumption

5) Cocaine
• Use of cocaine is associated mainly with preterm birth
• Risk for spontaneous miscarriage

6) NSAIDS
• PGs inhibitors interfere with the role PG in implantation
↓
Leading to abnormal implantations and pregnancy failure.
7) Fever
• 38°c or more may increase the risk of miscarriage

8) Caffeine
• High intake might be related to maternal metabolism and clearance of this
substance.

9) Maternal weight
• Pre pregnancy body mass index of less than 18 or above 30 kg/m2

10) Celiac disease

• Untreated celiac disease
 ETIOLOGY
• Chromosomal abnormalities
• Trisomies (Down’s syndrome)
• Triploidies
• tetraploidies
• Monosomy X (Turner’s syndrome)
• Translocation(hereditary)
• Congenital anomalies
• Trauma
• External trauma
• Intrauterine procedures such as amniocentesis
• Uterine factors (both congenital and acquired abnormalities)
• Submucosal leiomyoma, intrauterine adhensions/septum, bicornuate uterus

• Infections
• Toxoplasma gondii, parvovirus B19, rubella, herpes simplex,
cytomegalovirus,lymphocytic choriomeningitis virus

• Maternal endocrinopathies
• Thyroid dysfunction, Cushing’s Syndrome, Polycystic Ovarian Syndrome,
Diabetes Mellitus, Luteal Phase Defect
• Environmental Factors

• Smoking, Alcohol, Contraceptive Agents

• Hypercoagulable state due to inherited or acquired thrombophilia and

abnormalities of the immune system, Eg:- Systemic lupus erythematosus,anti-
phospholipid syndrome

that leads to immunological rejection or placental damage.

 CLASSIFICATIONS
• Spontaneous Miscarriage • Induced Miscarriage
• Threatened Miscarriage • Legal
• Inevitable Miscarriage • Illegal
• Incomplete Miscarriage
• Complete Miscarriage
• Missed Miscarriage
• Septic Miscarriage
Case scenario
• A 23 year old nulliparous woman has had 6 weeks of

amenorrhea. She has not been using any contraception.

She normally has a regular menstrual cycle every 28 days. A

pregnancy test is positive. She has noticed slight vaginal

spotting. On vaginal examination, os closed. Upon

ultrasound scan , gestational sac present.

 Threatened Miscarriage
• Clinical entity where process of miscarriage has started but has not progressed to a state
from which recovery is impossible.

• Clinical Features:
• Mild bleeding per vagina.
• Mild or absence of Suprapubic pain

• On examination:
• P/A : uterus correspond to date
• PSE: Os: closed, +/- blood

• Investigation:
• Ultrasound: To determine viable fetus, observe fetal cardiac motion, and to detect
whether gestation sac is intact or not.
• Regular IUGS
• CRL present- FH+
Management
• Advise adequate rest at home/hospital

• Observe for progression to incomplete or missed abortion

• Ultrasound examination to confirm gestational period and viability

• Rule out molar pregnancy and ectopic pregnancy

• Discharge if no per vaginal bleeding within 12-24 hours

• Reassure patient that pregnancy will progress well in 80 % of cases and to come
again immediately if increasing per vaginal bleeding and abdominal. To bring the poc
if passed out for confirmation

• Start on Duphaston 40mg stat and 10mg BD once viability confirmed for 2 weeks, can
be extended until 16 weeks if there is history of abortion
 Inevitable Miscarriage
• Abortion is imminent with increased bleeding and painful uterine contractions reaches its peak
intensity . At this point, pregnancy cannot be continued.

• Clinical features:
• PV bleed
• Moderate Vaginal pain
• Aggravating abdominal pain
• Cervical os is open.

• On examination:
• P/A : Suprapubic tenderness
V/E: os open ,POC at os

• Investigation:
TAS: IUGS + ( maybe near cervix)
+/- FH activity
Case scenario
• A 24 year old lady , G2P1 , with POG 11w presented to ED with abdominal
cramping and heavy vaginal bleeding with clots. Over the past 2 days , she has
experienced light spotting which has increased in severity that morning. O/w
she has no fever ,chills ,uti/urti sx ,no nausea or vomiting. On examination
product of conception are felt through os . Os open. No cervical tenderness or
adnexal tenderness was observed. BHCG 9400mIU/mL. Transvaginal
scan ,appeared to be abnormal gestational sac near to cervical canal
Management
• Analgesic e.g IM pethidine 1mg/kg max 100mg

• Pad charting/ observation chart

• Repeat pelvic examination if per vaginal bleeding and abdominal pain increasing

• KIV ERPOC if bleeding increased/ incomplete abortion

• Expectant management

• If pregnancy progress to give analgesics

1. If aborted ,to admit ward for observation/ pad charting

 MISSED MISCARRIAGE
Definition: No clinical expulsion of POC but the gestational sac contains dead embryo/ fetus.

Presentation Ultrasound findings

• PV bleeding - Nil/ staining What to look for - Confirm intra-uterine location

• Abdominal pain - +/- - Viability of fetus
• Passing out POC - No - Gestational sac
- Embryo (CRL) or POC

Physical findings - Uterine abnormality

• Per abdomen - Uterus size less In missed miscarriage:

than date
• Gestational sac >22mm but no fetal pole or yolk
• Per speculum - Os closed sac (anembryonic)
• Fetal pole >6mm with no fetal heart activity
 Normal pregnancy Anembryonic pregnancy

Transvaginal image demonstrating a normal embryo Large, empty 6-week gestational sac that does not
and yolk sac.  contain yolk sac, amnion, or embryo.
Presence of fetal pole in No blood flow seen to the embryo and
the gestational sac in the gestational sac

Absence of fetal
heart activity
 INCOMPLETE MISCARRIAGE
Definition: When the fetal part is not completely expulsed.

Presentation Ultrasound findings

• PV bleeding - ++
• Abdominal pain - +/-
• Passing out POC - +/-

Physical findings

• Per abdomen - Uterus size less than date

• Per speculum - May/ may not have POC

- Os open Retained products of conception after incomplete abortion at 7
weeks of gestation in a 29-year-old woman with vaginal bleeding.
Sagittal image of the uterus from a transvaginal ultrasound
examination reveals an abnormally thickened endometrium,
measuring 12.4 mm.
 Retained products of conception after missed abortion at 7 weeks of gestation in a 41-year-old woman with vaginal bleeding. 
A, Sagittal image of the uterus from a transvaginal ultrasound examination reveals a focal echogenic mass (arrow) within the
endometrium. B, Coronal image of the uterus from the same examination reveals the endometrial mass (arrowhead) , which is distinct in
three dimensions. C, Close-up view from same examination with color Doppler ultrasound shows blood flow within the endometrial mass.
 COMPLETE MISCARRIAGE
Definition: When the fetal part is not completely expulsed.

Presentation Ultrasound findings

• PV bleeding - Resolves - Empty uterus

• Abdominal pain - Resolves - Endometrial thickness <15mm

• Passing out POC - Yes

Physical findings

• Per abdomen - Uterus not palpable

• Per speculum - Os closed

Complete spontaneous abortion at 6 weeks of gestation in a 33-year-old woman with vaginal bleeding.
Sagittal image of the uterus from a transvaginal ultrasound examination reveals a thin endometrium,
measuring 3.2 mm in thickness. A small ovarian cyst is also present adjacent to the uterine fundus.
CASE SCENARIO 1.0

Mrs. N, a 35-year-old G3 P1+1 at 13 weeks POA presents to PAC with per vaginal spotting for 3 days. She has no
history of lower abdominal pain.
On examination, vital signs are stable and uterus is not palpable on abdominal examination. Pelvic examination
reveals bulky uterus with closed cervical os and blackish discharge seen on the examining finger.

Q1. What further history would you elicit from this patient?

- If known to be pregnant: dating based on LMP, previous scan findings

- Per vaginal spotting: quantify the bleeding, any anemic symptoms
- History of passing out of POC?
- Past obstetrics hx: previous miscarriage/ ectopic pregnancy increases the risk
- Past gynae hx: cervical/ uterine surgery, contraception, pap smear result
- Past medical hx: DM, hypothyroidism, PCOS
- Social hx: Smoking/ alcohol/ illicit drug use
On further history, she has a 6-year-old healthy boy delivered vaginally. One year ago, she had a complete miscarriage
at 8 weeks of gestation. She is a business executive and smokes 2 sticks per day and drinks alcohol during weekend
parties with her business partners.
Ultrasound was done with the following findings:

Q2. What is your provisional diagnosis?

These findings (CRL more than 7 mm and absent embryonic heart rate) are consistent with missed miscarriage. 
 MANAGEMENT

• General management
• Specific management - Expectant management
- Medical management
- Surgical management

*Choice of management depends on types of miscarriages and several factors

General management
- Secure airway, breathing and circulation.
- Monitor vital signs: anticipate for hypovolemic shock if severe bleeding.
- Run urgent investigations:
• FBC – TWC (to look for ongoing infection), Hb (to consider the need of blood transfusion)
• GSH with ABO group and rhesus factor
- If Rh –ve, anti-D should be considered

Should all women with early pregnancy loss receive anti-D?

• Non-sensitized Rh negative mother should receive anti-D in the following:

- All miscarriages over 12 weeks (including threatened)

- All miscarriages where the uterus is evacuated (medically/ surgically)
- Ectopic pregnancy

Uterus > 12 weeks
Expectant management
• To allow the spontaneous expulsion of
POC without any immediate intervention.
• Indications: - Patient’s preference
- Hemodynamically stable
• Allow up to 14 days of expectant mx.
• Follow-up review at 1-2 weeks interval
with ultrasound:
- if continued bleeding, pain or evidence
of retained POC on ultrasound, discuss
further management (surgical option)
- can TCA earlier if already passed out
POC, re-scan to ensure miscarriage is
complete and send POC for HPE.
MISSED MISCARRIAGE
Uterus < 12 weeks
Medical management Surgical management
• To assist with natural expulsion of POC. • Evacuation of retained POC/
• Indication: - Patient’s preference Suction & curettage
• Drug choice: • Indications:
- Cervagem pessary 1 mg 3 hourly up to - Persistent excessive bleeding
5 mg per course. - Hemodynamic instability
• Expulsion of POC is expected within 24 - Evidence of infected retained tissue
hours after insertion. • Prior to procedure, cervical preparation
should be done with Cervagem pessary
1mg 3 hours prior to surgery.
• Complications: • Evacuated POC should be sent for HPE.
- Heavy bleeding
- Infected POC
 INCOMPLETE MISCARRIAGE
ET 15-50mm ET >50mm
Expectant management Medical management
• Indications: - Patient’s preference • Indication: - Patient’s preference
- Hemodynamically stable • Drug choice:
• Allow up to 14 days of expectant mx. - Cervagem pessary 1 mg 3 hourly up to
• Follow-up review at 7-10 days with 5 mg per course.
ultrasound: • Expulsion of POC is expected within 24
- if continued bleeding, pain or evidence hours after insertion.
of retained POC on ultrasound, discuss
further management (surgical option)
- can TCA earlier if already passed out
POC, re-scan to ensure complete • Complications:
expulsion of POC and send POC for HPE. - Heavy bleeding
- Infected POC
Surgical management
• Evacuation of retained POC/
Suction & curettage
• Indications:
- Persistent excessive bleeding
- Hemodynamic instability
- Evidence of infected retained tissue
• Prior to procedure, cervical preparation
should be done with Cervagem pessary
1mg 3 hours prior to surgery.
• Evacuated POC should be sent for HPE.
COMPLETE MISCARRIAGE

ET < 15mm

TCA stat if bleeding/ pain persists > 2weeks

Cervagem
• Gemeprost is an alprostadil (prostaglandin E1)
analogue. It softens and dilates the cervix and induce
uterine contractions.
Uses:
- Therapeutic termination Adverse Reactions: 

- Cervical dilatation prior to surgery - Significant: Uterine rupture,

Dosage and route of administration: spontaneous abortion, vaginal bleeding

- As pessary 1 mg 3 hourly up to 5 mg per course, and mild uterine pain.

inserted into the posterior fornix. - Others: GI disturbances (nausea,

- A second course of treatment may be started 24 hours vomiting, diarrhea)

after the initial commencement of treatment if

termination is not well established.
Complications of surgical uterine evacuation:

• Uterine perforation
• Hemorrhage
• Intrauterine adhesion
• Intra-abdominal trauma
CASE SCENARIO 1.1

• Mrs. N, 35-year-old / G3 P1+1 at 13 weeks POA

Mrs. N’s scan findings show a fetus corresponding to 7 weeks of gestation with absent fetal heart and hence
was diagnosed with missed miscarriage.

Q3. What are her treatment options?

Surgical management with suction & curettage

Q4. How would you prepare the patient for surgery?

• Admit
• Take consent
• KNBM at least 6 hours prior to op
• Prime the cervix with Cervagem 1mg 3 hours prior to op
Q5 : Can Cervagem be used as an alternative to
Prostin for induction of labour?

YES NO
Cervagem use in pregnancy
- CERVAGEM pessaries should not be used for the induction of
labour or cervical softening at term as fetal effects have not
been ascertained.
- Every effort should be made to ensure that once gemeprost
has been administered to pregnant women, termination of
the pregnancy is completed.
- Studies in animals have shown evidence of an increased
occurrence of fetal damages, the significance of which is
considered uncertain in humans.

Reference: https://apps.medicines.org.au/files/swpcerva.pdf
SEPTIC MISCARRIAGE
DEFINITION

• Abortion associated with clinical evidences of infection of the uterus

and its contents

• Due to Incomplete evacuation, improper aseptic technique,

anadvertent injury to other organs/structures
INCIDENCE

• Mostly associated with incomplete abortion

Majority of case, infection occurs following illegal induced abortion

 Also occur following spontaneous abortion

• Most bacteria causing septic abortion are part of normal vaginal flora

• In 80% cases, organisms are endogenous in origin

Infection localized to the conceptus, no myometrial involvement

• 15% cases : Infection produced localized endomyometritis

• Some cases : Generalised peritonitis / endotoxic shock

 Severe necrotizing infections and toxic shock syndrome caused by group A

streptococcus-S.pyogenes
SIGNS & SYMPTOMS

• Tachypneic

• Tachycardia

• Diarrhea & vomiting

• Altered mental status

INVESTIGATIONS

• FBC, RP, FLFT, Coag profile, ESR, BCNS

• Swab

• Urinalysis

• TAS/TVS : TRO ectopic, retained POC, free fluid

TREATMENT

• Resuscitation with IV fluid or blood if necessary

• Intensive antibiotic therapy :

- IV Cefoperazone 1g 12hourly or IV Cefurozime 750mg 8hourly + IV

Metronidazole 500mg 8hourly

- IV Augmentin 1.2g 8hourly + IV Gentamicin 3-5mg/kg/day + IV

Metronidazole 500mg 8hourly
• Arrange for evacuation of uterus after adequate antibiotic therapy (12
hours)

• Urgent evacuation if profuse per vaginal bleeding

• IV antibiotic should be continued until afebrile for at least 48 hours. Then

oral antibiotics can be instituted for 10 days and adjusted according to
C&S result

• Laparatomy, hysterectomy
COMPLICATIONS

• Pelvic abscess

• Septic shock

• Chronic PID

• Uterine synechiae
 RECURRENT
MISCARRIAGE
DEFINITION
• Habitual abortion/Recurrent pregnancy loss (RPL)
Occurrence of three or more consecutive spontaneous miscarriages

• American Society for Reproductive Medicine (2013) defines RPL as

two or more failed pregnancies confirmed by sonographic or
histopathological examination
 RISK FACTORS
Maternal age- associated with a decline in both the number and quality of the

remaining oocyte

Previous miscarriages- risk increases with each successive pregnancy loss,40%

after 3 consecutive pregnancy losses

Obesity-increases risk of both sporadic and recurrent miscarriage

Environmental factors-Cigarette smoking, caffeine and alcohol consumption,

CAUSES

• Three widely accepted causes of RPL are parental chromosomal

abnormalities, antiphospholipid antibody syndrome, and structural uterine
abnormalities.

• Genetic factors usually result in early embryonic losses, whereas autoimmune

or uterine anatomical abnormalities more likely cause second-trimester losses

• Approximately 40 to 50 percent of women have idiopathic RPL

GENETIC FACTORS
• Repetitive first trimester losses

• Anembryonic pregnancies

• History of malformations or mental retardation

• Advanced maternal age

Parental Chromosomal abnormalities-
• One of the partner carries a balanced structural chromosomal anomaly
• Most common is balanced reciprocal and Robertsonian translocation
which causes unbalanced translocation in the fetus

Embryonic Chromosomal abnormalities-

• Due to abnormalities in the egg, sperm or both .
Most common- Monosomy or trisomy
Mainly responsible for sporadic miscarriage
MANAGEMENT

• Genetic counselling

• Assisted reproductive technologies, including PGD (preimplantation

genetic diagnosis)

• Use of either donor oocyte or donor sperm

depending on the affected partner
AUTOIMMUNE – ANTI-PHOSPHOLIPID
SYNDROME
Sydney revision of Saporo criteria
 When to start treatment
• Heparin with low dose aspirin is preferred regime .

• Aspirin is started when pregnancy is being

attempted or documented.

• Heparin is started as soon as cardiac activity is

documented on TVS.
APS-Treatment dose

1. Unfractionated Heparin 5000-10000 IU subcutaneous twice a day

Or Low molecular weight Heparin is better option

2. Low dose Aspirin (75-85mg/day)

ANATOMIC FACTORS
• Acquired or congenital anomalies
• Congenital uterine anomalies: 6 - 7 % in women with RPL vs. 2 % in all
women.
• Pathogenesis uncertain but attributed to :
Reduced intrauterine volume
Poor vascular supply
CONGENITAL ACQUIRED

• Septate uterus 65 % • Uterine Leiomyomas

• Unicornuate uterus 50% loss • Intrauterine
• Uterus didelphys 40% loss Adhesions(Asherman’s
• Bicornuate uterus 30 % loss Syndrome)
• DES exposure - many have • Incompetent cervix
abnormal uterine structure (T
shaped uterus+/-cervical
changes)-24%
 Cervical insufficiency/Cervical incompetence
• Defnition- Inability of the cervix to retain a pregnancy in the second
trimester,in the absence of uterine contractions.

• Presents as acute, painless dilatation of the cervix which causes

recurrent mid trimester pregnancy loss
• Ultrasound Diagnosis (Transvaginal )-Following USG features are suggestive of
cervical incompetence

• Cervical length<3cm

• Internal os width>1.5cm in first trimester

>2.0cm in second trimester

• Bulging/funneling of membranes into internal os and endocervical canal.

SURGICAL TREATMENT
• Shirodkar operation
• McDonald operation
• Abdominal cerclage
• Espinosa Flores operation
• Wurm operation
Circlage Principle-
• A non absorbable encircling suture is placed
around the cervix at the level of internal os
• Operates by interfering with the uterine polarity
and the adjacent lower segment from being
taken up.
Timing of operation
• Elective cerclage-In proven cases around 14
weeks or at least 2 weeks earlier than the
lowest period of previous wastage as early as
10th week.
• Emergency cerclage- when the cervix is dilated
and the membranes are bulging.
Complications
• Slipping or cutting through the suture
• Chorioamniotis
• Rupture of the membrane
• Abortion /Preterm labour
ENDOCRINE FACTORS
Endocrine factors that may predispose to an increased risk of pregnancy
loss include :

• Thyroid disease

• Diabetes mellitus

• Polycystic ovary syndrome

• Luteal phase deficiency

INFECTIONS

• No infectious agent has been proven to cause recurrent pregnancy loss

• Certain infections have been associated with spontaneous loss

• Toxoplasma gondii, Chlamydia trachomatis, Ureaplasma urealyticum,

Mycoplasma hominis, Listeria monocytogenes, Campylobacter species
• Rubella, HSV, CMV can directly infect the fetus and the placenta

• Bacterial vaginosis in the first trimester can cause 2nd trimester miscarriage and
preterm delivery
INHERITED THROMBOPHILIC
DEFECTS
• Pregnancy is a hypercoagulable state

• Women with heritable or acquired thrombophilic disorders have significantly

increased risks of pregnancy loss
• Factors that favour clotting when increased

Fibrinogen

Factors VII,VIII,X

• Factors that favour clotting when decreased

Antithrombin III

Protein C

Protein S
• Thrombosis on maternal side of the placenta  impaired placental
perfusion
• Late fetal loss, IUGR, abruption, or PIH

• Relationship with early loss is less clear

• Tx : The combined use of low-dose aspirin (75-80mg/dl) and
subcutaneous unfractionated heparin (5000unit twice daily)
MANAGEMENT OF PATIENTS WITH
IDIOPATHIC RECURRENT ABORTIONS
Preconception

Counselling of the couple-after 3 consecutive miscarriages chance of a successful

pregnancy is high(70%)

1.Folic acid

2.Correct nutritional deficiencies

3.Empiric antibiotics

4.Luteal support
Q1. The uterine anomaly most commonly implicated in the etiology of
recurrent abortions is

• Septate uterus
• Unicornuate uterus
• Uterus Didelphys
• Arcuate uterus
Q2. All are causes of recurrent pregnancy loss except
• PCOS
• Diabetes
• Thyroid dysfuncton
• Anaemia
Q3. Ultrasound features suggestive of cervical incompetence include

• Cervical length<3 cm
• Internal os width>1.5 cm
• Bulging of membranes into internal os
• All of the above
References
1. Ectopic pregnancy and miscarriage: Diagnosis and initial management. Retrieved
December 5, 2021, from
https://www.nice.org.uk/guidance/ng126/resources/ectopic-pregnancy-and-misca
rriage-diagnosis-and-initial-management-pdf-66141662244037

2. Australian product information CERVAGEM ... - medicines.org.au. (n.d.). Retrieved

December 5, 2021, from https://apps.medicines.org.au/files/swpcerva.pdf.