Miscarriage (early pregnancy loss)

geekymedics.com /miscarriage-early-pregnancy-loss/

Lucy 12/15/2015
Hempenstall

Miscarriage is the spontaneous loss of an intrauterine pregnancy before 20 weeks gestation (or weighing less than
400g depending on the jurisdiction). It occurs in approximately 10-20% of all clinical pregnancies. The risk of
miscarriage increases with increasing maternal age; miscarriage occurs in 21% of pregnancies between the age of
35-40 years old and increases to 41% above the age of 40 years old. Most miscarriages (~80%) are diagnosed
between 8-12 weeks, with the risk of miscarriage decreasing as gestational age increases.

Causes of miscarriage
In the first trimester the most common cause of miscarriage is chromosomal abnormality (50-60%):

Autosomal trisomy is the most common abnormality trisomy 16 is the most common trisomy in miscarriage
The most common single chromosomal anomaly is 45X karyotype
Maternal age is related to aneuploidy risk = increasing maternal age increases aneuploidy risk

In the second trimester miscarriage is commonly due to an incompetent cervix:

Important risk factor is previous cervical surgery

Other potential causes of miscarriage include:

Fetal malformations e.g. neural tube defects

Uterine structural abnormalities e.g uterine septum, Ashermans syndrome, fibroids

Chronic maternal health factors:

Thrombophilia
Antiphospholipid syndrome
SLE
PCOS

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 Poorly controlled diabetes mellitus
Thyroid dysfunction

Active infections including:

Rubella
CMV
Herpes simplex virus
Listeria infection
Toxoplasmosis
Parvovirus B19

Iatrogenic causes:

Amniocentesis
Chorionic villus sampling

Social factors:

Tobacco
Alcohol
Cocaine

Exposure to environmental toxins

Advanced paternal age

Definitions of miscarriage
Miscarriage can be classified according to stage.

Stages

1. Threatened miscarriage

The fetus is threatened (i.e. a miscarriage may happen). There is some vaginal bleeding BUT the cervical os is
CLOSED and ultrasound reveals a VIABLE intrauterine pregnancy.

IMPORTANT TO NOTE: 90% of threatened miscarriages will continue to grow to normal gestation.

2. Inevitable miscarriage

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The miscarriage is inevitable i.e. a miscarriage is going to happen. There is vaginal bleeding +/- cramping
abdominal pain AND the cervical os is OPEN but the products of conception have not yet passed.

3. Incomplete miscarriage

The miscarriage is incomplete, i.e. currently happening. There is heavy and increased vaginal bleeding, intense
lower abdominal pain and passage of some products of conception. On examination the cervical os is OPEN and
there are PRODUCTS OF CONCEPTION present in the canal.

4. Complete miscarriage

The miscarriage is complete. Products of conception have been passed. On examination the cervical os is
CLOSED. Ultrasound reveals an EMPTY uterine cavity.

Other types of miscarriage

Missed miscarriage

The miscarriage was missed i.e. a NONVIABLE INTRAUTERINE pregnancy has remained inside the uterus (the
fetus has not spontaneously aborted). The patient is amenorrhoeic but has not had any vaginal bleeding or
abdominal pain. On examination there is no passage of tissue and the cervical os is CLOSED. Ultrasound confirms
a non-viable intrauterine pregnancy.

Blighted ovum

Missed miscarriage in which embryonic development stopped before the embryonic pole was visible. The
gestational sac may continue to grow.

Septic miscarriage

Miscarriage + sepsis (symptoms of fever / significant abdominal tenderness).

Recurrent miscarriage

Occurrence of 3+ miscarriages.

Clinical assessment

History

Symptoms:

Amenorrhoea
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 Vaginal bleeding (details regarding quantity and pattern) +/- syncope (indicating significant blood loss)
Cramping abdominal pain
Passage of any fetal tissue
Fever ?septic miscarriage

Menstrual cycle: LMP / cycle length / days bleeding / clots / flooding

If known to be currently pregnant: dating based on LMP / USS results

Past obstetric history:

Outcomes from previous pregnancies and complications

Previous miscarriage or ectopic pregnancy increases the risk

Past gynecological history:

Including cervical / uterine surgery

Risk factors for ectopic pregnancy previous ectopic, previous STI/PID, IUD, previous tubal surgery
Contraception
Pap smears abnormal results LETZ surgery

General medical and surgical history

Family history

Medications / Allergies

Social history: Smoking / Alcohol / Illicit drug use

Important points on examination

Vitals: assessment of haemodynamic stability / pyrexia

Abdominal examination: benign in miscarriage (if rebound tenderness present consider ectopic pregnancy)

Pelvic examination considerations:

Speculum examination

Determine the source of the bleeding

Quantify the bleeding
Is the cervical os open or closed?
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 Evidence of products of conception in the cervical os
Purulent cervical discharge ? septic miscarriage

Bimanual examination

Uterine size
Cervical motion tenderness (if present increases likelihood of ectopic pregnancy)
Adnexal mass ?ectopic pregnancy

Investigations

Blood tests

Complete blood count with differential.

Quantitative b-hCG:

A single level to assist in USS interpretation (discussed below)

Level may be less than expected for dates in miscarriage (b-hCG doubles every 48 hours reaching 100 000
at 10 weeks, and then plateauing and decreasing to 10 000 at term)
Serial testing every 48 hours showing a falling b-hCG indicates a failing pregnancy (if less than 10 weeks
gestation)

If bleeding is significant: group and hold / cross match

Antibody screen: rhesus negative patients will require anti-D

Transvaginal ultrasound

Ensure that the b-hCG level is above that of the discriminatory zone:

The discriminatory zone is the level of serum b-hCG above which the gestational sac is visible on USS
To confirm a pregnancy by transvaginal ultrasound the b-hCG must be above 1500.
This correlates with a gestational age of approximately 5 weeks gestation.
The discriminatory zone for an abdominal ultrasound is 6500.

Five points to check in pregnancy:

Dating
Location: is the pregnancy intrauterine? = important to rule out ectopic pregnancy
Multiple pregnancy
Molar pregnancy = snowstorm appearance
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 Nonviable pregnancy includes:

Gestation sac > 25mm diameter with no yolk sac or embryo

No cardiac activity: fetal heart rate is typically detected at 5.5 to 6 weeks

Look for retained products of conception (if from the history the miscarriage is incomplete or complete)

Histological examination of any tissue passed vaginally.

Differential diagnosis of early pregnancy bleeding

1) Miscarriage

2) Ectopic pregnancy

3) Molar pregnancy

4) Implantation bleed

5) Genital tract trauma

6) Cervical pathology: ectropion / polyp / malignancy

Management

Management considerations

Emergency
Surgical
Medical
Expectant
Psychological support

In every case:

Is the patient haemodynamically stable?

Rule out ectopic pregnancy
Check rhesus status, if rhesus negative give anti-D

Emergency management (haemodynamically unstable)

The key points in this situation are to make an accurate assessment of the patient, initiate basic resuscitation
(ABCD) and inform seniors as soon as possible.

Resuscitation of the patient using the ABCD approach.

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Urgent O&G specialist input consultant / registrar input is essential.

Urgent speculum examination to remove POC as clinically indicated:

This may stop the bleeding and restore blood pressure (POC in the cervical os causes cervical dilatation
which causes a vasovagal response)

Urgent ultrasound scan: exclude ectopic pregnancy

Anti-D should be considered if the patient is rhesus negative.

Continued bleeding in a haemodynamically unstable patient warrants surgical evacuation.

Surgical evacuation (dilation & curettage)

Dilation and curettage (D&C) refers to the dilation (widening) of the cervix and surgical removal of part of the lining
of the uterus and/or contents of the uterus by scraping and scooping (curettage).

This procedure is indicated in the following situations:

Haemodynamic instability
Excessive bleeding
Infected retained tissue
Suspected molar pregnancy
Unsuccessful expectant or medical management

Risks of the procedure:

Risks of general anaesthesia (e.g. N/V, DVT/PE )

Risks of any operation (e.g. infection, haemorrhage)
Possibility of retained products after operation
Uterine perforation
Cervical tears
Intrauterine adhesions (Ashermans syndrome)

Medical management

Medical management involves the use of a prostaglandin agent to induce uterine contractions and effacement of
the cervix (Misoprostol is commonly used).

If haemodynamically stable, women may prefer this option.

It has an 85% success rate.

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Risks include:

Bleeding that may continue for up to 3 weeks

Increased pain in association with the bleeding
Infected products of conception

Patient education its essential to inform the patient of the potential risks and explain the need to seek review

Follow up patients are usually followed up approximately 1 week later

Expectant management

Expectant management involves waiting for spontaneous passage of the products of conception, without any
medical or surgical intervention.

Risks include:

Bleeding that may continue for several weeks

Increased pain in association with the bleeding
Infected products of conception

Patient education its essential to inform the patient of the potential risks and explain the need to seek review

The patient may require anti-D if they are rhesus negative.

Follow-up review at 7-10 days with ultrasound if continued bleeding, pain or evidence of retained POC on
ultrasound discuss further management (suction curettage)

Psychological support

Break bad news appropriately and ensure support.

Provide written information.

Communicate to general practitioner via letter.

Offer referral to relevant healthcare professionals and support groups prior to discharge particularly for
counseling/psychological support.

Risk of recurrence
There is no increased risk of having another miscarriage after having one miscarriage (10-20% for the
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general population).

After two miscarriage the risk of having another miscarriage is 25%.

After three miscarriages the risk is approximately 40%.

Recurrent miscarriages
3+ miscarriages, requires specialist review

There is an underlying cause in 50% of patients.

Causes include:

Increased maternal age

Parental genetic factors (balanced translocations, mosaicism)
Thrombophilic disorders
Endocrine disorders (diabetes mellitus, thyroid disorders, PCOS)
Structural uterine abnormalities

Pertinent features on history:

Menstrual cycle history

Medical Hx: clotting (DVT, PE), endocrinopathy (diabetes mellitus, thyroid dysfunction)
Hx of cervical surgery or uterine instrumentation (cervical incompetence, Ashermans syndrome)
Hx of congenital abnormalities that may be heritable
Detailed family history
Exposure to environmental toxins (e.g. occupational exposures)

Physical examinations should include general physical assessment, any signs of endocrinopathy and any pelvic
organ abnormalities.

Investigations:

Cytogenetic analysis performed on the products of conception of the third and any subsequent miscarriages
Parental karyotyping and genetic counseling

Female requires:

Pelvic ultrasound and MRI, sonohysterography, hysteroscopy for further structural evaluation
Thrombophilia screen
Antiphospholipid antibody screen, anticardiolipin antibodies and lupus anticoagulant
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 Thyroid function: TSH, free T4, thyroid peroxidase antibodies

Ensure adequate psychological support.

The chance of subsequent success of an intrauterine pregnancy is still up to 75%,

The prognosis is improved if one live birth has occurred.

References
Click to show

Early Pregnancy Loss by Elizabeth Puscheck on Medscape http://reference.medscape.com/article/266317-

overview
Early Pregnancy Loss, Maternity and Neonatal Clinical Guidelines, Queensland Clinical Guidelines, QLD
Department of Health, published Sept 2011 amended July 2015, 33 pages.
Examination in Obstetrics and Gynaecology by Judith Goh and Michael Flynn, Churchill Livingstone, 3rd
edition, 2010, 324 pages ISBN-10: 0729539377
Gynaecology by Ten Teachers, edited by Ash Monga and Stephen Dobbs, CRC Press, 19th edition, 2011,
216 pages, ISBN-10: 034098354X
Miscarriage and Recurrent Miscarriage articles on UpToDate
Obstetrics and gynaecology: an evidence based guide by Jason Abbott, Lucy Bowyer and Martha Finn,
Churchill Livingstone, 2nd edition, 396 pages, IBSN-10: 0729540731
Toronto Notes A Comprehensive Medical Reference and Review for MCCQE and USMLE II, Editors: Miliana
Vojvodic & Ann Young, Torontoa Notes for Medical Students, 30th edition, Toronto Canada, 2014 pp.OB23-
OB24.

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