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Miscarriage can be defined as the spontaneous loss of intrauterine pregnancy

that occurs before the period of viability which is 28 weeks of gestation in the
Caribbean.

It may be categorized into the following sub groups :

1.Gestational period:
1st trimester/early (0-12 weeks)
2nd trimester/late (12-28 weeks)
Preterm delivery (>28 weeks) passed the period of viability (fetus has a chance
of survival)

2.Stage of miscarriage at the time of detection:


-Missed/silent
-Threatened
-Inevitable
-Incomplete
-Complete
-Septic

3. Frequency of miscarriage
Recurrent miscarriages is defined as spontaneous miscarriages that occur on 3
or more consecutive pregnancies (either 1st or 2nd trimester)

Due to the following :


1. Chromosomal abnormalities
2. Luteal phase insufficiency
3. Anti-phospholipid syndrome
4. PCOS
5. Uterine abnormalities eg septate uterus
6. Severe metabolic/endocrine abnormalities eg diabetes, lupus
7. Cervical incompetence
8. Unexplained
9. Fibroids
10.Very high or low BMI

Differential Diagnosis:
 Ectopic preg
 Torsion/hemorrhage of ovarian cyst
 Appendicitis
1st Trimester Miscarriages
Threatened Incomplete Missed Complete Septic Ectopic
Signs/Sx - Heavy bleeding - Very heavy - Incidental - Hx of heavy - Usually follows - ongoing abdo
- No POC bleeding finding vaginal incomplete pain
- pain - POC ++ - No prior Sx bleeding - fever +/- bleeding/
- ongoing abdo - Mild vaginal - POC ++ - purulent foul spotting in 1st
pian discharge - minimal smelling discharge trimester
bleeding now - vomiting - ab tenderness
- UPT neg - rigors - rebound
tenderness
(if ruptured)
- amenorrhea
BimanualVE - Uterine size = - Uterine size < - Uterine size - Uterine size < Same as incomplete - uterine size <
to dates dates < dates dates - vaginal discharge dates
for uterine size
- Cervical os - Cervical os open - Cervical os - cervical os - cervical excitation - cervical &
exc uterine masses
closed - POC protrusion closed closed tenderness adnexal
Speculum for - No POC in cervical os - No POC +/- POC in - adnexal tenderness tenderness
vaginal bleeding - Some bleeding - Bleeding - No bleeding vagina - cervical os
Exc local causes closed
Cervical os open or - no discharge
closed - NO HVB &
Protrusion of POC foul discharge

Trans - Fetal cardiac - No cardiac - USS < dates - USS< dates - POC - No intrauterine
activity noted activity - No fetal - no POC - thick endometrium gestational sac
vaginal USS - USS= dates - thick cardiac - endometrial - fluid in +/- adnexal
findings 6 wk = gest sac endometrium activity thickness endometrial cavity mass
8 wk = fetal pole - POC seen - Empty normal indicates +/- free fluid in
- no viable fetus gestational sac - no viable infection/inflam ab if ruptured
fetus
Management - Conservative - Surgical - Medical Rx - Conservation - Medical Unruptured =
management but management +/- surgical + antibiotics resuscitation Rx based on
if heavy vag - ERPC intervention (Iv fluids, criteria –
bleeding, refer to - Curettage (ERPC) antibiotics, vitals) medical or
hospital. then surgical to surgical
evacuate uterus
-Intravaginal Ruptured –
progesterone resuscitation +
surgical

2nd Trimester – Inevitable Miscarriage


S/S
- heavy bleeding
VE
- uterine size = dates
- cervical os open with bulging membranes
- palpable fetal parts & membranes
Investigations
1. UPT kits which detect beta-HCG. At day 9 post fertilization, its level is approx.
25lu/l. 1st void morning urine sample is ideal because bHCG levels are higher.

2. Serum progesterone: viable preg if >25nmol/L but <5 suggests poor prognosis.

3. USS – the preferred method is transvaginal

Gestational Age Trans ab USS Trans vag USS Beta-HCG (lu/L)


4-5 weeks --- Gestational sac >1500
5-6 weeks Gestational sac Gestational sac Yolk 3000-5000
sac
6-7 weeks Gestational sac Gestational sac Yolk >20000
Yolk sac sac
No FHR FHR

4. FBC – fe therapy vs blood transfusion

5. Coagulation studies – (PT/PTT/INR) rule out DIC

6. Blood Grouping – if she is rh neg then aan anti-D inj is needed to prevent rh iso in
future preg
(<20 weeks: 250microgm & >20 weeks: 500microgm) and also for BT

7. Screening for infection – eg for Chlamydia

Treatment

Medical management
intact sacs or incomplete Surgical
Expectant misc antiprogesterone Management
management (mifepristone) or vacuum
prostaglandin analogues aspiration
(misoprostol/gemeprost)
Recurrent Miscarriages
Cuases Tests Treatment
Chromosomal abnormalities POC sent for cytogenic studies Genetic counselling
1 common anomalies is balanced
reciprocal or Robertsonian
translocations

Inherited Thrombophilic Thrombosis of the utero-pacental Thromboprophylaxis


defects vasculature is considered the
- activated protein C resistance probable cause of recurrent
(due to factor V Leiden gene miscarriage.
mutation)
- deficiencies of protein C, S
and antithrombin III
- hyperhomocysteinaemia
- prothrombin gene mutation

Anti-phosphate syndrome Confirmed if positive on 2 Thromboprophylaxis in the form of


refers to the association bet anti- occasions, 6weeks apart with either low dose aspirin and low dose
phos ab and adverse preg medium - high titres of Anti- heparin during preg
outcomes or vascular cardiolipin antibodies. (aCL) of IgG
thrombosis. or IgM class or the presence of
lupus anticoagulant

Uterine abnormalities More common in late misc Hysteroscope


USS (telescopic surgery through the
Surgical tech - hysteroscopy & cervix)
laparoscopy

Cervical incompetence Clinical diag based on hx of: Cervical or trans-abdo


Early preg: progressive painful Cerclage:
dilatation of cervix or spontaneous Mersilene tape inserted around cervix
rupture of mem confirmed on USS to prevent its dilatation via a
Late preg: 3 or more consecutive Macdonald stitch or Shirodkar (for a
misc which are painless, complete, short cervix)
rapid w minimal bleeding

Outside preg:
Hegar Dilator test or
Cervicography

Conditions NOT associated with recurrent miscarriages:


 Occult diabetes
 Well controlled diabetes
 Occult hypothyroidism
 PCOS
 Hyperprolactinemia
 TORCH infections
Gestational Trophoblastic Diseases
The conditions which fall under this heading are:

- Molar Pregnancy (Hydatiform Mole)


- Invasive mole
- Choriocarcinoma
- Placental site trophoblastic tumor

Types and causes Clinical Investigations Treatment Follow up


presentation

1. Complete mole -irregular Diagnostic: Surgical assessment of


Caused by: vaginal Serum beta-HCG evacuation urine or blood
80%:duplication of a bleeding levels are raised is the treatment HCG levels. If
sperm after -hyperemesis and inconsistent of choice for these levels return
fertilisation of an -excessive with gestational complete and to normal within
‘empty’ ovum uterine age partial molar 56 days ,then these
20%: dispermic enlargement pregnancies women are
fertilisation of an -failed USS shows a followed up for up
empty ovum pregnancy snowstorm to six months.
-grape-like appearance of the Ripening of If the HCG levels
2. Partial mole POC on tissue cervix prior to do not return to
Caused by: speculum/VE evacuation is normal within 56
90%: triploid due to safe. days then, they are
dispermic Others: Oxytocin followed up for up
fertilisation of an Hb infusion should to six months from
ovum Thyroid status not be used the date these level
Blood group prior to return to normal
evacuation due
to the risk of
embolisation of Methotrexate,
trophoblastic Dactinomycin,
tissue. Etoposide,
Cyclophosphamide
and Vincristine
(EMACO).