Miscarriage (Abortion)

Definition

Miscarriage: spontaneous termination of pregnancy. Abortion: induced termination of pregnancy. It is expulsion or extraction of products of conception before fetal viability i.e.

before 24 weeks of gestation (during the 1st 2 trimesters).

Incidence

• Is the commonest gynecological & obstetric disorder

• ~ 15% (clinically recognized) & rise to 30% (unrecognized pregnancies).

• Most abortions occur between 8-12 weeks of pregnancy.

Causes of 1st Trimester Abortion (up to 12w):• Chromosomal abnormalities

• 50-70% The commonest cause of abortion• Particularly trisomy, triploidy & monosomy• The incidence increased with the increase in the maternal age

• Multiple gestation• Blighted ovum (Anembryonic pregnancy)• Parental balanced translocation• Infections: genital tract infection, systemic infection & ToRCH syndrome• Endocrine abnormalities (DM, thyroid dysfunction, PCOS, corpus luteal

insufficiency)• Uterine disorders

• Uterine anomalies (septated uterus)• Asherman’s syndrome (adhesions inside the uterine cavity)• Sub-mucous fibroid

• Thrombophilia: anti-phospholipids syndrome, congenital deficiency of protein C, S & anti-thrombin III

• Immunological disorders : Anticardiolipin syndrome & SLE• Cigarette smoking, anaesthetic agents & chemical agents.• Trauma, Rh isoimmunization, Psychological & neurological disorders

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Causes of 2nd Trimester Abortion (13-24w):• Multiple pregnancy• Cervical incompetence (congenital & acquired )• Uterine anomalies & sub-mucous fibroid• Genital tract infection & PROM

Types:• Threatened abortion "المنذر"• Inevitable abortion "الحتمي" • Incomplete abortion "الناقص"• Complete abortion "الكامل"• Missed abortion "المنسي"• Septic abortion "االلتهابي"• Recurrent abortion "المتكرر"

Threatened abortion:History• Mild vaginal bleeding (main complaint).• No or mild abdominal pain

Examination• Good general condition• Closed cervix• The uterus is usually the correct size for date

U/S (essential for the diagnosis)• Showed the presence of fetal heart activity

Management:1. Reassurance (If fetal heart activity is present, > 90% of cases will be progressed

satisfactorily)2. Advice (decrease activity & avoid intercourse for 1-2wks until the condition get

stabilized because semen contain PG which cause softening and dilatation of the cervix)3. Hormones (Progesterone & hCG used in the 1st trimester to support pregnancy)4. Anti-D (Rh –ve, non-immunised patients, whose husbands are Rh +ve)5. ANC as high risk patients (more liable to late pregnancy complications such as APH

& preterm labor).The definition of abortion is not exactly applied, because there is no expulsion or extraction.

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Inevitable & incomplete abortions:History• Heavy vaginal bleeding with:

• No passage of products conception (inevitable)• Passage of products of conception (incomplete)

• Severe lower abdominal pain which follows the bleedingExaminations • Poor general condition (maybe shock).• Dilated cervix & products of conception may be passing through the os• The uterus size:

• Correct for date (inevitable)• Small for date (incomplete)

U/S (not essential for diagnoses): fetal heart activity may or may not present.Management

1. CBC, blood grouping, XM 2 units of blood2. Resuscitation à large IV line, fluids & blood transfusion3. Oxytoxic drugs à Ergometrine 0.5 mg IM + Oxytocin infusion (20-40 units in 500 cc

saline) or PG to encourage the uterine contraction & minimize the bleeding.4. Evacuation & curettage.5. Post-abortion management.

Complete abortion:History (history of things happened days ago)• Heavy vaginal bleeding• Lower abdominal pain which follows the bleeding• Passage of all conceptive material

Examination • Closed cervix• Small for date

U/S• Empty uterine cavity• RPOC

Management• Evacuation & curettage in the presence of RPOC.• Post-abortion management

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Missed abortion: Most of missed abortions are diagnosed accidentally during routine U/S in

early pregnancy.History (in some cases there may be):• Episodes of mild vaginal bleeding• Regression of early symptoms of pregnancy.• Stop of fetal movements after 20 weeks gestation.

Examination• Closed cervix• Small or compatible for date

U/S (essential for diagnosis):• Diagnosed if 2 U/S (T/V or T/A) at least 7 days apart showed an embryo of

>7 weeks gestation (CRL > 6mm in diameter & gestational sac > 20 mm in diameter) with no evidence of heart activity.

• 2 U/S 7 days apart because of the possibility of wrong dating due to irregular period, lactating or OCPs… If there was heart activity in previous ultrasound in the previous visit and now there is no heart activity then almost no need for 2nd ultrasound.

Management (the best method is the medical & the worst one is the conservative)

1. CB , blood grouping, XM 2 units of blood2. Platelets count to exclude the risk of DIC (not occur before 5 weeks of missed

abortion or IUFD and if occurred will be of mild grade)

3. Conservative management (More psychological trauma & risk of DIC)

• Leave the dead fetus inside the uterus until spontaneous expulsion4. Active management (less psychological trauma & risk of DIC)

a. Surgical evacuation (D & C)• Only in the 1st trimester (< 12 weeks) because the head development

• Shorter time, GA, surgical complicationsb. Medical evacuation by Misoprostol (Cytotec a PGE1)• At any gestation 1st or 2nd trimesters• Vaginal (the best) or oral tab 200 μg 2x/3h up to 5 doses daily, which

can be repeated next day if no response in the 1st day.• In 90% will be complete abortion & 10% will need subsequent surgical

evacuation in cases of RPOC• S/E: nausea, vomiting & fever (no GA or surgical complications)

5. Post-abortion management

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Anembryonic pregnancy (Blighted ovum)• It is due to an early death and resorption of the embryo with the

persistence of the placental tissue• Diagnosis & treatment similar way to missed abortion.

Septic abortionDefinition: • Incomplete abortion complicated by infection of the uterine contents.• This may be due to criminal interferenceFeatures:• Poor general condition• Incomplete abortion features with or without history of evacuation.• Pelvic infection features: pyrexia, tachycardia, general malaise, lower

abdominal pain, pelvic tenderness & purulent vaginal discharge.Bacteriology: Mixed infection• The commonest organisms are G-ve E.coli , strep, staphylococcu &

anaerobics (bacteroides)• Rarely Cl. tetani , which is potentially lethal if not treated adequately.Types: • Mild 80%à the infection is confined to decidua• Moderate 15%àthe infection extended to myometrium• Severe 5%àthe infection extended to pelvis + Endotoxic shock + DIC

Management: 1. Investigations: • CBC, blood grouping, XM 2 units of blood.• Cervical swabs (not vaginal) for culture and sensivity • Coagulation profile, serum electrolytes & blood culture if pyrexia > 38.5

2. Antibiotics: IV Cephalosporin & Metronidazole3. Surgical evacuation of uterus à usually 12 hrs after antibiotic therapy (until

a reasonable tissue levels of antibiotics have been achieved)4. Post-abortion management.

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Complications of abortion:1. Hemorrhage (abortion is one of the leading cause of maternal death & mostly

due to hemorrhage).2. D&C or E&C (surgical) complication:

a. Uterine perforation à rupture uterus in the subsequent pregnancy.b. Cervical tear & excessive cervical dilatation àcervical incompetence.c. Infection à infertility & Asherman's syndrome.d. Excessive curettage à Adenomyosis

3. Rh-iso immunizations (anti-D is not given or the dose is inadequate).4. Psychological trauma.

Post-abortion management:1. Support from the husband, family& obstetric staff2. Anti-D (Rh –ve, nonimmunized patients, whose husbands are Rh+ve)3. Counseling & explanation:

a. Contraception should start immediately after abortion, because ovulation can occur 14 days after abortion and the pregnancy can occur before the expected next period.

b. It’s better to wait for 3 months before trying again. Regulate the cycles & knowing the LMP. Give folic acid. To be in the best shape (physically & emotionally) for the next

pregnancy.c. Why has it happened: the majority of cases there is no obvious cause. In

the 1st trimester the most common cause is fetal chromosomal abnormality.

d. Can it happen again? As the commonest cause is the fetal chromosomal abnormality which is not a recurrent cause, so the chance of successful pregnancy next time in the absence of obvious cause is very high even after 2-3 abortions. Success rate in the next pregnancy is 85%.

e. Not to feel guilty: as it is extremely unlikely that anything the patient did can cause abortion

f. No evidence that intercourse in early pregnancy is harmfulg. No evidence that bed rest will prevent it

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Recurrent abortionDefinition:• 3 or more consecutive spontaneous abortions.

Types:1. Primary: All pregnancies have ended in loss (before 24w).2. Secondary: One or more pregnancies has proceeded to viability (>24 w) with

all others ending in loss.

Incidence: 1% of women of reproductive age.

Causes (50% Idiopathic & 50% known causes):1. Chromosomal disorders:• Fetal chromosomal & structural abnormalities.• Parental balanced translocation (not affects the parents but affect their

fertility).2. Anatomical disorders:• Cervical incompetence (congenital and acquired)• Uterine causes

Submucous fibroids Uterine anomalies Asherman’s syndrome

3. Medical disorders:• Endocrine disorders (DM, thyroid disorders, PCOS & corpus luteum

insufficiency.• Immunological disorders: Anticardiolipin syndrome & SLE.• Thrombophilia:

Acquired: anti-phospholipid syndrome Congenital deficiency of Protein C&S, anti-thrombin III & presence of

factor V Leiden.4. Infections:• ToRCH, esp. CMV.• Genital tract infection (Bacterial vaginosis).

5. Rh-isoimmunization

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Diagnosis:1. History:

• Previous abortions: GA, place & fetal abnormalities.• Medical history: DM, thyroid disorders, PCOS, autoimmune diseases &

thrombophilia.

2. Examination:• General: weight , thyroid & hair distribution• Pelvic: cervix (length & dilatation) & uterine size.

3. Investigations:For chromosomal disorders:

• Parental karyotyping: Parental balanced translocation.• Fetal karyotyping: Fetal chromosomal anomalies.

For anatomical disorders:• TV/US: fibroids, cervical incompetence & PCOS.• Hysteroscopy or HSG: fibroids, cervical incompetence, uterine anomalies

& Asherman's syndrome.For medical disorders:

• Blood grouping & indirect Coomb’s test in Rh –ve women• Endocrinal screening: Blood sugar, TFT & LH /FSH ratio• Immunological screening: Anti anticardiolipine Abs & lupus inhibitor.• Thrombophilia screening: Protein C & S, antithrombin III levels, factor V

Leiden, APTT & PT.Infection screening:

• High vaginal & cervical swabs• TORCH profile (scientifically is not necessary)

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Management:1. Idiopathic:

• Support & good antenatal care, the chance of successful spontaneous pregnancy is about 60-70%.

• Advice: stop smoking & alcohol intake, decrease physical activity• Tender loving care• Drug therapy

i. Progesterone & HCG: once she gets pregnant, start from the luteal phase & up to 12 weeks.

ii. Low dose aspirin (75 mg/day) start from the diagnosis of pregnancy (4th -5th wk) & up to 37wks.

iii. LMWH (low molecular weight heparin) (20-40 mg/day) subcutaneously start from the diagnosis of fetal heart activity (7th wk) & up to 37 wks

2. Endocrine disorders• Control DM and thyroid disorders before pregnancy.• PCOS: ovulation induction drugs, ovarian drilling or IVF.• Corpus luteum insufficiency: progesterone or hCG.

3. Anti-cardiolipin syndrome:• Low dose aspirin (75 mg/day) & prednisilone (20-30 mg /day)• Starting when pregnancy is diagnosed till 37 weeks.

4. Thrombophilia:• Low dose aspirin (75 mg/day) starting when pregnancy is diagnosed and• LMWH (20-40 mg/day) starting when fetal heart activity diagnosed & to

continue both till 37 weeks.5. Uterine disorders:

• Cervical cerclage in cervical incompetence, best time at 14w GA• Myomectomy in submucus fibroid• Excision of uterine septum in septate & subseptate uterus• Adhesolysis in Asherman's syndrome.

6. Infection: treatment of the genital tract infection.7. Rh-isoimmunization: Repeated intrauterine transfusion8. Parental balanced translocation

• Explain the risk of fetal chromosomal disorders (30%)• Encourage to try again or adoption.

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