Miscarriage

spontaneous fetal loss before 24 weeks gestation ND </= 500G

causes

• 1st trimester
  • chromosomal abnormalities
  • PCOS
  • APS (antiphospholipid syndrome)
  • endocrine disorder (untreated DM or thyroid disease)
  • uterine abnormalities (submucosal fibroid, subseptate uterine, endometrial polyp)
  • infection: TORCHES

• 2nd trimester
  • Cervical incompetence
  • Asherman syndrome
  • bacterial vaginosis
  • uterine abnormalities (higher in 2nd trimester)
  • thrombophilias
  • infection: TORCHES
  • bactrerial vaginosis

1. threatened miscarriage

• PV bleed
• viable fetus
• os close
• symptoms of pregnancy
• uterus correspond to date

mx:

• ABC
• remove POC at os
• put prostin for priming for cervical os 3hours prior to arrange for ERPOC

2. inevitable miscarriage

• PV bleed (a lot)
• abdominal pain
• os open but no POC seen
• viable fetus
• uterus correspond to date

3. incomplete miscarriage

• PV bleed (a lot)
• abdominal pain
• os open with POC seen
• non viable fetus, thick ET, retained POC in uterus
• uterus smaller than date

4. complete miscarriage

• PV bleed (gush of blood) with POC
• abdominal pain
• os close
• uterus empty, normal endometrial lining
• uterus smaller than date

5. missed miscarriage

• asymptomatic
• os close
• non viable fetus
• uterus smaller than date
• BhCG may still be produce by placenta

mx:

1. repeat US after 7-14 days if in doubt.
2. then arrange for ERPOC.
3. TCA stat if passed out POC, PV bleeding, fever.
4. psychological support and counselling.

6. septic miscarriage

• PV bleeding and discharge
• abdominal pain
• history of amniocentesis
• os open with POC
• cervical motion tenderness
• adnexal tenderness
• uterus smaller than date
• fetus non viable, thick ET, retained POC in uterus

mx: psychological support and counselling

7. recurrent miscarriage

more or equal to 3 consecutive miscarriage

• risk factor
  • woman is ≥35 years of age and the man ≥40 years of age
  • smoking and alcohol
  • antiphospholipid syndrome

mx:

• investigate the cause; DM, thyroid ds, renal ds, SLE
• rule out uterine/cervical abnormalities
• cervical cerclage for cervical incompetence
• Pregnant women with antiphospholipid syndrome should be considered for treatment with low-dose aspirin plus heparin to prevent further miscarriage

resources

Click to access gtg_17.pdf