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Monday, August 11, 2025

Miscarriage


Introduction
Miscarriage, also known as spontaneous abortion, is the loss of a pregnancy before the fetus reaches viability, generally defined as before 20–24 weeks of gestation (varies slightly by jurisdiction). It is the most common complication of early pregnancy and may occur due to genetic, structural, hormonal, infectious, or immune-related factors. Miscarriages can be emotionally distressing, requiring both medical and psychological support.

Epidemiology

  • Occurs in approximately 10–20% of clinically recognized pregnancies.

  • Risk is higher in older mothers, particularly above 35 years of age.

  • Many miscarriages happen before a woman is aware of the pregnancy, often appearing as a delayed or heavy period.

Causes and Risk Factors

Genetic and Chromosomal Abnormalities

  • Responsible for about 50–70% of early miscarriages.

  • Most commonly due to random aneuploidies (e.g., trisomy, monosomy X).

Maternal Health Conditions

  • Uncontrolled diabetes mellitus.

  • Thyroid disorders (hypo- or hyperthyroidism).

  • Polycystic ovary syndrome (PCOS).

  • Autoimmune conditions (e.g., antiphospholipid syndrome).

Uterine and Cervical Abnormalities

  • Uterine septum, fibroids, adhesions (Asherman’s syndrome).

  • Cervical insufficiency.

Infections

  • Listeria, toxoplasmosis, cytomegalovirus, rubella, syphilis, chlamydia.

Lifestyle and Environmental Factors

  • Smoking, alcohol, illicit drug use.

  • High caffeine intake (>200 mg/day).

  • Exposure to radiation, heavy metals, certain chemicals.

Other Risk Factors

  • Advanced maternal age.

  • Previous history of miscarriage.

  • Trauma or severe systemic illness.

Classification of Miscarriage

  1. Threatened Miscarriage

    • Vaginal bleeding in early pregnancy, closed cervix, fetus alive on ultrasound.

    • Pregnancy may continue.

  2. Inevitable Miscarriage

    • Vaginal bleeding with dilated cervix; miscarriage will occur.

  3. Incomplete Miscarriage

    • Some pregnancy tissue has passed, some remains in the uterus.

  4. Complete Miscarriage

    • All pregnancy tissue has passed; uterus empty on ultrasound.

  5. Missed Miscarriage

    • Fetus has died but tissue remains in the uterus; no symptoms initially.

  6. Recurrent Miscarriage

    • Three or more consecutive pregnancy losses before viability.

Clinical Features

Symptoms

  • Vaginal bleeding (light spotting to heavy bleeding with clots).

  • Abdominal cramping or pelvic pain.

  • Passage of tissue.

  • Absence of pregnancy symptoms (in missed miscarriage).

Signs

  • Closed cervix (threatened miscarriage).

  • Dilated cervix (inevitable or incomplete miscarriage).

  • Uterus size smaller than gestational age in missed miscarriage.

Diagnosis

History and Examination

  • Duration and severity of bleeding.

  • Presence of pain or tissue passage.

  • Previous obstetric history.

Investigations

  • Ultrasound: Transvaginal preferred for early pregnancy assessment.

  • Serum beta-hCG: Serial measurements to assess progression or decline.

  • Blood type and Rh factor: Important for Rh-negative women (Rh immunoglobulin prophylaxis).

  • Additional tests for recurrent miscarriage: karyotyping, thrombophilia screening, hormonal profile, uterine imaging.

Management

Management depends on the type of miscarriage, gestational age, symptoms, and patient preference.

1. Expectant Management

  • Allow natural passage of tissue.

  • Suitable for stable patients with incomplete or missed miscarriage.

  • Follow-up with ultrasound to confirm complete evacuation.

2. Medical Management

Used to induce expulsion of retained tissue.

  • Misoprostol: 800 micrograms vaginally or orally as a single dose; may repeat after 3–7 days if incomplete.

  • Mifepristone (where available): 200 mg orally, followed 24–48 hours later by misoprostol as above.

3. Surgical Management

Indicated if heavy bleeding, infection, haemodynamic instability, or patient preference.

  • Manual Vacuum Aspiration (MVA) or Suction Curettage (D&C).

4. Supportive Measures

  • Analgesics: Paracetamol 500–1000 mg every 4–6 hours (max 4 g/day), Ibuprofen 400 mg every 6–8 hours with food.

  • Antibiotics if evidence of infection: e.g., doxycycline 100 mg twice daily for 7 days (with metronidazole if anaerobic infection suspected).

  • Rh immunoglobulin: For Rh-negative women – 50 micrograms (first trimester) or 300 micrograms (after 12 weeks) IM within 72 hours.

  • Psychological support and counselling.

Complications

  • Hemorrhage.

  • Infection (septic miscarriage).

  • Asherman’s syndrome (after surgical evacuation).

  • Psychological distress, depression, anxiety.

Prognosis

  • Most women go on to have successful pregnancies after a single miscarriage.

  • Risk of recurrence increases with number of prior miscarriages.

  • Prognosis improves with treatment of underlying causes in recurrent miscarriage.



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