Miscarriage

RUTHRA
B.SC OTAT
 DEFINITION

• Abortion is the expulsion or extraction from its mother of

an embryo or fetus weighing 500 g or less when it is not
capable of independent survival
• This 500 g of fetal development is attained approximately
at 22 weeks (154 days) of gestation.
• The expelled embryo or fetus is called abortus.
• The word miscarriage is the recommended terminology for
spontaneous abortion.
• About 75% miscarriages occur before the 16th week and of
these about 80% occur before the 12th week of pregnancy.
CLASSIFICATION OF ABORTION
 COMMON CAUSES OF MISCARRIAGE:

• First trimester: (1) Genetic factors (50%). (2) Endocrine

disorders (LPD, thyroid abnormalities, diabetes). (3)
Immunological disorders (autoimmune and
alloimmune). (4) Infection. (5) Unexplained.
• Second trimester: (1) Anatomic abnormalities—(a)
Cervical incompetence (congenital or acquired). (b)
Müllerian fusion defects (bicornuate uterus, septate
uterus). (c) Uterine synechiae. (d) Uterine fibroid. (2)
Maternal medical illness. (3) Unexplained.
 MECHANISM OF MISCARRIAGE

• In the early weeks, death of the ovum occurs first,

followed by its expulsion.
• In the later weeks, maternal environmental factors are
involved leading to expulsion of the fetus which may
have signs of life but is too small to survive
• Before 8 weeks: The ovum, surrounded by the villi with
the decidual coverings, is expelled out intact.
Sometimes, the external os fails to dilate so that the
entire mass is accommodated in the dilated cervical
canal and is called cervical miscarriage
Contd….

• Between 8 weeks and 14 weeks: Expulsion of the fetus

commonly occurs leaving behind the placenta and the
membranes. A part of it may be partially separated with
brisk hemorrhage or remains totally attached to the
uterine wall
• Beyond 14th week: the process of expulsion is similar to
that of a “mini labor”. the fetus is expelled first followed
by expulsion of the placenta after a varying interval.
 THREATENED MISCARRIAGE

• It is a clinical entity where the process of miscarriage has started

but has not progressed to a state from which recovery is impossible
CLINICAL FEATURES:
The patient, having symptoms suggestive of pregnancy, complains
of:
(1) Bleeding per vaginam is usually slight and may be brownish or
bright red in color. On rare occasion, the bleeding may be brisk,
especially in the late second trimester. The bleeding usually stops
spontaneously.
(2) Pain: Bleeding is usually painless but there may be mild
backache or dull pain in lower abdomen. Pain appears usually
following hemorrhage.
INVESTIGATIONS

• (1) Blood—for hemoglobin, hematocrit, ABO and Rh grouping. Blood

transfusion may be required if abortion becomes inevitable and anti-D
gamma globulin
• (2) Urine for immunological test of pregnancy is not helpful as the test
remains positive for a variable period even after the fetal death.
Ultrasonography (TVS) findings may be:
(1) A well-formed gestation ring with central echoes from the embryo
indicating healthy fetus.
(2) Observation of fetal cardiac motion. With this there is 98% chance of
continuation of pregnancy.
(3) A blighted ovum is evidenced by loss of definition of the gestation
sac, smaller mean gestational sac diameter, absent fetal echoes and
absent fetal cardiac movements
 TREATMENT

• Rest: The patient should be in bed for few days until

bleeding stops. Prolonged restriction of activity has got
no therapeutic value.
• Drugs: Relief of pain may be ensured by diazepam 5 mg
tablet twice daily.
• There is some evidence that treatment with
progesterone improves the outcome. Progesterone
induces immunomodulation to shift the Th-1
(proinflammatory response) to Th-2 (antiinflammatory
response). Use of hCG is not prefered
 ADVICE ON DISCHARGE

• The patient should limit her activities for at least 2 weeks and avoid
heavy work.
• Coitus is avoided during this period. She should be followed up with
repeat sonography at 3–4 weeks’ time.
• The following indicates unfavorable outcome: falling serum beta-
hCG, decreasing size of the fetus, irregular shape of the gestational
sac or decreasing fetal heart rate
• In isolated spontaneous threatened miscarriage, the following events
may occur: (1) In about two-thirds, the pregnancy continues beyond
28 weeks. (2) In the rest, it terminates either as inevitable or missed
miscarriage. If the pregnancy continues, there is increased frequency
of preterm labor, placenta previa, intrauterine growth restriction of
the fetus and fetal anomalies.
 INEVITABLE MISCARRIAGE

• It is the clinical type of abortion where the changes have

progressed to a state from where continuation of pregnancy is
impossible.
CLINICAL FEATURES:
The patient, having the features of threatened miscarriage,
develops the following manifestations:
(1) Increased vaginal bleeding.
(2) Aggravation of pain in the lower abdomen which may be
colicky in nature.
(3) Internal examination reveals dilated internal os of the
cervix through which the products of conception are felt
 INEVITABLE MISCARRIAGE

• On occasion, the features may develop quickly without

prior clinical evidence of threatened miscarriage. In the
second trimester, however, it may start with rupture of
the membranes or intermittent lower abdominal pain
(mini labor).
• MANAGEMENT is aimed: (a) to accelerate the process of
expulsion. (b) to maintain strict asepsis
• Excessive bleeding should be promptly controlled by
administering Methergine 0.2 mg if the cervix is dilated
and the size of the uterus is less than 12 weeks. The
blood loss is corrected by intravenous (IV) fluid therapy
and blood transfusion.
 Active Treatment

• Before 12 weeks: (1) Dilatation and evacuation followed

by curettage of the uterine cavity by blunt curette using
analgesia or under general anesthesia. (2) Alternatively,
suction evacuation followed by curettage is done.
• After 12 weeks: (1) the uterine contraction is
accelerated by oxytocin drip (10 units in 500 mL of
normal saline) 40–60 drops per minute. If the fetus is
expelled and the placenta is retained, it is removed by
ovum forceps, if lying separated. If the placenta is not
separated, digital separation followed by its evacuation
is to be done under general anesthesia.
 COMPLETE MISCARRIAGE

• When the products of conception are expelled asa

whole ,it is called complete miscarriage.
CLINICAL FEATURES:
There is history of expulsion of a fleshy mass per
vaginam followed by: (1) Subsidence of abdominal pain.
(2) Vaginal bleeding becomes trace or absent. (3) Internal
examination reveals: (a) Uterus is smaller than the period
of amenorrhea and a little firmer. (b) Cervical os is closed
(c) Bleeding is trace. (4) Examination of the expelled
fleshy mass is found complete. (5) Ultrasonography
(TVS): reveals empty uterine cavity.
 COMPLETE MISCARRIAGE

• MANAGEMENT: Transvaginal sonography is useful to

see that uterine cavity is empty, otherwise evacuation
of uterine curettage should be done.
• Rh-NEGATIVE WOMEN: A Rh-negative patient without
antibody in her system should be protected by anti-D
gamma globulin 50 μg or 100 μg intramuscularly in
cases of early miscarriage or late miscarriage
respectively within 72 hours. However, anti-D may not
be required in a case with complete miscarriage before
12 weeks of gestation where no instrumentation has
been done
 INCOMPLETE MISCARRIAGE

• When the entire products of conception are not expelled, instead a

part of it is left inside the uterine cavity, it is called incomplete
miscarriage. This is the commonest type met amongst women,
hospitalized for miscarriage complications.
CLINICAL FEATURES:
History of expulsion of a fleshy mass per vaginam followed by: (1)
Continuation of pain in lower abdomen. (2) Persistence of vaginal
bleeding. (3) Internal examination reveals— (a) uterus smaller than
the period of amenorrhea (b) patulous cervical os often admitting tip
of the finger and (c) varying amount of bleeding. (4) on
examination, the expelled mass is found incomplete (5)
Ultrasonography—reveals echogenic material (products of
conception) within the cavity.
 INCOMPLETE MISCARRIAGE

• COMPLICATIONS: The retained products may cause: (a) profuse

bleeding (b) sepsis or (c) placental polyp
• MANAGEMENT:In recent cases—evacuation of the retained products
of conception (ERCP) is done. She should be resuscitated before any
active treatment is undertaken.
• Early abortion: Dilatation and evacuation under analgesia or general
anesthesia is to be done. Evacuation of the uterus may be done using
MVA(manual vacuum aspiration) also
• Late abortion: The uterus is evacuated under general anesthesia and
the products are removed by ovum forceps or by blunt curette. In late
cases, dilatation and curettage operation is to be done to remove the
bits of tissues left behind. The removed materials are subjected to a
histological examination.
• Medical management of incomplete miscarriage may be
done. Tablet misoprostol 200 Pg is used vaginally every
4 hours. Compared to surgical method, complications
are less with medical method.
 MISSED MISCARRIAGE

• When the fetus is dead and retained inside the uterus

for a variable period, it is called missed miscarriage or
early fetal demise
PATHOLOGY:
The causes of prolonged retention of the dead fetus in
the uterus are not clear. Beyond 12 weeks, the retained
fetus becomes macerated or mummified. The liquor
amnii gets absorbed and the placenta becomes pale, thin
and may be adherent. Before 12 weeks, the pathological
process differs when the ovum is more or less completely
surrounded by the chorionic villi.
• CLINICAL FEATURES: The patient usually presents with features of
threatened miscarriage followed by:
• (1) Persistence of brownish vaginal discharge.
• (2) Subsidence of pregnancy symptoms.
• (3) Retrogression of breast changes.
• (4) Cessation of uterine growth which in fact becomes smaller in size. (5)
Nonaudibility of the fetal heart sound even with Doppler ultrasound if it
had been audible before.
• (6) Cervix feels firm.
• (7) Immunological test for pregnancy becomes negative.
• (8) Realtime ultrasonography reveals an empty sac early in the
pregnancy or the absence of fetal cardiac motion and fetal movements.
 COMPLICATIONS

• The complications of the missed miscarriage are those

mentioned in intrauterine fetal death
• Blood coagulation disorders are less likely to occur in
missed miscarriage.
• Expectant management—Many women expel the
conceptus spontaneously
• Medical management: Prostaglandin E1 (misoprostol)
800 mg vaginally in the posterior fornix is given and
repeated after 24 hours if needed. Expulsion usually
occurs within 48 hours.
 COMPLICATIONS

• Suction evacuation or dilatation and evacuation is done

either as a definitive treatment or it can be done when
the medical method fails. The risk of damage to the
uterine walls and brisk hemorrhage during the operation
should be kept in mind.
• Prostaglandin E1 analog (misoprostol) 200 Pg tablet is
inserted into the posterior vaginal fornix every 4 hours
for a maximum of 5 such.
• Oxytocin—10–20 units of oxytocin in 500 mL of normal
saline at 30 drops/min is started. If fails, escalating dose
of oxytocin to the maximum of 200 mIU/min may be
used with monitoring.
 TREATMENT

• Many patients need surgical evacuation following

medical treatment. Following medical treatment,
ultrasonography should be done to document empty
uterine cavity. Otherwise evacuation of the retained
products of conception (ERPC) should be done.
• Dilatation and evacuation is done once the cervix
becomes soft with use of PGE1 . Otherwise cervical
canal is dilated using the mechanical dilators or by
laminaria tent Evacuation of the uterine cavity is done
thereafter slowly
 SEPTIC ABORTION

• Any abortion associated with clinical evidences of

infection of the uterus and its contents is called septic
abortion
• . Although clinical criteria vary, abortion is usually
considered septic when there are: (1) rise of
temperature of at least 100.4°F (38°C) for 24 hours or
more, (2) offensive or purulent vaginal discharge and
(3) other evidences of pelvic infection such as lower
abdominal pain and tenderness
• In the majority of cases, the infection occurs following
illegal induced abortion but infection can occur even
after spontaneous abortion
 MODE OF INFECTION

• The microorganisms involved in the sepsis are usually

those normally present in the vagina (endogenous)
• Mixed infection is more common. The increased
association of sepsis in unsafe induced abortion is due
to the fact that: (1) proper antiseptic and asepsis are
not taken, (2) incomplete evacuation and (3)
inadvertent injury to the genital organs and adjacent
structures, particularly the bowels.
CLINICAL FEATURES
 INVESTIGATIONS

• (1) Cervical or high vaginal swab is taken prior to

internal examination
• (2) Blood for hemoglobin estimation, total and
differential count of white cells, ABO and Rh grouping.
• (3) Urine analysis including culture.
 COMPLICATIONS

• Immediate: Most of the fatal complications are

associated with illegally induced abortions of grade III
type.
• Hemorrhage related due to abortion process and also
due to the injury inflicted during the interference.
• Injury may occur to the uterus and also to the adjacent
structures particularly the bowels
• Spread of infection leads to: Generalized peritonitis,
Endotoxic shock, Acute renal failure, atelectasis, ARDS ,
thrombophlebitis.
 PREVENTION

• (1) To boost up family planning acceptance in order to

curb the unwanted pregnancies.
• (2) Rigid enforcement of legalized abortion in practice
and to curb the prevalence of unsafe abortions.
Education, motivation and extension of the facilities are
sine qua non to get the real benefit out of it
• (3) To take antiseptic and aseptic precautions either
during internal examination or during operation in
spontaneous abortion
 RECURRENT MISCARRIAGE

• Recurrent miscarriage is defined as a sequence of three or

more consecutive spontaneous abortion before 20 weeks.
Some, however, consider two or more as a standard. It may
be primary or secondary (having previous viable birth). A
woman procuring three consecutive induced abortions is not a
habitual aborter.
• ETIOLOGY:
• The causes of recurrent abortion are complex and most often
obscure. More than one factor may operate in a case. Factors
may be recurrent or nonrecurrent. There are known specific
factors which are responsible for early or late abortion and
they are grouped accordingly.
• Chronic maternal illness—such as uncontrolled diabetes
with arteriosclerotic changes, hemoglobinopathies,
chronic renal disease. Inflammatory bowel disease,
systemic lupus erythematosus.
• Infection—Syphilis, toxoplasmosis and listeriosis may
be responsible in some cases.
• Unexplained.
INVESTIGATIONS FOR RECURRENT
MISCARRIAGE
• (1) Blood-glucose (fasting and postprandial), VDRL, thyroid function test, ABO
and Rh grouping (husband and wife), toxoplasma antibodies IgG and IgM.
• (2) Autoimmune screening—lupus anticoagulant and anticardiolipin antibodies
• (3) Serum LH on D2 /D3 of the cycle.
• (4) Ultrasonography—to detect congenital malformation of uterus, polycystic
ovaries and uterine fibroid.
• (5) Hysterosalpingography in the secretory phase to detect—cervical
incompetence, uterine synechiae and uterine malformation.
• (6) This is supported by hysteroscopy and/or laparoscopy.
• (7) Karyotyping (husband and wife).
• (8) Endocervical swab to detect chlamydia, mycoplasma and bacterial
vaginosis.
TREATMENT

• To alleviate anxiety and to improve the psychology

• Hysteroscopic resection
• Uterine unification operation (metroplasty) is done for
cases with bicornuate uterus.
• Women with PCOS are best treated for their insulin
resistance, hyperinsulinemia and hyperandrogenemia.
Metformin therapy is helpful
• The chance of successful pregnancy is about 70–80%
with an effective therapy. Reassurance and tender
loving care are very much helpful
 INDUCTION OF ABORTION

• Deliberate termination of pregnancy either by medical

or by surgical method before the viability of the fetus is
called induction of abortion.
• The induced abortion may be legal or illegal (criminal).
• There are many countries in the globe where the
abortion is not yet legalized. In India, the abortion was
legalized by “Medical Termination of Pregnancy Act” of
1971, and has been enforced in the year April 1972. The
provisions of the act have been revised in 1975.
MEDICAL TERMINATION OF PREGNANCY
(MTP)
• Since legalization of abortion in India, deliberate induction of
abortion by a registered medical practitioner in the interest of
mother’s health and life is protected under the MTP Act. The
following provisions are laid down:
• The continuation of pregnancy would involve serious risk of life or
grave injury to the physical and mental health of the pregnant
woman.
• There is a substantial risk of the child being born with serious
physical and mental abnormalities so as to be handicapped in life
• When the pregnancy is caused by rape, both in cases of major and
minor girl and in mentally imbalanced women.
• Pregnancy caused as a result of failure of a contraceptive
MTP
• In practice, the following are the indications for termination under the MTP
Act:
• To save the life of the mother (Therapeutic or Medical termination): the
indications are limited and scarcely justifiable nowadays except in the
following cases:
• (i) Cardiac diseases (Grade III and IV) with history of decompensation in the
previous pregnancy or in between the pregnancies.
• (ii) Chronic glomerulonephritis.
• (iii) Malignant hypertension.
• (iv) Intractable hyperemesis gravidarum.
• (v) Cervical or breast malignancy.
• (vi) Diabetes mellitus with retinopathy.
• (vii) Epilepsy or psychiatric illness with the advice of a psychiatrist.
• Eugenic: Structural (Anencephaly),
chromosomal(Down’s syndrome) or genetic
(Hemophilia) abnormalities of the fetus.
• ii. When the fetus is likely to be deformed due to action
of teratogenic drugs (warfarin) or radiation exposure
(>10 rad) in early pregnancy.
• iii. Rubella, a viral infection affecting in the First
trimester, is an indication for termination
• In the revised rules, a registered medical practitioner is qualified to
perform an MTP provided: (a) One has assisted in at least 25 MTP in an
authorized center and having a certIFcate.
• (b) One has got 6 months house surgeon training in obstetrics and
gynecology.
• (c) One has got diploma or degree in obstetrics and gynecology.
• Pregnancy can only be terminated on the written consent of the woman.
Husband‘s consent is not required.
• Pregnancy in a minor girl (below the age of 18 years) or lunatic cannot
be terminated without written consent of the parents or legal guardian.
• Termination is permitted up to 20 weeks of pregnancy. When the
pregnancy exceeds 12 weeks, opinion of two medical practitioners is
required
 MTP

• VACUUM ASPIRATION (MVA/EVA) is done up to 12 weeks with minimal

cervical dilatation. It is performed as an outpatient procedure using a
plastic disposable cannula (up to 12 mm size) and a 60 mL plastic
(double valve) syringe
• It is quicker (15 minutes), effective (98–100%), less traumatic and
safer than dilatation, evacuation and curettage
• DILATATION AND EVACUATION: Rapid method: This can be done as an
outdoor procedure with diazepam sedation and paracervical block
anesthesia
• Slow method: : Slow dilatation of the cervix is achieved by inserting
laminaria tents (hygroscopic osmotic dilators) into the cervical canal
(synthetic dilators like Dilapan, Lamicel are also used). It is is
followed by evacuation of the uterus after 12 hours.
 MTP

• OXYTOCIN: High-dose oxytocin as a single agent can be

used for second trimester abortion.
• It is effective in 80% of cases. It can be used with
intravenous normal saline along with any of the
medications used either intra-amniotic or extra-amniotic
space in an attempt to augment the abortion process.
• The drip rate can be increased up to 50 milliunits or
more per minute. Currently high dose (up to 300 units in
500 mL of dextrose saline) is favored.
 MTP

• It is difficult to terminate pregnancy in the second

trimester with reasonable safety as in first trimester.
The following surgical methods may be employed.
• Between 13 weeks and 15 weeks: Dilatation and
Evacuation in the midtrimester is less commonly done.
Pregnancies at 13–14 menstrual weeks are evacuated
• The procedure may need to be performed under
ultrasound guidance to reduce the risk of complications
Simultaneous use of oxytocin infusion is useful.
 MTP

• Extra-amniotic: Extra-amniotic instillation of 0.1% ethacridine

lactate (estimated amount is 10 mL/ week) is done
transcervically through a No. 16 Foley‘s catheter. The catheter is
passed up the cervical canal for about 10 cm above the internal
os between the membranes and myometrium and the balloon is
inflated (10 mL) with saline. It is removed after 4 hours
• Isotonic saline is infused extra-amniotically using a transcervical
catheter balloon. Results are similar to that of Foley’s catheter
use alone
• Contraindications: It should not be used in presence of
cardiovascular or renal lesion or in severe anemia because of
sodium load.
 COMPLICATIONS OF MTP

• There is no universally safe and effective method which

is applicable to all cases.
• However, the complications are much less (5%) if
termination is done before 8 weeks by MVA or suction
evacuation/ curette. The complications are about five
times more in midtrimester termination.
• Use of PG analogs and mifepristone has made second
trimester MTP effective and safe. The complications are
either related to the methods employed or to the
abortion process.
 COMPLICATIONS OF MTP

• Prostaglandins—intractable vomiting, diarrhea, fever,

uterine pain and cervicouterine injury.
• Oxytocin—water intoxication and rarely convulsions
• Saline—hypernatremia, pulmonary edema, endotoxic
shock, Disseminated intravascular coagulation (DIC),
renal failure, cerebral hemorrhage
• Gynecological complications include—(a) menstrual
disturbances, (b) chronic pelvic in$ammation, (c)
infertility due to cornual block, (d) scar endometriosis
(1%) and (e) uterine synechiae leading to secondary
amenorrhea.
 COMPLICATIONS OF MTP

• Obstetrical complications include—(a) recurrent midtrimester

abortion due to cervical incompetence, (b) ectopic pregnancy
(threefold increase), (c) preterm labor, (d) dysmaturity, (e)
increased perinatal loss, (f) rupture uterus, (g) Rh-
isoimmunization in Rh-negative women, if not prophylactically
protected with immunoglobulin and (h) failed abortion and
continued pregnancy
• Failed abortion, continued pregnancy and ectopic pregnancy:
Pregnancy may continue following MVA (in spite of
histologically proven villi). When no chorionic villi are found on
tissue examination, ectopic pregnancy need to be excluded by
quantitative serum hCG and vaginal ultrasound.
 COMPLICATIONS OF MTP

• Failed MTP is defined when there is a failure to achieve

TOP within 48 hours. Failed second trimester MTP with
PG analogs and the rate of live birth is 4–10%
• The maternal death is lowest (about 0.6/100,000
procedures) in first trimester termination specially with
MVA and suction evacuation. Concurrent tubectomy
even by abdominal route doubles the mortality rate.
The mortality rate increases five to six times to that of
first trimester. Contrary to the result of the advanced
countries, the mortality from saline method has been
found much higher in India compared to termination by
abdominal hysterotomy with tubectomy