MISCARRIAGE

10 January 2022 1 By DR. U.J. Agim

The terms miscarriage and abortion are often used interchangeably but what is the most appropriate term for a spontaneous pregnancy loss? If your answer is miscarriage, then you are right. The term miscarriage is considered to be non judgemental while the term abortion is often associated with criminal abortion. Spontaneous miscarriage is a considerable cause of emotional and psychological trauma for patients including symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD) that can last for months. It is defined as the spontaneous loss of a pregnancy prior to viability. The incidence of early pregnancy loss is as high as 3 in 10 chemical pregnancies (urine or blood test confirmed pregnancies), though the incidence decreases to approximately 1 in 10 pregnancies when considering only losses occurring in clinically recognized pregnancies (ultrasound scan confirmed pregnancies).

TYPES OF MISCARRIAGE

Incomplete miscarriage is a pregnancy that is associated with vaginal bleeding, opening of the cervix or mouth of the womb, and passage of product of conception. Usually, the cramps are intense, and the vaginal bleeding is heavy. Patients may describe passage of tissue, or the examiner may observe evidence of tissue passage within the vagina. Ultrasound will show that some of the product of conception are still present in the womb.

Complete miscarriage; there is complete passage of the product of conception, the pain resolves, bleeding reduce, the cervix is closed and scan demonstrate empty womb.

Threatened miscarriage; usually mild bleeding from the womb with mild pain, the cervix is closed with scan demonstrating a viable pregnancy.

Inevitable miscarriage; there is bleeding and pain, the cervix is open with no tissue passed, scan may show a viable or non-viable pregnancy

Missed miscarriage; this is a non-viable pregnancy that is retained in the womb. It might be an incidental finding on scan or the patient might notice her pregnancy is not growing well.

Septic miscarriage; constitutes any of the above miscarriages with infection.

CAUSES OF MISCARRIAGE

Causes of miscarriage includes;

  • Chromosomal abnormalities
  • Maternal disease; antiphospholipid syndrome, polycystic ovarian disease, obesity, diabetes, thyroid disease
  • Medication and substance use; methotrexate, some antiepileptic drugs, cocaine, smoking, caffeine, alcohol
  • Abnormalities of the womb; cervical incompetence (inability of the cervix to retain the fetus due to some defect resulting in a painless cervical opening and subsequent pregnancy loss), fibroid
  • Infection; varicella, rubella, parvovirus B19, Syphilis, cytomegalovirus
  • Environmental factors and exposure; ionizing radiation, Lead, arsenic
  • Placenta causes; Abruptio placenta, placenta previa
  • Maternal stress
  • Advanced maternal age > 35years and advanced paternal age
  • The cause of miscarriage could be unexplained in about 4 to 6 in 10 cases.

SYMPTOMS AND SIGNS OF MISCARRIAGE

Bleeding and lower abdominal cramping are the most common presenting complaints of pregnancy loss. Others are fever, foul-smelly vaginal discharge in cases of septic miscarriage. If ultrasound is available, serum human chorionic gonadotrophin and progesterone have limited utility in the diagnostic evaluation of pregnant women with early pregnancy loss.

COMPLICATIONS OF MISCARRIAGE

The most common complications associated with pregnancy loss are retained product, bleeding and infection. Others are renal failure, pelvic abscess, uterine or gut perforation from surgical treatment and death. These complications can be prevented when help is sort on time and in a health facility with the requisite man power to manage miscarriage.

TREATMENT OF MISCARRIAGE

The treatment of miscarriage depends on the type of miscarriage but also include post abortal care for all types. For complete miscarriage treatment constitute what is known as the post abortal care; treating anaemia or any complications if present, providing contraceptive counselling and services when needed and other reproductive services like pap smear or screening for sexually transmitted diseases.

If a diagnosis of missed or incomplete miscarriage is made, the options of management include surgical, medical or expectant management. Surgery was the standard of care in the past because of the concern of retained product associated with medical and expectant management. For missed, incomplete, or inevitable abortion presenting before 13 weeks’ gestation, treatment may include misoprostol as an alternative to surgery or performance of suction dilation and curettage. Surgical management is achieved using electric or manual vacuum aspiration trans-vaginally through an appropriately dilated cervix at a gestational age <15 weeks. Surgical treatment will shorten treatment duration, associated with less pain and blood loss. However, in less experience hand, surgical treatment might result in perforation of the womb or adhesion formation in the womb due to excessive curettage of the womb. Unless a patient present with incomplete or inevitable miscarriage, pre-operative cervical softening and dilatation is common prior to surgical evacuation.

Medical treatment eliminate the risk associated with surgical treatment however, it is associated with prolonged duration of treatment, increase pain and blood loss with subsequent blood transfusion and it attendant risk. Patient with recurrent miscarriage (≥ 2 consecutive pregnancy losses) requires proper evaluation to identify the possible cause before another attempt at conception should be made. Miscarriage due to cervical incompetence will require insertion of a cervical cerclage to help retain the pregnancy.