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Miscarriage (Early Pregnancy Loss)

BASICS

Description

  • Also known as early pregnancy loss (EPL) or spontaneous abortion (SAb)
  • Defined as loss before 13 weeks’ gestational age (WGA)

Related terms: - Anembryonic gestation, complete abortion, embryonic/fetal demise, incomplete abortion - Induced abortion, inevitable abortion, threatened abortion, septic abortion - Synonym: SAb - DSM terms like missed abortion and blighted ovum are being phased out

EPIDEMIOLOGY

  • Incidence:
  • Threatened abortion: 20–25% of clinical pregnancies
  • EPL: 10–15% of recognized pregnancies; up to 30% with biochemical evidence
  • Age-related: risk doubles after age 40

ETIOLOGY AND PATHOPHYSIOLOGY

  • Chromosomal anomalies (50%): trisomies, triploidy, monosomies
  • Maternal factors: uterine defects, infections, endocrine/metabolic/hypercoagulable states
  • Genetics: 50% of 1st-trimester EPLs involve chromosomal abnormalities

RISK FACTORS

  • Advanced maternal age
  • Uterine anomalies, chronic diseases, endocrine disorders, obesity
  • Smoking, alcohol, cocaine, infection, luteal phase defect

PREVENTION

  • No consistent benefit from aspirin, anticoagulants, vitamins, hCG, or bed rest
  • Oral progestogens may reduce EPL risk in threatened abortion
  • In APS, heparin + aspirin reduces EPL risk

DIAGNOSIS

History

  • Suspect in any reproductive-aged woman with vaginal bleeding
  • Note: LMP, abdominal pain, ROM, genetic/family history, prior EPL or ectopic

Physical Exam

  • Vitals: assess hemodynamic stability
  • Abdominal exam
  • Speculum and bimanual exam: evaluate cervix, uterine size, adnexa

Differential Diagnosis

  • Ectopic pregnancy (rule out immediately)
  • Subchorionic bleeding, cervical conditions, molar pregnancy, hCG tumors

Diagnostic Tests

  • Quantitative hCG: should rise ≥53% in 48h if viable
  • US (TVUS preferred): assess fetal viability, rule out ectopic
  • CBC, gonorrhea/chlamydia cultures

TVUS signs of nonviable pregnancy: - No heartbeat in 7-mm fetal pole - No embryo in 25-mm gestational sac - No growth over 1 week - Disappearance of previously seen IUP

Follow-Up

  • Weekly hCG if IUP not seen and hCG <2,000
  • US once threshold hCG is reached
  • Warn about ectopic signs
  • If hCG rise <53%, consider methotrexate

TREATMENT

General Measures

  • Discuss contraception; ovulation resumes quickly
  • Expectant management effective in 90% of incomplete abortion
  • Consider if symptoms of impending loss are present

Medication

  • Misoprostol 800 mcg vaginally
  • Alternative: 600 mcg SL q3h × 3 (WHO)
  • Addition of mifepristone improves efficacy to ~84%
  • Side effects: pain, cramping, diarrhea
  • Stable patients preferring non-surgical approach

Second Line

  • Treat anemia if present (e.g., iron)

Referral

  • Monitor for pathologic grief up to 1 year

PROCEDURES

Surgical Management

  • D&C or manual vacuum aspiration (MVA)
  • Indications: septic abortion, bleeding, persistent IUP, preference
  • MVA preferred over curettage (less painful, safer)
  • Consider doxycycline 200 mg prophylaxis

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Chinese herbal medicine may show benefit, but data is low quality

INPATIENT/NURSING

  • If unstable, initiate IV fluids and/or blood products

ONGOING CARE

Follow-Up

  • Reevaluate at 2–6 weeks: bleeding, menses, grief, contraception
  • No need to follow hCG if normal menses resumes
  • Confirm expulsion by US or hCG post-medical treatment

Contraception

  • Offer immediate IUD if not desiring pregnancy
  • If pregnancy desired, no delay necessary

Diet

  • NPO if undergoing D&C under GA

Patient Education

PROGNOSIS

  • Excellent once bleeding is controlled
  • Recurrent EPL: 70% have successful pregnancy with proper care

COMPLICATIONS

  • D&C risks: perforation, adhesions, infection
  • Retained products, especially with incomplete abortion

ICD-10

  • O03.9: Complete/unspecified spontaneous abortion without complication
  • O03.4: Incomplete spontaneous abortion
  • O02.1: Missed abortion

Clinical Pearls

  • Always rule out ectopic in pregnancy with bleeding/pain
  • Patient’s preference guides management choice
  • Medical, expectant, surgical approaches have similar outcomes