Early pregnancy loss

General Gynecology

Clinicals - History

Fact Explanation
Per-vaginal bleeding Miscarriage is defined as pregnancy loss under 24 weeks’ gestation. Spontaneous miscarriage is further classified according to clinical presentation and USS findings to threatened miscarriage, inevitable miscarriage, incomplete miscarriage, complete miscarriage & missed miscarriage. The incidence of miscarriage is 10-20% of all pregnancies. Early pregnancy loss is most commonly seen in the 1st trimester but can occur in the 2nd trimester as well. Per-vaginal bleeding
Miscarriage is defined as pregnancy loss under 24 weeks’ gestation. Spontaneous miscarriage is further classified according to clinical presentation and USS findings to threatened miscarriage, inevitable miscarriage, incomplete miscarriage, complete miscarriage & missed miscarriage. The incidence of miscarriage is 10-20% of all pregnancies. Early pregnancy loss is most commonly seen in the 1st trimester but can occur in the 2nd trimester as well.
Lower abdominal pain The patient may experience cramping type lower abdominal pain due to uterine spasms. Pain & per-vaginal bleeding may be resolved in complete miscarriage while absent in missed miscarriage. Lower abdominal pain
The patient may experience cramping type lower abdominal pain due to uterine spasms. Pain & per-vaginal bleeding may be resolved in complete miscarriage while absent in missed miscarriage.
Passage of tissue parts per-vaginally In incomplete and complete miscarriage products of conception will be passed per-vaginally. Passage of tissue parts per-vaginally
In incomplete and complete miscarriage products of conception will be passed per-vaginally.
Fever Due to the development of infection of the products of conception. Fever
Due to the development of infection of the products of conception.
The patient can present in a collapsed state Hypovolaemic shock can develop due to heavy per-vaginal bleeding. The patient can present in a collapsed state
Hypovolaemic shock can develop due to heavy per-vaginal bleeding.
Missed miscarriage is diagnosed by ultrasound scan (USS) where the woman is asymptomatic Missed miscarriage is the ultrasonic diagnosis of miscarriage in the absence of symptoms. The patient may present with or without pain & bleeding. She may experience loss of pregnancy symptoms. Missed miscarriage is diagnosed by ultrasound scan (USS) where the woman is asymptomatic
Missed miscarriage is the ultrasonic diagnosis of miscarriage in the absence of symptoms. The patient may present with or without pain & bleeding. She may experience loss of pregnancy symptoms.
Some patients may present with recurrent miscarriages Recurrent miscarriage is defined as three or more consecutive miscarriages. Etiological agents include antiphospholipid syndrome, genetic causes, fetal chromosomal abnormalities, uterine anatomical abnormalities, thrombophilic diseases, cervical incompetence (late miscarriage) etc. Some patients may present with recurrent miscarriages
Recurrent miscarriage is defined as three or more consecutive miscarriages. Etiological agents include antiphospholipid syndrome, genetic causes, fetal chromosomal abnormalities, uterine anatomical abnormalities, thrombophilic diseases, cervical incompetence (late miscarriage) etc.

Clinicals - Examination

Fact Explanation
General examination: Features of shock – Increased pulse rate, low blood pressure, low urine output Due to heavy per-vaginal bleeding. General examination: Features of shock – Increased pulse rate, low blood pressure, low urine output
Due to heavy per-vaginal bleeding.
General examination: Fever Infection can develop as a complication. General examination: Fever
Infection can develop as a complication.
Abdominal examination The patient may exhibit mild lower abdominal tenderness. Abdominal examination
The patient may exhibit mild lower abdominal tenderness.
Speculum examination This is used to assess whether the cervical os is open / closed. Cervical os is closed in threatened miscarriage while it is open in inevitable miscarriage, incomplete miscarriage. A closed cervix is observed in complete & missed miscarriage. Visualization of products of conception and blood at the external os can also be made. Speculum examination
This is used to assess whether the cervical os is open / closed. Cervical os is closed in threatened miscarriage while it is open in inevitable miscarriage, incomplete miscarriage. A closed cervix is observed in complete & missed miscarriage. Visualization of products of conception and blood at the external os can also be made.
Vaginal examination Assess the uterine size and cervical dilatation. Adnexal mass, cervical excitation & unilateral tenderness may suggest an ectopic pregnancy which should be considered as a differential diagnosis. Vaginal examination
Assess the uterine size and cervical dilatation. Adnexal mass, cervical excitation & unilateral tenderness may suggest an ectopic pregnancy which should be considered as a differential diagnosis.

Investigations - Diagnosis

Fact Explanation
Pregnancy test - urine For the diagnosis of pregnancy. Pregnancy test - urine
For the diagnosis of pregnancy.
Ultrasound scan (USS) of the abdomen Aids in arriving at a diagnosis. The type of miscarriage can also be decided. Retained products of conception can be visualized. Ultrasound scan (USS) of the abdomen
Aids in arriving at a diagnosis. The type of miscarriage can also be decided. Retained products of conception can be visualized.
USS : Threatened miscarriage Intrauterine gestation sac is present with a fetal pole. Fetal heart activity is present. USS : Threatened miscarriage
Intrauterine gestation sac is present with a fetal pole. Fetal heart activity is present.
USS : Inevitable miscarriage Intrauterine gestation sac is present with or without fetal pole and fetal heart beat. USS : Inevitable miscarriage
Intrauterine gestation sac is present with or without fetal pole and fetal heart beat.
USS : Incomplete miscarriage Retained products of conception can be seen. The gestation sac may be absent. USS : Incomplete miscarriage
Retained products of conception can be seen. The gestation sac may be absent.
USS : Complete miscarriage The uterus will be empty with an endometrial thickness < 15mm. USS : Complete miscarriage
The uterus will be empty with an endometrial thickness < 15mm.
USS : Missed miscarriage The fetal pole (>6mm) may be seen with no fetal heart activity or the gestational sac may be present with no fetal pole. USS : Missed miscarriage
The fetal pole (>6mm) may be seen with no fetal heart activity or the gestational sac may be present with no fetal pole.

Investigations - Management

Fact Explanation
Full blood count For assessment of the hemoglobin level. An elevated white cell count can be seen in the presence of infection. Full blood count
For assessment of the hemoglobin level. An elevated white cell count can be seen in the presence of infection.
Blood cross matching For emergency management of heavy per vaginal bleeding. Blood cross matching
For emergency management of heavy per vaginal bleeding.

Management - Supportive

Fact Explanation
Patient education The patient should be educated about the disease course and the management options. The patients should be made aware about the sudden risk of spontaneous heavy PV bleeding and advised to seek medical care as quickly as possible. Patient education
The patient should be educated about the disease course and the management options. The patients should be made aware about the sudden risk of spontaneous heavy PV bleeding and advised to seek medical care as quickly as possible.
Psychological support Patients who experience miscarriage need emotional support. Patients should be told that it is not their fault and stress at work, heavy work, sex etc has minimal effect in precipitating a miscarriage. Advise on adequate bed rest. Psychological support
Patients who experience miscarriage need emotional support. Patients should be told that it is not their fault and stress at work, heavy work, sex etc has minimal effect in precipitating a miscarriage. Advise on adequate bed rest.
Patient counseling on future pregnancies The patient should be counseled that miscarriage occurs in about 10-20% of pregnancies and this same risk carries into subsequent pregnancies. There is no specific consensus on how long to wait before conceiving again. The couple can try to conceive again once both partners are physically and emotionally ready. Patient counseling on future pregnancies
The patient should be counseled that miscarriage occurs in about 10-20% of pregnancies and this same risk carries into subsequent pregnancies. There is no specific consensus on how long to wait before conceiving again. The couple can try to conceive again once both partners are physically and emotionally ready.

Management - Specific

Fact Explanation
Management options Miscarriages can be managed expectantly, medically and surgically. Management options
Miscarriages can be managed expectantly, medically and surgically.
Expectant management Expectant management is considered in women who have minimal bleeding. Patients diagnosed with incomplete miscarriage can be considered for expectant management. Patients should be warned of sudden heavy PV bleeding needing emergency surgical treatment. Failure of resolution with expectant management will require surgical evacuation on a later date. Expectant management
Expectant management is considered in women who have minimal bleeding. Patients diagnosed with incomplete miscarriage can be considered for expectant management. Patients should be warned of sudden heavy PV bleeding needing emergency surgical treatment. Failure of resolution with expectant management will require surgical evacuation on a later date.
Medical management Prostaglandin analogues (misoprostol/ gemeprost) are administered either vaginally or orally. In combination, anti-progesterone agents such as mifepristone can be used. As with conservative management precautions should be taken for the occurrence of sudden heavy PV bleeding. Medical management
Prostaglandin analogues (misoprostol/ gemeprost) are administered either vaginally or orally. In combination, anti-progesterone agents such as mifepristone can be used. As with conservative management precautions should be taken for the occurrence of sudden heavy PV bleeding.
Surgical management Evacuation of retained products of conception (ERPC) is used in patients who have heavy per vaginal bleeding. The procedure performed under general anesthesia, involves cervical dilatation and manual curettage of the uterine cavity. ERPC has a high success rate of 95-100%. However surgical evacuation can lead to complications such as pelvic infection, uterine perforation, haemorrhage, cervical trauma with subsequent cervical incompetence, intrauterine adhesion formation etc. Surgical management
Evacuation of retained products of conception (ERPC) is used in patients who have heavy per vaginal bleeding. The procedure performed under general anesthesia, involves cervical dilatation and manual curettage of the uterine cavity. ERPC has a high success rate of 95-100%. However surgical evacuation can lead to complications such as pelvic infection, uterine perforation, haemorrhage, cervical trauma with subsequent cervical incompetence, intrauterine adhesion formation etc.
Management of heavy bleeding Manage the airway, breathing and circulation if presenting in a state of shock. After resuscitation and stabilization of the patient surgical evacuation is required. Management of heavy bleeding
Manage the airway, breathing and circulation if presenting in a state of shock. After resuscitation and stabilization of the patient surgical evacuation is required.
Anti-D prophylaxis The bleeding associated with early pregnancy loss may lead to sensitization of a non sensitized rhesus-negative patient. This can be prevented by administering anti-D antibodies. Anti-D 250 IU intramuscularly (IM) is administered for women undergoing uterine evacuation whose gestational age is less than 12 weeks. All women whose gestational age is more than 12 weeks need Anti-D prophylaxis with 250 IU IM before 20 weeks and 500 IU IM after 20 weeks. Anti-D prophylaxis
The bleeding associated with early pregnancy loss may lead to sensitization of a non sensitized rhesus-negative patient. This can be prevented by administering anti-D antibodies. Anti-D 250 IU intramuscularly (IM) is administered for women undergoing uterine evacuation whose gestational age is less than 12 weeks. All women whose gestational age is more than 12 weeks need Anti-D prophylaxis with 250 IU IM before 20 weeks and 500 IU IM after 20 weeks.

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