Comprehensive Guide to Miscarriage and Ectopic Pregnancy

Introduction and Topic Learning Outcomes

Presenters:

1. Muhammad Qasim b Ahmad Yusaini

2. Nur Farhah Ardini Binti Mohamad Zin

3. Deepiga Ganesh Chandru

4. Khavilashny Prakas Rao

Topic Learning Outcomes (TLO):

• Define different types of miscarriages.

• Describe the aetiology and epidemiology of miscarriage.

• Describe the clinical features, investigation, and management of different types of miscarriage.

• Develop the knowledge of complications associated with miscarriage.

• Explain different options for management, including Conservative, Medical, and Surgical management.

Definition and Epidemiology of Miscarriage

Definition of Miscarriage:

• Miscarriage is defined as fetal loss between the time of conception and the time of fetal viability, which occurs at $24\text{ weeks}$ gestation.

• Alternative inclusion: Cases involving the expulsion of a fetus or embryo weighing $\le 500\,g$.

• Distinction: Fetal loss occurring after the time of fetal viability ($24\text{ weeks}$) is termed "intrauterine fetal demise."

Epidemiology of Miscarriage:

• Criteria in Malaysia: A fetus weighing less than $500\,g$ or a gestation of less than $22\text{ weeks}$ is considered a miscarriage.

• Incidence: It is the most common complication of early pregnancy, with an incidence rate of $8-20\%$ among known pregnant women.

• Timeline: The majority ($80\%$) of miscarriages occur in early pregnancy, typically between the $9^{th}$ and the $13^{th}\text{ week}$.

Aetiology of Miscarriage

Common Causes:

• Chromosomal Abnormalities: The most frequent cause; these arise from errors during cell division in the embryo or fetus and are the leading cause of early pregnancy loss.

• Uterine Abnormalities: Structural issues like a septate uterus, bicornuate uterus, or fibroids can interfere with embryo implantation and development.

• Endocrine Disorders: Conditions including Polycystic Ovary Syndrome (PCOS), diabetes, and thyroid disorders impact hormonal balance.

• Immunologic Factors: Certain autoimmune disorders and immune system abnormalities are linked to increased risk, though the relationship is complex/not fully understood.

• Infections: Rubella, cytomegalovirus (CMV), and toxoplasmosis pose risks, particularly when contracted in early pregnancy.

• Hormonal Imbalances: Fluctuations in progesterone (crucial for maintaining pregnancy) or imbalances caused by ovarian dysfunction.

• Lifestyle Factors: Smoking, excessive alcohol, and illicit drug use. Poor nutrition and obesity also contribute.

• Environmental Exposures: Toxins, pollutants, chemicals, and certain workplace exposures or medications.

• Blood Clotting Disorders: Antiphospholipid syndrome (APS) can interfere with uterine blood flow and cause recurrent loss.

• Genetic Factors: Parental factors such as balanced translocations or other genetic abnormalities affecting fertility.

• Incompetent Cervix: Weakened cervical tissue leading to premature dilation, primarily in the second trimester.

Risk Factors for Miscarriage

1. Mother’s Age: Older mothers face a higher risk of chromosomal abnormalities in fetuses compared to younger mothers.

2. Previous History: A history of prior miscarriage increases current risk.

3. Smoking: Identified as a significant risk factor.

4. Alcohol: Consumption is associated with a slight increase in miscarriage rates.

5. High Grade Fever: Elevated body temperature can trigger loss.

6. Trauma: Uterine trauma from road traffic accidents (RTA), falls, or abdominal massages.

7. Caffeine: Excessive intake of coffee or caffeinated drinks like Cola is not advised.

8. Other Factors: Exposure to infections, specific medications/drugs, severe physical stress, radiation, or chemicals.

Classification and Types of Miscarriage

General Classification (Abortion):

• Spontaneous (Miscarriage):
      * Isolated (Sporadic): Single occurrence.
      * Recurrent: Repeated losses.

• Induced (Deliberate):
      * Legal (MTP): Medical Termination of Pregnancy.
      * Illegal (Unsafe).

• Septic: Can be common or less common depending on the underlying type.

Specific Clinical Types:

• Threatened: Potential risk; pregnancy remains viable.

• Inevitable: Miscarriage is in progress; cannot be prevented.

• Complete: All products of conception (POC) are expelled.

• Incomplete: Some POC remain in the uterus.

• Missed: Fetus has died but is not expelled by the body.

Clinical Features, Investigation, and Management of Miscarriage Types

Threatened Miscarriage

• Definition: Symptoms suggesting risk, but the pregnancy is still viable.

• Clinical Features: One or two drops of brownish or bright red blood; mild or no lower abdominal pain. Examination shows blood stains, a closed external os, and uterine size mapping to gestational age.

• Investigations: TVS (Transvaginal Ultrasound) showing a viable fetus, gestational sac with fetal pole, fetal movement, and heart activity. Serum progesterone $\ge 25\,ng/mL$. Serum hCG level may decrease.

• Management: Pelvic rest, hydration, supportive care, observation, monitoring, and medical treatment.

Missed Miscarriage

• Definition: Embryo/fetus death without expulsion of tissues.

• Clinical Features: Brownish discharge, subsidence of pregnancy symptoms, cessation of uterine growth, firm cervix, and retrogression of breast changes.

• Investigations: Ultrasound showing no viable fetus, empty sac (early), or absence of fetal cardiac activity/movement.

• Management: Medical treatment with Mifepristone first, followed by Misoprostol $48\text{ hours}$ later; or ERCP (Evacuation of Retained Product of Conception).

Inevitable Miscarriage

• Definition: Dilated cervix and active bleeding; miscarriage cannot be stopped.

• Clinical Features: Severe vaginal bleeding, severe abdominal pain, and cervical dilation.

• Investigations: Ultrasound shows intrauterine pregnancy without fetal cardiac activity.

• Management: IV fluid therapy and blood transfusion (to correct loss), Misoprostol $600\,mcg$, and ERCP.

Septic Miscarriage

• Definition: Miscarriage associated with uterine infection.

• Clinical Criteria: Offensive/purulent vaginal discharge, lower abdominal pain, tenderness, and pelvic infection evidence.

• Clinical Features: Slight bleeding, pyrexia, thick/smelly discharge, abdominal cramps, pelvic/uterine tenderness, and a boggy feeling in the pouch of Douglas.

• Investigations:
      * Routine: Cervical/vaginal swab for culture/sensitivity and Gram-stain; Blood (TWC, coagulation profile, electrolytes, ABO/Rh); Urine analysis/culture.
      * Specific: Pelvic/abdominal USG to detect retained products, foreign bodies, or free fluid in the peritoneal cavity/pouch of Douglas.

• Management: Broad-spectrum IV antibiotics (including anaerobic coverage). Dilatation and Curettage (D&C) once the patient is stable and antibiotic tissue levels are adequate.

Complete Miscarriage

• Definition: Complete expulsion of all POC; cervical os is closed. Usually occurs before the $12^{th}\text{ week}$ (prior to $20^{th}\text{ week}$).

• Clinical Features: History of expelling a "fleshy" mass, followed by subsidence of pain and trace/absent bleeding.

• Investigations: Routine swabs, blood tests (TWC, ABO/Rh), and urine analysis.

• Management: Send products to verify pregnancy; curettage performed between the $8^{th}-14^{th}\text{ week}$ if incomplete status is suspected; observation for infection/bleeding.

Incomplete Miscarriage

• Definition: POC is not fully expelled; some parts remain in the uterine cavity.

• Clinical Features: Expulsion of fleshy mass followed by persistent heavy bleeding and colicky lower abdominal pain. Uterine size is smaller than gestational age.

• Investigations: Ultrasound identifying POC in the cavity; quantitative hCG blood test.

• Management: Hemodynamic stabilization (IV fluids/blood grouping), Ergometrine $0.5\,mg$ IM (to contract uterus/control bleeding), ERCOP, and histopathology of removed tissue.

Second Trimester Miscarriage and Complications

Details of Second Trimester Miscarriage:

• Occurs between the $13^{th}$ and $28^{th}\text{ weeks}$ of gestation.

• Less common than first-trimester loss; rates decrease as gestation increases.

• Causes: Chromosomal, placental problems, infections, APS, cervical incompetence, thrombophilia, or congenital abnormalities.

• Symptoms: Heavy bleeding, contractions, water breaking, passage of fetal tissue, and loss of fetal movements.

Complications of Miscarriage:

• Hemorrhage.

• Risk of Infection.

• Septic Miscarriages.

• Recurrent Miscarriages.

• Infertility (specifically linked to incomplete miscarriages).

General Management Options

1. Conservative Treatment:
       * Applicable if miscarriage is below $13\text{ weeks}$ and the patient is stable.
       * Spontaneous expulsion usually occurs within $1-2\text{ weeks}$.
       * Follow-up: Ultrasound after expulsion and a urinary pregnancy test after $7-14\text{ days}$.

2. Medical Treatment:
       * Speeds up tissue passage using pills (oral or vaginal).
       * Vaginal Misoprostol: Single dose of $800\,mg$ for Missed Miscarriage; single dose of $600\,mg$ for Incomplete Miscarriage.
       * Side effects: Pain, diarrhea, vomiting. Pregnancy test required $3\text{ weeks}$ post-treatment.

3. Surgical Treatment:
       * Dilatation & Curettage (D&C): Used if the patient does not want to wait or bleeding is severe.
       * Hysterectomy: To inspect the uterine lining and remove remaining tissue.

Ectopic Pregnancy

Definition: A fertilized egg implants and grows outside the uterus (e.g., fallopian tubes, ovaries, abdomen, or cervix).

Sites of Ectopic Pregnancy:

• Common (Tubal - $92.7\%$): Ampullae, Isthmus, Infundibulum.

• Less Common: Interstitium/Cornual ($2.68\%$), Ovarian ($1.56\%$), Cesarean scar ($0.63\%$), Abdominal ($0.61\%$), Cervical ($0.49\%$), Heterotopic ($0.43\%$).

Risk Factors:

• PID, previous ectopic pregnancy (risk of recurrence is $1$ in $10$), tubal damage, endometriosis.

• Contraceptive use (IUCD, POP - progesterone inhibits tube peristalsis).

• Age > 35\text{ y/o}, smoking (interrupts ciliary action), history of infertility, Assisted Reproductive Techniques (IVF risk for heterotopic pregnancy).

Clinical Presentation:

• Unruptured: Early pregnancy symptoms, abdominal/pelvic pain, slight uterine enlargement.

• Ruptured: Collapse, weak pulse ($\ge 110\text{ per minute}$), hypotension, hypovolemia, acute pain, abdominal distention (shifting dullness indicates free blood), and rebound tenderness.

Investigations:

1. TVUS: Confirms if intrauterine; empty uterus plus adnexal mass has $90\%$ sensitivity. Free fluid suggests rupture.

2. Serum hCG: Normally doubles every $48\text{ hours}$; in ectopic cases, the rise is suboptimal.

3. Hemoglobin: Assesses blood loss and rhesus status.

Management:

1. Expectant: Observation if \text{hCG} < 100\,IU/L and falling, sac < 4\,cm, and no fetal heart activity/rupture.

2. Medical: IM Methotrexate $50\,mg/m^2$ for stable patients with \text{hCG} < 3000\,IU/L and tubal diameter < 4\,cm.

3. Surgical: Laparoscopy is standard (Laparotomy if unstable). Choices include Salpingectomy (tube removal) or Salpingostomy (opening the tube).