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Early pregnancy loss (Miscarriage)



Miscarriage refers to a natural pregnancy loss prior to 20 weeks of gestation. Recently, it is being defined as loss of a documented nonviable intrauterine pregnancy.

There are other terms related to early pregnancy loss. These are

Threatened pregnancy loss: the cervical os remains closed, and the embryo or fetus still appears viable on ultrasound but there is bleeding and cramping.

Incomplete pregnancy loss: there is still product of conception (POC) that remains within the uterus after diagnosis.

Recurrent pregnancy loss:  ≥2 pregnancy losses

Septic miscarriage: rare condition where early pregnancy loss is complicated by an intrauterine infection.

Etiology

The common etiologies include

  • Chromosomal abnormality (>60%).

  • Maternal anatomic abnormalities - based on their size and position uterine leiomyomas (fibroids), polyps, adhesions, may be related with pregnancy loss. 

  • Trauma - trauma that results in direct impact to the uterus

  • Inflammatory and immunologic dysregulation is also thought to play a role in some cases. [1]

 

Risk Factors

  • Maternal age – extremes of age (<20 years and >35 years(most significant))

  • Previous history of miscarriages

  • very low or very high body-mass index,

  • Substance use - smoking, alcohol

  • Structural uterine abnormalities such as Müllerian anomalies, leiomyoma, and intrauterine adhesions.

  • Chronic diseases - including obesity, diabetes, hyperprolactinemia, celiac disease, thyroid disease (Both hyper- and hypothyroidism), and autoimmune conditions (particularly antiphospholipid syndrome).

  • Chronic stress

  • Infections - such as syphilis(21% risk), parvovirus B19 (8%), Zika virus(6%), and cytomegalovirus (2.5%).

  • Paternal - age (>40 years), metabolic syndrome

  • Environmental exposure to pesticides, arsenic, lead.

  • Black ethnicity

Clinical features

Most common symptoms include vaginal bleeding (women experiencing a missed abortion do not experience bleeding prior to recognition of the pregnancy loss) and pelvic or abdominal cramping. Septic miscarriages are also accompanied by uterine tenderness, purulent cervical and vaginal discharge, and in severe cases, systemic signs.

Consequences

Physical – Bleeding, Infection, Recurrent miscarriage also lead to obstetric complications (including preterm birth, fetal growth restriction, placental abruption, and stillbirth in future pregnancies)

Psychological - include increases in the risk of anxiety, depression, post-traumatic stress disorder, and suicide especially in the first month following the pregnancy loss.

Management

Management of early pregnancy loss can be expectant, through medication or surgical.

  • Expectant management: Without any intervention 25% - 50% of patients pass pregnancy tissue within 1 week, and more than 80% of patients completely expel POC within 2 weeks. But this option should be taken with caution in case of complications.

  • Medication management: combination therapy with mifepristone followed by misoprostol after 24 hours is more effective than misoprostol alone. Can be done at home but should be used in caution.

               Complications - The risk of complications generally rises with increasing gestational age and commonly include retained POCs, infection, hemorrhage, and (rarely) death.

  • Surgical management: aspiration with manual vacuum aspiration (MVA) device or electric vacuum aspiration (EVA) is the preferred technique for treatment of first-trimester pregnancy loss.

                      Complications - The overall risk is relatively low but increases with increasing gestational age. Common complications include retained POCs (approximately 1%), bleeding or atony, infection, Cervical trauma (approximately 3.3 percent), Perforation (<1 percent).



References

1. Alves, Clark, et al. “Early Pregnancy Loss (Spontaneous Abortion).” PubMed, StatPearls Publishing, 2023, www.ncbi.nlm.nih.gov/books/NBK560521/#article-29399.r3. Accessed 27 Dec. 2023.

2. Farren, Jessica, et al. “The Psychological Impact of Early Pregnancy Loss.” Human Reproduction Update, vol. 24, no. 6, 11 Sept. 2018, pp. 731–749, https://doi.org/10.1093/humupd/dmy025.

3. Prager , Sarah, et al. “Pregnancy Loss (Miscarriage): Description of Management Techniques.” Sso.uptodate.com, 13 Oct. 2023, sso.uptodate.com/contents/pregnancy-loss-miscarriage-description-of-management-techniques?search=spontaneous%20abortion&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2. Accessed 27 Dec. 2023.

5. Quenby, Siobhan, et al. “Miscarriage Matters: The Epidemiological, Physical, Psychological, and Economic Costs of Early Pregnancy Loss.” The Lancet, vol. 397, no. 10285, 26 Apr. 2021, pp. 1658–1667, www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00682-6/fulltext, https://doi.org/10.1016/S0140-6736(21)00682-6. Accessed 27 Dec. 2023.

6. Sapra, Katherine J., et al. “Signs and Symptoms of Early Pregnancy Loss.” Reproductive Sciences, vol. 24, no. 4, 27 Sept. 2016, pp. 502–513, https://doi.org/10.1177/1933719116654994. Accessed 27 Dec. 2023.

7. Walter, Kristin. “Early Pregnancy Loss.” JAMA, 7 Apr. 2023, https://doi.org/10.1001/jama.2023.4973. Accessed 27 Dec. 2023. Assessed and Endorsed by the MedReport Medical Review Board

 

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