Management of Early Pregnancy Loss (EPL) Miscarriage (cont.)

Management of early pregnancy loss Assessment of the patient should include a full history and examination. Investigations may include: Pelvic ultrasound scan Full blood count Blood group and save serum

Incomplete, missed abortion: If bleeding is heavy, there is considerable pain, then emergency medical attention is recommended to be sought. Otherwise, there are three treatment options: Expectant management Medical management Surgical management

Expectant management With no treatment (watchful waiting), most of these cases (65–80%) will pass naturally within two to six weeks. This path avoids the side effects and complications possible from medications and surgery. This is mostly applied to missed abortion and blighted ovum.

Medical management Misoprostol Mifepristone plus Misoprostol Methotrexate plus Misoprostol There is no medical regimen for management of early pregnancy loss that is FDA approved.

Misoprostol Prostoglandin E1 analogue FDA approved for prevention of gastric ulcers Used off-label for many ob/gyn indications Labor induction Cervical ripening Medical abortion (with mifepristone) Prevention/treatment of post-partum hemorrhage Can be administered by oral, buccal, sublingual, vaginal and rectal routes

Why misoprostol? Do something while still avoiding surgery Cost effective Few side effects (especially with vaginal) Stable at room temperature Readily available It’s a great option for women who want to do something, but avoid surgery

800 mcg. per vagina (or buccal) Repeat x 1 at 12-24 hours if incomplete Intervene with surgical management if: Continued gestational sac Clinical symptoms Patient preference Time (?)

Surgical management Surgical treatment (most commonly vacuum aspiration, sometimes referred to as a D&C or D&E) is the fastest way to complete the miscarriage. It also shortens the duration and heaviness of bleeding, and is the best treatment for physical pain associated with the miscarriage. In cases of repeated miscarriage , D&C is also the best way to obtain tissue samples for pathology examination. D&C, however, has a higher risk of complications, including risk of injury to the cervix and uterus, perforation of the uterus, and potential scarring of the intrauterine lining.

Who should have surgical management? Unstable Infected Very heavy bleeding Anyone who wants immediate therapy

Dilatation & curretage

Postmiscarriage care Anti D at time of diagnosis or surgery for non sensitized Rh negative woman with Rh positive husband Pelvic rest for 2 weeks No evidence for delaying conception Expect light-moderate bleeding for 2 weeks Menses return after 6 weeks Negative BhCG values after 2-4 weeks Appropriate grief counseling

Future miscarriage risk Increased risk of miscarriage in future pregnancy 20% after 1 SAb 28% after 2 SAbs 43% after 3+ SAbs

Septic abortion A septic abortion or septic miscarriage is a form of miscarriage that is associated with a serious uterine infection. The infection carries risk of spreading infection to other parts of the body and cause septicemia, a grave risk to the life of the woman. The infection can occur during or just before or after an abortion.

Symptoms In a woman with septic abortion, symptoms that are related to the infection are mainly: High fever, usually above 101 °F , chills Severe abdominal pain and/or cramping /or strong perineal pressure Prolonged or heavy vaginal bleeding Foul-smelling vaginal discharge Backache or heavy back pressure

As the condition becomes more serious, signs of septic shock may appear, including: hypotension hypothermia oliguria Respiratory distress (dyspnea) Septic shock may lead to kidney failure, bleeding diathesis, and disseminated intravascular coagulation (DIC). If the septic abortion is not treated quickly and effectively, the woman may die.

Risk factors The risk of a septic abortion is increased by mainly the following factors: The fetal membranes surrounding the unborn child have ruptured, sometimes without being detected The woman has a sexually transmitted infection such as chlamydia An intrauterine device (IUD) was left in place during the pregnancy

Tissue from the unborn child or placenta is left inside the uterus after a miscarriage Unsafe abortion was made to end the pregnancy Mifepristone (RU-486) was used for a medical abortion

Treatment The woman should have intravenous fluids to maintain blood pressure and urine output. Broad-spectrum intravenous antibiotics should be given until the fever is gone. A dilatation and curettage (D&C) may be needed to clean the uterus of any residual tissue. In cases so severe that abscesses have formed in the ovaries and tubes, it may be necessary to remove the uterus by hysterectomy, and possibly other infected organs as well.

Recurrent pregnancy loss

Definition 3 or more consecutive pregnancy losses prior to 20 weeks not including ectopic, molar, biochemical

causes

1. Uterine Pathology 10-50% of RPL via abnormal implantation and uterine distention Mullerian anomalies of septate, bicornuate, didelphic uteri (not arcuate) Submucous leimyoma >>intramural or subserous Intrauterine synechiae (Asherman’s) Cervical incompetence – midtrimester Evaluation: Sonohysterography or Hysterosalpingogram; 2nd line tests include hysteroscopy, laparoscopy, or MRI

2. Hypercoagulable States Antiphospholipid syndrome 5-15 % of RPL, as well as late fetal death History of thromboembolism or pregnancy complication with high titers of anti-cardiolipin antibody and/or lupus anticoagulant Treat with heparin (5,OOO-10,000 units BID) and aspirin .

3. Endocrine Disorders 15-60 % of RPL Poorly controlled diabetes with HgA1c > 8 PCOS Poorly controlled thyroid disease and potentially subclinical hypothyroidism Hyperprolactinemia Historically luteal phase defects Diagnosis in question and suggested treatments not effective, but source of progesterone trial

4. Immunologic Factors Alloimmune reaction of mother to “foreign” tissue of embryo HLA-mediated factors

5. Chromosomal Factors 2-4% of RPL with chromosomal rearrangement: ½ balanced translocation; ¼ Robertsonian translocation; other sporadic mutations, inversions Evaluation: Parental karyotype and karyotype of abortus if possible Treatment: Genetic counseling; IVF with preimplantation screening of embryos or gamete donation

6. Environmental Factors No good evidence for recurrent SAb Sporadic pregnancy loss affected by Smoking, alcohol, anesthetic gases, caffeine > 300mg/day, obesity.

Cervical incompetence

Cervical incompetence is a medical condition in which a pregnant woman's cervix begins to dilate (widen) and efface (thin) before her pregnancy has reached term. Cervical incompetence may cause miscarriage or preterm birth during the second and third trimesters. In a woman with cervical incompetence, dilation and effacement of the cervix may occur without pain or uterine contractions. If the responses are not halted, rupture of the membranes and birth of a premature baby can result.

Risk factors history of conization (cervical biopsy), Diethylstilbestrol exposure, which can cause anatomical defects, and uterine anomalies Repeated procedures (such as mechanical dilation, especially during late pregnancy) appear to create a risk. Additionally, any significant trauma to the cervix can weaken the tissues involved

Symptoms of Cervical Incompetence Women with incompetent cervix typically present with "silent" cervical dilation (i.e., with minimal uterine contractions) between 16 and 28 weeks of gestation. When the cervix reaches 4 cm or more, active uterine contractions or rupture of membranes may occur.

Diagnosis of Cervical Incompetence Cervical incompetence is an important, but undoubtedly over-diagnosed, condition. A diagnosis of cervical incompetence is usually made on the basis of a woman's past pregnancy history. Classically this is following one or more late second trimester or early third trimeser losses . Usually they begin with a gradual painless dilatation of the cervix, with membranes bulging into the vagina. Transvaginal ultrasound (TVS) during pregnancy has shown some promise. The usual length of the cervix is about 4cm as measured on TVS. Women with a cervical length of less than 2.5cm have been found to have a 50% risk of preterm delivery in one study. Other studies have looked at opening of the internal section of the cervix ('funnelling' or 'beaking') in response to pressure on the top of the uterus.

Treatment Cervical cerclage is the treatment that is offered. This involves placing a stitch high up around the cervix to try & keep it closed. The stitch can be placed either vaginally or via an abdominal incision. The latter is usually used when vaginally placed stitches fail. They are called McDonald or Shirodkar stitches. The Shirodkar variant involves a bit more extensive surgery to ensure the stitch is high up on the cervix. This is usually performed after the twelfth week of pregnancy, the time after which a woman is least likely to miscarry for other reasons - but it is not done if there is rupture of the membranes or infection. The stitch is usually removed around 37 weeks and labour ensues fairly rapidly if the diagnosis was correct. Abdominal cerclage requires an elective caesarean section and the stitch is usually left in-situ for future pregnancies. Complications of the stitch include rupture of the membranes at the time of placement, and increased risk of infection