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

Management of early pregnancy loss On initial assessment, a history and examination should be performed with the following: • observations: BP, pulse, temperature; • laboratory investigations: haemoglobin, group and save (or crossmatch if patient is severely compromised); • patients with miscarriage can have expectant, medical or surgical management.

Management can be individualized. Expectant, medical, and surgical management are all reasonable options unless there is serious bleeding or infection. Surgical treatment is definitive and predictable, but is invasive and not necessary for all women. Expectant and medical management may obviate curettage, but are associated with unpredictable bleeding, and some women will need unscheduled surgery.

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 Three medications for early medical abortion have been widely studied and used: the antiprogestin mifepristone; the antimetabolite methotrexate; and the prostaglandin misoprostol. 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, and vaginal routes When used alone, 800 μg vaginally, repeated for up to three doses.

Why misoprostol? Cost effective Few side effects (especially with vaginal route) Stable at room temperature Readily available Again, women undergoing medical management of miscarriage need to understand that they may need surgical treatment if medical treatment fails. It’s a great option for women who want to do something, but avoid surgery Oral route may be less effective and with more nausea and diarrhea. May be given sublingually, or buccally. Postprocedure pelvic infection significantly higher with vaginal versus oral route. Possibly more effective when given at 36-48 hours instead of at 6 hours.

Surgical management [Dilatation & Curettage] (D&C) Surgical treatment 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.

Dilatation & curretage

D&C, however, has a higher risk of complications, including risk of injury to the cervix and creation of false passage, perforation of the uterus, hemorrhage, incomplete removal of the fetus and placenta, infections. and potential scarring of the intrauterine lining. The likelihood of complications increases after the first trimester. Accordingly, sharp or suction curettage should be performed before 14 to 15 weeks.

Who should have surgical management? Very heavy bleeding Presence of infection Anyone who wants immediate therapy

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, however, ovulation may resume as early as 2 weeks after an early pregnancy is terminated, whether spontaneously or induced. Negative BhCG values after 2-4 weeks Appropriate grief counseling

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 Foul-smelling vaginal discharge Severe abdominal pain and/or cramping /or strong perineal pressure Prolonged or heavy vaginal bleeding 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: Rupture of the fetal membranes, 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

Retained product of conception 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. Treatment of infection includes prompt administration of intravenous broad-spectrum antibiotics followed by uterine evacuation (D&C). With severe sepsis syndrome, acute respiratory syndrome or disseminated intravascular coagulopathy may develop, and supportive care is essential 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, affect 1% of couples trying to conceive. not including ectopic, molar, biochemical

causes

Uterine Pathology Hypercoagulable States: Antiphospholipid syndrome, Inherited thrombophilic defect. Endocrine Disorders Immunologic Factors Chromosomal Factors Environmental Factors

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. The diagnosis is usually based on a history of second-trimester miscarriage preceded by spontaneous rupture of membranes or painless cervical dilatation. 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. Transvaginal cerclage: McDonald: a transvaginal purse-string suture placed at the cervicovaginal junction without bladder mobilization. Shirodkar (high transvaginal cerclage): a transvaginal purse-string suture placed following bladder mobilization, to allow insertion above the level of cardinal ligament. Transabdominal cerclage: for women with a previous failed transvaginal cerclage. Transabdominal cerclage can be performed preconceptually or in early pregnancy. A suture placed via a laparotomy or laparoscopy, placing the suture at the cervicoisthmic junction

This is usually performed after the twelfth week of pregnancy, the time after which a woman is least likely to miscarry for other reasons. The stitch is usually removed around 37 weeks. Complications of the stitch include rupture of the membranes at the time of placement, and increased risk of infection