Management of first trimester miscarriage

1. Management
of first
trimester
miscarriage
Aboubakr Elnashar
Benha university Hospital
Egypt
ABOUBAKR ELNASHAR

2. CONTENTS
1. DEFINITION
2. PREVENTION
3. VIABLE PREGNANCY
4. NON VIABLE PREGNANCY
5. COMPLICATIONS
6. FOLLOW UP
 SUMMARY AND RECOMMENDATION
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3. 1. DEFINITION
Spontaneous abortion, or miscarriage
Clinically recognized pregnancy loss before 20 w
Expulsion or extraction of an embryo or fetus
weighing 500 g or less.
(WHO)
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4. 2. PREVENTION
Preconceptual and prenatal counseling and care:
most important interventions for prevention of
spontaneous abortion in women with no prior
history of miscarriage.
Use of pharmacologic therapy
estrogen, vitamins
has not been found to be effective.
Most miscarriages are not preventable
{chromosomal abnormalities account for
approximately 50%
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5. Modifiable etiologies and risk factors for
spontaneous abortion
1. Maternal disease:
diabetes, thyroid disease, thrombophilia:
Preconceptual and prenatal care: routine screening
and optimal disease management for conditions that can
result in miscarriage or other adverse effects to the fetus or
mother during pregnancy.
2. Extremes of maternal weight:
underweight or obese
should be addressed during preconceptual counseling.
Evaluation and management of underlying causes should be
offered.
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6. 3. Uterine structural abnormalities
uterine septum, submucosal leiomyoma, intrauterine
adhesions can be corrected if recognized prior to pregnancy.
4. Exposure to teratogens or infection
Preconceptual and prenatal counseling
should include a review of current
prescription and common over thecounter medications and
other exposures (eg, alcohol, smoking, foods that may be
contaminated by Listeria monocytogenes, radiation) that may
result in spontaneous abortion or congenital anomalies.
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7. 3. VIABLE INTRAUTERINE PREGNANCY
THREATENED MISCRRAIGE
vaginal bleeding has occurred and the cervical os
is closed, but the diagnostic criteria for spontaneous
abortion have not been met.
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8. Adverse effects
low likelihood
At 8 w if FH +ve: 90% will not miscarry.
Prognosis
Good:
bleeding light
limited to early pregnancy ≤6 w
Bad:
bleeding is heavy
extends into 2nd T
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9. ABOUBAKR ELNASHAR

10. Management
No effective interventions
NICE, 2015
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11. Progestins
Most promising tt
The rate of spontaneous abortion was statistically
significantly lower with progestin tt compared with
either placebo or no tt
(14 vs 26%; relative risk 0.53, 95% CI 0.350.79).
Progestins were administered either orally or
vaginally, and a subgroup analysis found a
significant decrease in the rate of abortion only for
oral progestins; the analysis of vaginal progestins lacked
sufficient statistical power to detect a difference.
There was no significant increase in congenital anomalies
or pregnancy induced hypertension in the progestin group.
(Cochrane SR, 2011)
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12.  Oral progestin dydrogesterone , compared with
placebo or supportive care (eg, bed rest)
significant decrease in the rate of miscarriage in
the progestin group (13 vs 24%; odds
ratio [OR] 0.47, 95% CI 0.310.7).
[Carp, 2012 MA].
Limitation:
small number of participants and events
poor methodologic quality of studies
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13. .
Many miscarriages are caused by genetic
abnormalities in the conceptus. It is unlikely that
progestins could prevent a miscarriage of this
etiology.
The data are insufficient to make a
recommendation for or against progestins for
women with threatened abortion.
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14. Other medications
HCG
Uterine muscle relaxants: tocolytics, betaagonists
Vitamin supplementation
Chinese herbal medicine
high quality data do not support their use
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15. Bed rest
commonly recommended
unnecessary and will not affect outcome
RCT: bed rest at home or in the hospital is not
beneficial in preventing fetal loss
[Aleman et al, 2005].
Abstinence from sexual intercourse and physical
exertion
typically advised
no data to support this.
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16. 4. Non-viable pregnancy
Incomplete,
Silent, Delayed, missed, early fetal demise.
•Inevitable abortion
vaginal bleeding, typically accompanied by crampy pelvic
pain, and the cervix is dilated. Products of conception can
often be felt or visualized through the internal cervical os.
●Incomplete abortion
vaginal bleeding and/or pain are present, the cervix is
dilated, and products of conception are found within the
cervical canal on examination.
●Missed abortion
spontaneous abortion in a patient with or without symptoms
and with a ● closed cervical os.
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17. Choosing a treatment method
Surgical (dilation and curettage) or
Medication (misoprostol)
Expectant management.
All have similar efficacy
Choice depends mainly upon patient preference.
[Sotiriadis et al, 2005MA].
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18. Medical Vs Surgical
 Both are safe and effective approaches for
appropriately selected patients.
 The choice is based upon
1. Patient preference.
Counseling of both is recommended
2. Availability
3. Gestational age:
Medical tt is less successful in the late 1st T
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19. Surgical management
1. Do not want to wait for a pregnancy to pass
spontaneously or with medication
2. Avoid the experience of pain and bleeding that
accompanies the passage of the products of
conception.
3. Heavy bleeding or intrauterine sepsis in whom
delaying therapy could be harmful.
4. Contraindications to misoprostol
5. Medical co morbidities: controlled method of
uterine evacuation in a hospital setting (eg,
coagulopathy).
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20.  Expectant or medical
women prefer to avoid surgery and anesthesia.
{concern about risks or may be due to a preference
to pass the pregnancy without instrumentation}
Expectant management
spontaneous miscarriage <14 w
stable vital signs
no evidence of infection.
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21. Petrou et al, 2006
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22. ABOUBAKR ELNASHAR

23. ABOUBAKR ELNASHAR

24. Complete Incomplete Silent/Delayed/Missed/EFD
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25. Alloimmunization prevention
United States and Canada, women with bleeding
during pregnancy who are
Rh(D)negative and unsensitized receive
Rh(D)immune globulin.
Other countries, guidelines vary regarding whether
Rh(D)immune globulin is required for first trimester
spontaneous abortion.
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26. RCOG, 2006
50 mcg is effective through the 12 w of gestation {small
volume of red cells in the fetoplacental circulation (mean red
cell volume at 8 and 12w is 0.33 mL and 1.5 mL)
No harm in giving the standard 300 microgram dose
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27. Expectant management
Up to 70% of women will choose expectant
management if given the choice.
Most women are willing to wait when appropriately
counseled and prepared for what to expect.
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28. Success within 2–6 w :
anembryonic pregnancies: 65%
missed abortions: 75%
incomplete miscarriages: 85%
(Butler et al, 2005)
The majority of expulsions occur in the first 2w
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29. Rates of incomplete abortion:
30% at 2w
10% at 6-8w
If expectant tt is unsuccessful after 4w:
Medical or surgical evacuation.
US follow up:
some routinely to evaluate the uterine cavity
others perform US selectively in patients whose
clinical examination is suggestive of retained products of
conception (eg, cervical os is not closed, active bleeding).
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30. Prediction of success:
1. An increasing bleeding pattern at inclusion
2. Incomplete miscarriage is more likely to proceed
to expulsion within 2w than a missed abortion.
3. Ultrasound findings:
blood flow within intervillous spaces
4. Biochemical markers:
hCG,
Progesterone
inhibin A and inhibin pro-alpha C RI: significant
differences in those pregnancies that resolve
spontaneously
(Elson et al, 2005)
Other ultrasound parameters such as
endometrial thickness and the presence or absence
of a gestational sac did not add any further ABOUBAKR ELNASHAR

31. Complications
1. Infection
2. Excessive pain or bleeding:
1% vs 2% for surgical tt
3. If spontaneous expulsion does not occur,
medication or surgical tt can be administered.
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32. Medical management
Misoprostol advantage: prostaglandin E1 analog
most commonly used
Cheap
not requiring refrigeration
low incidence of side effects
readily available
timing of use can be controlled by the patient.
clinical assessment and subsequent administration
can be safely performed by appropriately trained
non clinician providers
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33. Route
Vaginal is preferable
1. mean time to expulsion is shorter
2. As effective as oral misoprostol
3. Incidence of diarrhoea and fatigue: lower
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34. Dose:
Single is preferred
1. Single and repeated doses of oral misoprostol
600 ug (with the dose repeated after 4 hours to a
total of 1 200 ug):
 equally effective
 diarrhoea is less.
(Nguyen et al, 2005)
2. The expulsion rate: higher with a single dose of 600
to 800 mcg given vaginally (70 to 90%)
{local effect of misoprostol on the uterine cervix, the high
drug concentration achieved in uterine tissue, and the
increased bioavailability with vaginal administration].
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35. How much:
Single-dose vaginal misoprostol 800 μg was more
effective than 400 ug
(55.4% vs 40.2%)
more effective in delayed miscarriage compared with
cases where there was an empty sac
(50.3% vs 40.2%)
A single oral dose of 400 mcg misoprostol:
low rate (13%) of expulsion
same dose given multiple times: expulsion rate of 50
to 70%
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36. Incomplete abortion
Oral: 600 ug (single dose)
[WHO, 2007]
Vaginal: 800ug
Oral : 400 μg.
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37. Silent, delayed, missed miscarriage or
early fetal demise
•Vaginal: 800 ug per or
•Sublingual: 600 ug(single dose)
[WHO, 2007]
oral, sublingual or vaginal
400, 600 or 800 g in single or repeated doses
Sublingual: 400 g appears to be a safe, effective
alternative to the oral or vaginal routes.
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38. Success:
1. Dose.
2. Route
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39. 3. Type of failed pregnancy, but not by the duration
of the pregnancy.
In medically managed patients, complete expulsion occurred in 71% of all
women by day 3 and 84% by day 8.
An anembryonic gestation had a lower success
rate than an embryonic or fetal death (81 vs 88%).
In contrast to induced medical abortion, pregnancy duration
did not affect the rate of successful expulsion in missed,
incomplete, or inevitable abortions
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40. Silent, Delayed, Missed
miscarriage or
Early fetal demise
Incomplete
miscarriage
70–84%
median induction to
miscarriage interval
8 h
61–95%
lower risk of
surgical
intervention than
expectant
management
Success
rates
91%95%.Satisfaction
rates
8 dayslasted 4–6 daysBleeding
Medical tt and type of failed pregnancy
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41. Surgical evacuation
tt of choice if
endometrial thickness: 50 mm
Bleeding: excessive
vital signs: unstable
infected tissue is present in the uterine cavity:
must be done under antibiotic cover
10% who miscarry fall into these categories.
Certain women will still prefer surgical
evacuation: their choice should be accepted.
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42. Surgical advantages:
1. Shorter time to completion of tt.
complete evacuation within 48 h is more likely with surgical
than medical and more likely with medical than expectant
[Sotiriadis et al, 2005MA].
2. lowers risk of unplanned hospital admissions and
need for subsequent tt.
(MIST (Miscarriage treatment trial) randomized trial, the only trial to
compare all three treatment strategies: E, M, S
[Trinder et al, 2006])
(49 vs 18 vs 8%).
Further Surgical intervention
(44 vs13 vs 5%)
3. Blood transfusions
(2 vs, 1vs 0%)
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43. Rare surgical risks
1. Uterine perforation (1%)
2. Cervical tears, intra-abdominal trauma (0.1%)
3. Intrauterine adhesions
4. Haemorrhage,
5. Infection
6. Anaesthetic complications.
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44. Techniques:
Vacuum aspiration
Recommended for pregnancies up to12 to 14 w
(WHO ,2012)
safe, quick
significant decreased blood loss
less painful than sharp curettage.
uterine perforation, and other morbidity: rare.
Dilation of the cervix, followed by suction
evacuation, and then sharp curettage of the uterus
to check that the uterine cavity is free of remaining
tissue (dilation and curettage, dilation and
evacuation, or evacuation and curettage.
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45. Analgesia and sedation
should be provided as necessary for the procedure.
typically performed under IV conscious sedation and
a paracervical block.
Prophylactic antibiotics
1 g rectal metronidazole at the time of surgery then
100 mg oral doxycycline twice daily for 7 days.
(RCOG, 2004)
Cervical priming
should be assessed.
(Forna et al, Cochrane SR, 2001)
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46. US guidance
not required
Value:
guide the placement of the instruments during the
procedure.
visualization of a thin endometrial stripe at the end
of the curettage: the majority of the pregnancy tissue
has been removed.
Hysteroscopic guidance
may be used if there is a uterine septum.
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47. 5. COMPLICATIONS
1. Hemorrhage
Timing:
around the time of the spontaneous passage of
products of conception
during or after surgical uterine evacuation.
Etiology
subinvolution of the placental implantation site
uterine atony
cervical injury, or uterine perforation, with possible
vascular injury.
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48. TT: of the cause
products of conception: evacuated surgically.
uterine atony: oxytocin, misoprostol
cervical injury or uterine perforation:
Significant hge following a curettage for
spontaneous abortion:
± underlying, not previously recognized
coagulopathy: hypofibrinogenemia, factor deficiency
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49. 2. Uterine perforation
Avoided by
Careful surgical technique.
If high risk of perforation: anatomic alterations,
uterine infection: US guidance.
3. Retained products of conception
Suspected
uterine bleeding that increases in volume or persists
for more than 2w after uterine evacuation.
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50. 4. Endometritis
Mild endometritis:
mild uterine tenderness
empty uterus on US examination
with or without fever:
oral broad spectrum antibiotics.
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51. 5. Miscarriage with infection: Septic abortion
Uncommon in: spontaneous miscarraige
more common in: induced abortion.
Important to recognize S&S
{ life threatening}.
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52. Management:
1. Stabilize with fluids or blood products.
2.Blood and endometrial cultures
3.Broad spectrum IV antibiotics. as for PID.
 until the patient has improved and afebrile for
48h, followed by
 oral antibiotics to complete a 10-14d
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53. 4. Surgical evacuation
risk of perforation is high:
suction evacuation
a gritty texture obtained with a sharp curette.
Avoid excessive curetting
{intrauterine adhesion formation}.
US guidance
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54. Indications for further surgery(± hysterectomy)
1. Failure to respond to uterine evacuation and
antibiotics
2. Pelvic abscess
3. Clostridial necrotizing myonecrosis (gas
gangrene).
Discolored, woody appearance of the uterus and
adnexa
crepitation of the pelvic tissue
radiographic evidence of air within the uterine wall
are indications for total hysterectomy and
adnexectomy.
Surgery, if indicated, may be performed by laparoscopy.
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55. 6. FOLLOWUP
I. Confirming complete evacuation
1. Examination of Products of conception
Fetal membranes are readily identifiable and confirm
passage of at least part of an intrauterine pregnancy.
An embryo may or may not be identified.
 Intact gestational sac may be noted.
Placental villi can be difficult to distinguish from organized
clot.
One method is to rinse with water and then float the tissue in
a dish of water, preferably with a good light source underneath.
Villi have a frond like
appearance, which has been described as similar to seaweed
floating in the ocean.
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56. 2. Histopathology
Of all products of conception
Karyotyping is requested for women with three or more pregnancy losses
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57. 3. Ultrasound
Criteria for an empty uterus:
homogeneous intrauterine dimension ≤11 cm in
combined transverse and sagittal planes
[Leung et al, 2006].
Indication of evacuation:
retained tissue with a diameter ≥15 mm .
Using the latter criteria, 5% of women had complications, and 40% required another
intervention (medical or surgical). However, there is also evidence that increased endometrial
thickness is not predictive of morbidity in asymptomatic women (Creinin et al, 2004)
If the ultrasound reveals retained tissue and the patient is asymptomatic or having only
minimal bleeding, we offer the patient surgical evacuation of the uterus or expectant
management for another two weeks.
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58. 4. hCG testing
return to normal within 2-4 w after a completed
miscarriage
After E, M or S TT: many clinicians measure a
serum hCG level weekly until it is undetectable.
Not common practice after surgical evacuation.
Do not routinely do follow up hCG testing after any
method of evacuation, unless normal menstrual
cycles do not resume within 4-6w.
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59. If hCG do not return to undetectable level:
retained products of conception
undiagnosed ectopic pregnancy
Undiagnosed gestational trophoblastic disease.
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60. ABOUBAKR ELNASHAR

61. II. Postabortion instructions
Maintain pelvic rest
nothing per vagina for 2 w after evacuation or
passage of the products of conception, at which time
coitus and use of tampons may be resumed.
Light vaginal bleeding can persist for a couple of
weeks after miscarraige.
Patients should call their provider if
heavy bleeding
fever
abdominal pain
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62. Menses typically resume within 6 w.
Although rare, IU adhesions could occur after
surgical evacuation of the uterus. In the severe form,
menses do not resume or are scanty.
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63. III. Grief counseling
Etiology of the loss
1. known or suspected:
the couple should be informed and counseled about
recurrence risks.
2. Rreversible:
these can be addressed, as appropriate, in a
nonjudgmental way.
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64. 3. cannot be determined:
reassure the woman and her partner that there is no
evidence that routine activities cause miscarriage
sexual intercourse
heavy lifting
bumping her abdomen
stress
dispel myths about miscarriage
The most commonly believed causes of miscarriage:
stress: 76%
lifting a heavy object: 64%
prior IUD use: 28%
prior oral contraceptive: 22%
(Bardos et al, 2015)
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65. IV. Contraception
Any type of contraception, including placement of
intrauterine contraception, may be started
immediately after miscarriage has been completed
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66. V. Interval to conception
To postpone for 2-3 months: not advised
{no greater risk of adverse outcome with a shorter
interpregnancy interval
(Goldstein et al, 2004).
In one prospective study (n = 677), the overall rates
of live birth, miscarriage, and other pregnancy
complications after a pregnancy loss among women
with interpregnancy interval of ≤3 months and >3
months were similar}
[Makhlouf et al, 2014].
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