This document summarizes information about miscarriages, including definitions, types, causes, presentations, investigations, and treatment. It defines miscarriage as the loss of an intrauterine pregnancy before 24 weeks of gestation. The main types discussed are spontaneous/sporadic miscarriages and recurrent miscarriages (3 or more consecutive losses). Potential causes include fetal, placental, maternal factors, and unknown causes (25% of cases). Presentations depend on type and include threatened, inevitable, incomplete, complete, missed, and septic. Investigations may include ultrasounds and cervical assessments. Treatment options range from bed rest to surgical evacuation depending on type and severity.

2. Miscarriages
Dr. Sarah Safdar
PGR - I
Unit – II, LWH

3. Definition
“Miscarriage is defined as the loss of a
intrauterine pregnancy before 24
completed weeks of gestation”
WHO definition
“The expulsion of fetus or an embryo
weighing 500 g or less and also a
gestational age limit of less than 22
completed weeks of pregnancy”

4. Types :
• Sporadic/Spontaneous
• Recurrent

5. Spontaneous Miscarriages
• Expulsion of a fetus before 24 completed weeks of
gestation or an embryo weighing 500 g or less
spontaneously
• Incidence = 15%(1 in 6)
• Actual incidence is difficult to assess because
 Some women abort without knowing that they have been
pregnant
 Some women have vaginal bleeding after variable amenorrhea
but not having confirmed evidence of pregnancy
 Spontaneous origin by deliberate interference

6. Etiology
• Fetal
• Placental
• Maternal
• Unknown in 25% of cases

7. 1) Fetal causes
• Chromosomal abnormalities
i) Aneuploidy ~ 50%
a. Trisomy
b. Monosomy
c. Triploidy/Tetraploidy
ii) Structural chromosomal abnormalities ( common in recurrent
M)
• Developmental defects(NTDs,cleft
palate,cyclopia,amniotic bands,syrinomelia & caudal regression)

8. Causes……
2) Placental
Haemorrhage in decidua basalis or necrotic tissue in tissue
adjacent to bleeding
Hydropic degeneration in plcental villi
3) Maternal
 More common in second trimester
 Mostly associated wd recurrent miscarriages
 These includes
 Uterine Anomalies
 Infections
 other maternal causes

9. Causes……
 Uterine Anomalies
– Bicornuate and subseptate uterus
– Cervical incompetence(most common Cause of 2nd
trimester abortions)
– Uterine myomas
– Asherman syndrome

11. Causes…….
 Infections
– More commonly associated with isolated abortions
– Any acute illness like typhoid fever, malaria,
pyelonphritis & appendicitis can cause miscarriage
Bacteria : L monocytogenes,Compylobacter,Mycoplasma,ureaplasma
Spirochetes : Treponema Pallidum
Parasites : Toxoplasma gondii
Viruses : Cytomegalovirus,Rubella,Herpes,Coxsackie

12. Causes…..
 Other Maternal ailments :
Chronic ailments
 40 yrs
Smoking
Diabetes
Hypertension
Renal disease
Thyroid disease

13.  Fetal Sex,Multiple Pregnancy,Maternal
age and Parity
4) Unproved Causes ~ 25 %
 Progesterone deficiency
 Immunological causes
 Radiations
 Direct or indirect trauma

14. Presentations Of Spontaneous
Miscarriages
o Threatened
o Inevitable
o Incomplete
o Complete
o Missed
o Septic

15. Threatened Miscarriage Inevitable Miscarriage
P/V
bleeding
Fresh Blood,small in amnt Fresh blood ,more in amount wd
sum clots
Pain Painless Typical L pains
Others Cervical Shock syndrome
Abdominal
Ex
Fundal ht = dates Fundal ht = dates
P/S Fresh blood coming thru cervix Bag of membrns bulging thru
cervix
P/V Cervical os closed Cervical os open
Ix FCA present on USG FCA may or may not b present
Rx Bed Rest,Avoid Coitus,Hormonal
Rx, Antibiotics
Evacuation of uterus

16. Outcome

17. Incomplete Complete
P/V bleeding Heavy bleeding wd passage of
clots & tissue
May b asymptomatic WD Hx of
bleeding & RPOC’s passage
earlier
Pain Crampy lower abd pain May gv Hx of pain Earlier
Others Hypovolemic shock
Abdominal Ex Fundal Ht < dates FH < dates
P/S POC’s present in cx or vagina Cervical os may appear close
P/V Cervical os open,POC may be
felt in uterus
Cervical os may appear close
or open
Ix RPOC’s on USG Empty uterus on USG
Rx Evacuation No Rx

18. Missed Miscarriage
P/V bleeding When present,old blood,small in amount
Pain Usually absent at the time of diagnosis
Others Absent fetal movements,& FCA
Regression of pregnancy symptoms
Abdominal Ex Fundal Ht < dates
P/S Old discolored blood if present
P/V Cervical os closed
Ix FCA absent,Spalding & Robert’s sign in advanced preg
Rx <12 wks ~ Suction & evacuation
>12 wks Expulsion F/b Curettage

19. %• Complications of
surgical evacuation :
• Tearing or laceration of cervix
• Perforation of uterus leading to
bowel perforation
• Bladder perforation
• Damage to broad ligament
• Infection
• Asherman syndrome

20. Septic Miscarriages
P/V bleeding Bleeding variable in amount,foul smelling,vaginal discharge in
case of infection
Pain Crampy lower abd pain
Others Pyrexia,Tachycardia,dehydration,electrolyte imbalance,abdominal
distension,paralytic illeus,septic shock
Abdominal Ex Tenderness,guarding.rigidity in lower abd,abdominal
distension,paralytic ileus
P/S Blood/pus coming through cervix
P/V Cervical os may be open or closed,pelvic tenderness,uterine
mobility restricted,adenexal mass
Ix POC’s within the uterus,tubo-ovarian mass
Rx Ab,fluid & electrolyte correction,blood transfusion,evacuation of
uterus.,laparotomy

21. Recurrent Miscarriages
• Three or more consecutive miscarriages
• TYPES OF RMC
• Primary RMC :
where there have been no previous live birth
• Secondary RMC ;
where atleast one successful pregnancy have been
occurred previously
Ectopic, molar, and biochemical pregnancies not
included.

22. RMC Subtypes
• All pregnancy losses, no viable pregnancy
• Viable pregnancy followed by pregnancy losses
• Pregnancy losses interspersed with
viable pregnancies

23. Causes Of Recurrent Miscarriages
Genetic
Anatomical
Infective
Endocrine
Immunological

24. Genetic
• Parental Chromosomal aneuploidy
– balanced reciprocal translocation
– robertsonian translocations
– Pericentric chromosomal inversion
• Recurrent aneuploidy
– Inc tendency to nondisjunction
– Mostly seen in IVF embryos

25. • Other genetic Factors
– euploidy
– single gene defect
– molecularr mutations
• Peripheral blood karyotyping
• Specialized genetic counselling

26. Anatomical Factors : Septate Uetrus
• Most common
• Poorest outcome
• Miscarriage > 60 %
• Fetal survival with untreated cases 6 to 28 %
• The mechanism
– Not clearly understood
– Poor blood supply
– poor implantation

27. Submucosal Fibroids
• The mechanism -
– Their position
– Poor endometrial receptivity
– Degeneration with increasing
cytokine production

28. Investigation and Treatment
• HSG,Laparoscopy,Hysteroscopy,MRI,CT & 3
D USG
Surgery :
• Hysteroscopy
Procedure of choice
Septum excision, polypectomy
• Laparoscopic myomectomy
For fibroids
• Laparotomy
• Likelihood of live births in untreated pts is as high as
66 %
• Open pelvic surgery wth RMC ~ Infertility

29. Cervical Incompetence
• Associated wd MC after 12-14 wks or PM labour
• Silent dilatation of cervix without painful cont
Dx:
Previous Hx of mid-trimester MC
Ix :
TVS
Rx :
Cervical cerclage after 12-14 wks
Mcdonald/Shirodkar

30. Infective factors
• Syphilis : recurrent late 2nd
trimester MC
» Routine screening
» Prophylaxis wd penicillins
• Bacterial Vaginosis
» Recurrent 2nd
trimester loss
» Metronidazole
• Regular sterile speculum EX
• Regular high n low vaginal swabs
• Low dose antibiotic for repeated positive
results

31. Endocrine Factors
• Systemic Endocrine Diseases
• Luteal Phase Defect
• PCO & Hypersecretion of LH

32. Luteal Phase Defect
– Progesterone is essential for
implantation and maintenance of
pregnancy
• A defect in Corpus luteum
impaired progesterone production.
• LPD cannot be diagnosed during
pregnancy; a consistently short luteal
phase duration is the most reliable
diagnostic criterion.

33. PCO & Hypersecretion of LH
• Polycystic ovary morphology itself does not predict an
increased risk of future pregnancy loss among ovulatory
women with a history of recurrent miscarriage who
conceive spontaneously
• Hyperinsulinemia & level of Plasminogen Activator↑
Inhibitor activity – implicated as the proximate cause of
incidence of loss(30-50%)among PCOS women
• METFORMIN treatment can reduce or eliminate risk of
miscarriage in PCOS women

34. Investigations :
• Thyroid Function Tests- T3 ,T4, TSH
• S.Prolactin
• Glucose tolerance test
• HbA1c
• S.FSH
• S.LH
• S.Progesterone

35. Treatment
• Luteal-phase insufficiency
– luteal-phase support with progesterone
– There is insufficient evidence to evaluate the effect
of progesterone supplementation in pregnancy to
prevent a miscarriage
• PCOS, hyperandrogenism, hyperinsullinemia
– insulin-sensitizing agents (METFORMIN)
• overt diabetes mellitus
– prepregnancy glycemic control
• hypothyroidism
– thyroid hormone replacement

36. Autoimmune & Thrombophilic Defects
Autoimmune :
Autoimmune Alloimmune
(directed to self) (directed to foreign
tissues/cells)
-Systemic Lupus Erythmatosus An Abnormal
maternal
-Antiphospholipid Syndrome immune response
to fetal or placental antigen.

37. • Systemic Lupus Erythmatosus (SLE)
-Risk for loss is 20%,mostly in 2nd
and 3rd
trimester of pregnancy and associated with
antiphospholipid antibodies.
• Antiphospholipid syndrome (APA)
– 5 - 15 % of women with RPL may have APA
APA likely induce microthrombi at placentation site.
Altered vascularity affects developing embryo,
induces MISCARRIAGES

38. Diagnosis :
CLINICAL
1) Thrombolic events :
arterial,venous,small vessel
2)Pregnancy loss-
» ≥3 losses at <10wks gestation
» fetal death after 10wks
» premature birth at <34wks associated with severe
preeclampsia or placental insufficiency.

39. LABS
1) Lupus Anticoagulant
2) Anticardiolipin antibodies(IgG or IgM)
Any lab test results must be observed on at least 2
separate occasions 8 wks apart.

40. • Treatment for APA
1. Low Molecular weight Heparin
– 3000 IU S/C twice a day
– Expensive treatment
1. Un-fractionated Heparin is better option
2. Low dose Aspirin
3. Steroids? Mainly for anti nuclear antibodies
– 10 – 20 mg prednisolone / day

41. Investigation

42. Treatment
• 50 % of Miscarriages ~No Cause
• Prognosis is good
• ReAssurance & Psychological Support
• 75 % of live births in unexplained RPL

43. • MiSCARRIAGES DON’T OCCUR IN A
UTERUS BUT IN A WOMAN,AND
MISCARRIAGES DO NOT OCCUR SOLELY
IN A WOMEN BUT IN A FAMILY

44. Support should Includes
• Care in Specialist clinic
• Psychological support
• Easy access to named contact
• Close monitoring including
 USG
 APPropriate reassurance
 helpful & caring staff

45. • Should be offered to all patients wd RPL
• Explanation of possible causes & prognosis
• After 3 consecutive early preg losses ~
60-70% chances of next successful pregnancies
• Even after 6 miscarriages~the chance of successful
preg is still 45 %
Counselling

46. Your Main Title