Miscarriage – A Matter of Concern

Miscarriage is a heartbreaking event that occurs when a pregnancy ends before 20 weeks gestation or the baby weighs less than 500g. According to the World Health Organization (WHO), miscarriage is one of the most common reproductive health problems, affecting many women worldwide.

Miscarriage Classification

• Early miscarriage: Miscarriage occurring before the 6th week of gestation, also known as a chemical miscarriage.

• Clinical miscarriage: Miscarriage occurring after the 6th week of gestation.

• Late miscarriage: Miscarriage occurring between the 13th and 24th week of gestation.

• Blighted ovum: An empty gestational sac without a fetal pole.

Miscarriage Frequency

The frequency of miscarriage can be as high as 50% of pregnancies. Miscarriage rates vary at different gestational ages:

• 25% of miscarriages occur around the 6th week.

• 8% of miscarriages occur after the 6th week.

• The risk of miscarriage significantly decreases after the 10th week of gestation.

• When a fetal heartbeat is present, the miscarriage rate is below 5%.

• Women aged 45 have a higher risk of miscarriage, reaching up to 75%.

Causes of Miscarriage

1. Chromosomal Abnormalities: Accounts for approximately 50% of miscarriages during the first trimester.

2. Reproductive Organ Abnormalities: Accounts for approximately 15% of miscarriages during the second trimester. Abnormalities can be due to:

• Congenital: Uterine malformations, uterine hypoplasia, congenital cervical incompetence.

• Acquired: Uterine adhesions (due to curettage, infection), cervical incompetence due to dilation and curettage procedures.

• Pathology: Fibroids that affect fetal implantation and nutrient supply, endometrial polyps.

3. Corpus Luteum Deficiency: Corpus luteum deficiency leads to progesterone deficiency. Progesterone plays a role in:

• Developing the endometrium during the first trimester.

• Suppressing uterine contractions.

• Inhibiting T lymphocyte production, thereby suppressing immune responses to the fetus.

4. Polycystic Ovarian Syndrome (PCOS): PCOS can cause miscarriage, accounting for 30-50% of miscarriages during the first trimester.

5. Other Endocrine Causes:

• Thyroid disorders (hypothyroidism + hyperthyroidism).

• Diabetes.

• Cushing’s syndrome.

6. Smoking:

• Smoking over 10 cigarettes/day increases the risk of miscarriage.

• Husband smoking <20 cigarettes/day increases the risk of miscarriage by 4%.

• Husband smoking >20 cigarettes/day increases the risk of miscarriage by 81%.

7. Caffeine:

• Consuming over 200mg of caffeine/day increases the risk of miscarriage by up to 25%.

• Without caffeine consumption, the miscarriage rate is only 13%.

8. Anti-inflammatory Drugs:

• Use within 7-10 days after conception can increase the risk of miscarriage.

9. Anticoagulants:

• Use during the first trimester can increase the risk of miscarriage.

10. Anticancer Drugs:

• Use during the first 6 weeks of pregnancy can increase the risk of miscarriage.

11. Multiple Gestations, Placental Abnormalities, Umbilical Cord Problems:

• Can cause miscarriage in the second trimester.

Pathology of Miscarriage

• Decidual degeneration, necrosis, blood vessel obstruction, hemorrhage at the placental attachment site.

• Placental edema, hydropic degeneration, making it difficult to distinguish from a molar pregnancy.

Miscarriage Classification Based on Clinical Presentation

• Complete miscarriage: Miscarriage occurring before 12 weeks of gestation.

• Incomplete miscarriage: Miscarriage occurring between 12 and 20 weeks of gestation.

• Missed miscarriage: Miscarriage occurring after 20 weeks of gestation, with the fetus expelled first and the placenta expelled later.

4 Stages of Spontaneous Miscarriage

• Threatened miscarriage: Cervical exam reveals a closed cervix, no pain upon cervical movement, vaginal bleeding, uterine size consistent with gestational age.

• Inevitable miscarriage: Examination reveals heavy vaginal bleeding, cervical dilation and thinning, uterine size consistent with gestational age.

• Incomplete miscarriage: The fetus has been expelled from the uterus but the placenta remains.

• Complete miscarriage: Both the fetus and placenta have been expelled from the uterus.

Recurrent Miscarriage

• Recurrent miscarriage: Miscarriage > 3 times before 20 weeks of gestation.

• Recurrent miscarriage frequency: Approximately 0.3-0.4%.

Ability to Conceive After Miscarriage

• 1 miscarriage: 76%.

• 2 miscarriages: 70%.

• 3 miscarriages: 65%.

Cervical Incompetence

• Clinical characteristics: Miscarriage usually occurs in the late second trimester, suddenly, without abdominal pain, and without bleeding.

• Treatment: Cervical cerclage.

Differential Diagnosis of Miscarriage

• Ectopic pregnancy: No placental image, only decidual cast seen.

• Missed miscarriage: B-hCG and ultrasound should be monitored again after 1 week.

• Molar pregnancy: Examination reveals a uterus larger than gestational age, hCG >200,000 IU/L.

Ultrasound Images

• Threatened miscarriage: The fetus is still developing, showing fluid collection behind the placenta or around the gestational sac.

• Incomplete miscarriage: Mixed echogenic material in the uterine cavity.

Management of Miscarriage

• Threatened miscarriage: Bed rest, avoid heavy lifting, and refrain from intercourse. Anti-uterine contraction medications, natural progesterone can be given.

• Miscarriage: Removal of the pregnancy by suction curettage (for small pregnancies) or cervical dilation and curettage if the pregnancy is larger. Perform histopathological examination of the curettage tissue. Avoid vaginal infections, administer antibiotics for 5-7 days.

Contraception After Miscarriage

• Wait at least 2 consecutive menstrual cycles.

Cervical Cerclage

• Indications: After 12 weeks and before 16 weeks of gestation.

• Contraindications: Amniotic fluid rupture, uterine contractions, cervical dilation of 4 cm, vaginal infection, cervix.

Complications of Cervical Cerclage

• Premature labor.

• Local infection at the cerclage site.

• Difficult labor due to cervical tissue damage.

• Complications from anesthesia.

Note

Miscarriage is a complex issue that requires timely diagnosis and treatment by specialized doctors.