Snapshot A 35-year-old G3P2 at 12 weeks of gestation presents to the emergency department with 6 hours of vaginal bleeding and cramping pain. She has had 2 prior vaginal deliveries and no history of pregnancy-related complications. She has been receiving regular prenatal care. Introduction Overview non-elective termination of pregnancy at < 20 weeks gestation Epidemiology incidence occurs spontaneously in 15% of all pregnancies demographics more common in women of advanced maternal age (age > 35 years) ~11% risk in women < 35 years old 17% in women 35-39 years old 33% in women 40-44 years old 57% risk in women ≥ 45 years old risk factors advanced maternal age (> 35 years old) number 1 risk factor due to strong association with fetal chromosomal abnormalities advanced paternal age prior pregnancy loss risk increases as number of prior miscarriages increase maternal diabetes type I or type II diabetes gestational diabetes begins > 20 weeks, so cannot contribute to miscarriage obesity thyroid disease hypo- or hyperthyroidism stress acute or chronic inherited thrombophilias or coagulopathies antiphospholipid syndrome conception < 3 months after live birth pregnancy with IUD in place subchorionic hematoma Causes fetal chromosomal abnormalities present in up to 70% of miscarriages infection listeria parvovirus B19 ~8% cumulative incidence of pregnancy loss 5.6x higher risk of pregnancy loss if infection occurs in first trimester syphilis 21% increased risk of fetal loss and stillbirth if untreated cytomegalovirus (CMV) 2.5 increased odds of early pregnancy loss compared with non-infected pregnant women incompetent cervix uterine abnormalities leiomyomas (fibroids) polyps adhesions septa bicornate uterus due to incomplete fusion of paramesonephric ducts uterus growth is limited trauma direct impact to uterus violent gunshot wounds penetrating injuries blunt abdominal trauma iatrogenic chorionic villus sampling amniocentesis toxins, radiation, and environmental exposures medications and substance abuse risk increases in dose-related fashion alcohol smoking cocaine and methamphetamines Prognosis very good if patient if properly treated risk of future miscarriage natural history of disease 14% risk of future miscarriage after 1 miscarriage 26% after 2 miscarriages 28% after 3 miscarriages Classification Types of Miscarriages Type Vaginal Bleeding Passage of Contents Cervical Os Ultrasound Threatened Yes No Closed Fetus present and has cardiac activity Inevitable Yes No Open Fetus present but does not have cardiac activity Incomplete Yes Yes Open Retained fetal parts Complete Yes Yes Closed No fetus present Missed No No Closed Fetus present but does not have cardiac activity Presentation Symptoms vaginal bleeding commonly occurs in first trimester without subsequent loss of pregnancy abdominal/pelvic cramping pain asymptomatic may note reduction in previous pregnancy symptoms decreased nausea decreased breast tenderness Physical exam vitals may exhibit signs of shock if significant hemorrhage speculum exam assess source and quantity of bleeding bleeding from cervix and open cervical os suggest miscarriage significant hemorrhage should prompt urgent evaluation and intervention bimanual exam determine whether cervix is open assess presence of tissue within cervical canal can estimate gestational age handheld Doppler listen for fetal heart tones absence of fetal heart ones in pregnancy ≥ 12 weeks suggests potential early pregnancy loss Imaging Transvaginal ultrasound indications critical for diagnosis of miscarriage can assess fetal cardiac activity findings looking for presence of intrauterine gestation and evidence of viability diagnosis of miscarriage if any one of the following gestational sac ≥ 25 mm without yolk sac or embryo embryo with crown rump length ≥ 7 mm that does not have cardiac activity following a pelvic ultrasound that showed a gestational sac without a yolk sac absence of an embryo with a heartbeat in ≥ 2 weeks following a pelvic ultrasound that showed a gestational sac with a yolk sac absence of an embryo with a heartbeat in ≥ 11 days may begin with transabdominal ultrasound, but proceed to transvaginal ultrasound if unable to demonstrate cardiac activity in an intrauterine pregnancy Hysterosalpingogram indications can elucidate potential cause of miscarriage only performed after treatment for confirmed miscarriage findings uterine structural abnormalities Studies Serum β-hCG not required for diagnosis useful in specific circumstances to determine concern for ectopic pregnancy if gestational sac not seen on ultrasound if ultrasound not available drop in β-hCG > 25% over 48 hours in setting of uterine bleeding highly suggestive of early pregnancy loss Serum progesterone needed for maintenance of endometrium low levels (< 35 nmol/L) associated with early pregnancy loss cannot use for definitive diagnosis due to high variability of normal levels among pregnancies Differential Normal intrauterine pregnancy key distinguishing factors serial ultrasounds demonstrate viable intrauterine gestation can have cramping and vaginal bleeding in normal pregnancy Ectopic pregnancy key distinguishing factors ultrasound findings no intrauterine pregnancy visible may see visible pregnancy that is outside the uterine cavity may see bleeding in the pelvis (suggestive of ruptured ectopic) may have abnormal β-hCG levels Hydatidiform mole key distinguishing factors ultrasound findings enlarged uterus “snowstorm” appearance of uterus abnormally elevated β-hCG Treatment Expectant management counseling and return precautions indications < 14 weeks of gestation threatened or inevitable abortion stable vital signs no evidence of infection desire to avoid surgery and/or medication desire to pass uterine contents at home majority of expulsions occur in first 2 weeks after diagnosis if unsuccessful after four weeks then proceed to surgical evaluation Medical misoprostol indications women with nonviable pregnancy up to 12 weeks + 6 days of completed gestation hemodynamically stable no evidence of hemorrhage, severe anemia, bleeding disorders no evidence of infection can be used in second trimester treatment in hospital setting modalities administered vaginally as single dose repeat dose in seven days if no response to first dose mifepristone indications pretreatment prior to misoprostol preferred method for first trimester miscarriage modalities single oral dose followed 24 hours later by single dose of intravaginal misoprostol rhoGAM indications all Rh(D)-negative mothers if father is Rh(D)-positive or unknown modalities single intramuscular or intravenous dose Surgical dilation and curettage (D&C) indications incomplete, inevitable, or missed abortion first trimester or early second trimester (< 16 weeks gestation) failed expectant or medical management modalities dilation of cervix and removal of pregnancy with sharp curettage and/or suction curettage dilation and evacuation (D&E) indications ≥ 16 weeks gestation modalities wide mechanical dilation of cervix with destruction of fetal parts and removal of tissue with large-bore vacuum curette hysteroscopic removal indications retained products of conception after failed expectant, medical, or surgical management no signs of hemorrhage no signs of infection modalities scope used to visualize abnormal tissue abnormal tissue removed with morcellator or grasper Follow-up weekly serum β-hCG after expectant or medical management continue to measure until serum β-hCG undetectable Complications Hemorrhage can occur during miscarriage or during/after surgical treatment could lead to maternal death risk factors uterine atony after surgical treatment cervical injury uterine perforation subinvolution of placental implantation site underlying coagulopathy treatment check for/remove any retained products of conception uterotonics for uterine atony oxytocin misoprostol surgical treatment of cervical injury or uterine perforation intravenous (IV) fluids and blood products if hemodynamically unstable Retained products of conception suspect in patients with uterine bleeding that increases in volume uterine bleeding that persists > 2 weeks after uterine evacuation treatment IV fluids and blood products if hemodynamically unstable urgent surgical intervention Endometritis presentation mild uterine tenderness empty uterus on ultrasound exam +/- fever occurs after complete miscarriage or uterine evacuation treatment oral broad-spectrum antibiotics Septic abortion miscarriage accompanied by intrauterine infection risk factors induced abortion (as opposed to miscarriage) retained products of conception treatment IV fluids and blood products if hemodynamically unstable obtain blood and endometrial cultures IV broad-spectrum antibiotics give until afebrile for 48 hours oral antibiotics give for 10-14 days after completion of IV antibiotic course surgical evacuation of any retained products of conception