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) login to view 4 more bullets risk factors advanced maternal age (> 35 years old) login to view 1 more bullet advanced paternal age prior pregnancy loss login to view 1 more bullet maternal diabetes login to view 2 more bullets obesity thyroid disease login to view 1 more bullet stress login to view 1 more bullet inherited thrombophilias or coagulopathies login to view 1 more bullet 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 login to view 2 more bullets syphilis login to view 1 more bullet cytomegalovirus (CMV) login to view 1 more bullet incompetent cervix uterine abnormalities leiomyomas (fibroids) polyps adhesions septa bicornate uterus login to view 2 more bullets trauma direct impact to uterus violent login to view 3 more bullets iatrogenic login to view 2 more bullets 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 login to view 6 more bullets 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 login to view 3 more bullets may have abnormal β-hCG levels Hydatidiform mole key distinguishing factors ultrasound findings login to view 2 more bullets abnormally elevated β-hCG Treatment Expectant management counseling and return precautions indications login to view 6 more bullets majority of expulsions occur in first 2 weeks after diagnosis if unsuccessful after four weeks then proceed to surgical evaluation Medical misoprostol indications login to view 5 more bullets modalities login to view 2 more bullets mifepristone indications login to view 2 more bullets modalities login to view 1 more bullet rhoGAM indications login to view 1 more bullet modalities login to view 1 more bullet Surgical dilation and curettage (D&C) indications login to view 3 more bullets modalities login to view 1 more bullet dilation and evacuation (D&E) indications login to view 1 more bullet modalities login to view 1 more bullet hysteroscopic removal indications login to view 3 more bullets modalities login to view 2 more bullets 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 login to view 2 more bullets 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 login to view 1 more bullet oral antibiotics login to view 1 more bullet surgical evacuation of any retained products of conception