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miscarriage

Spontaneous abortion of the products of conception & pregnancy prior to the middle of the 2nd trimester. Etiology: 1) chromosomal aberrations in > 50% [3] 2) cervical insufficiency is a risk factor - history of cervical intraepithelial neoplasia treated with LEEP or cervical cone biopsy [15] 2) violence NOT linked with miscarriage [2] 3) pharmaceutical agents: - azithromycin, clarithromycin, tetracyclines - doxycycline, minocycline - quinolones, ciprofloxacin, norfloxacin, levofloxacin - sulfonamides & metronidazole exposure early in pregnancy associated with 2-fold increased risk of miscarriage [9] Epidemiology: - increased association with maternal age [3] - 5% in women < 30 years of age - 22% in women > 40 ears of age - misperceptions about miscarriage common [6] - 45% of women believed they had received sufficient emotional support from the medical community Clinical manifestations: - low back pain or abdominal pain (dull to sharp, constant to intermittent) - tissue or clot-like material may pass from the vagina Laboratory: - antiphospholipid Ab (phospholipid antibody in serum) if recurrent miscarriage [15] - parenteral karyotype if recurrent miscarriage [15] Radiology: - transvaginal ultrasound - confirmation - assess risk of miscarriage before 24 weeks of gestation - a cervical length <= 25 mm is consistent with cervical insufficiency [15] - hysterosalpingogram if recurrent miscarriage [15] Complications: - miscarriage is associated with increased premature mortality [12] Management: 1) misoprostol 800 ug vaginally, repeat on day 3 if expulsion of retained placenta incomplete [4] a) 71% success at day 4, 84% at day 8 b) failures 16%, with vacuum aspiration needed at day 30 c) 200 mg oral mifepristone 24 hours prior to vaginal misoprostol improves success rate [10] 2) vacuum aspiration - may not be necessary in misoprostol-treated asymptomatic women with thickened endometrial stripe [5] - need for repeat vacuum aspiration at 30 days is 3% 3) vaginal progesterone of no benefit in preventing miscarriages [7] 4) neither anticoagulants nor aspirin of benefit in preventing miscarriage in women with thrombophilia [5] 5) preconception use of low-dose aspirin is associated with favorable outcomes in women with prior miscarriage [11] 6) live birth rates similar for women who conceive within 3 months of a miscarriage compared with those who waited longer [8]

Related

abortion threatened miscarriage

Specific

papyraceous fetus

General

pregnancy disorder; obstetric disorder; pregnancy complication

References

  1. Stedman's Medical Dictionary 27th ed, Williams & Wilkins, Baltimore, 1999
  2. Journal Watch 24(1):2, 2004 Nelson DB Fertil Steril 80:1205, 2003 PMID: 14607576
  3. Journal Watch 24(12):96, 2004 Spandorfer SD, Davis OK, Barmat LI, Chung PH, Rosenwaks Z. Relationship between maternal age and aneuploidy in in vitro fertilization pregnancy loss. Fertil Steril. 2004 May;81(5):1265-9. PMID: 15136087
  4. Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM; National Institute of Child Health Human Development (NICHD) Management of Early Pregnancy Failure Trial. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med. 2005 Aug 25;353(8):761-9. PMID: 16120856 - Winikoff B. Pregnancy failure and misoprostol--time for a change. N Engl J Med. 2005 Aug 25;353(8):834-6. No abstract available. PMID: 16120864
  5. Orciari Herman A, Fairchild DG, Di Francesco L Recommendations Issued on Managing Early Pregnancy Loss Physician's First Watch, April 22, 2015 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - ACOG News Release. April 21, 2015 ACOG Releases New Recommendations on Early Pregnancy Loss. http://www.acog.org/About-ACOG/News-Room/News-Releases/2015/ACOG-Releases-New-Recommendations-on-Early-Pregnancy-Loss
  6. Bardos J et al. A national survey on public perceptions of miscarriage. Obstet Gynecol 2015 Jun; 125:1313. PMID: 26000502
  7. Coomarasamy A, Williams H, Truchanowicz E et al. A randomized trial of progesterone in women with recurrent miscarriages. N Engl J Med 2015 Nov 26; 373:2141 PMID: 26605928
  8. Schliep KC, Mitchell EM, Mumford SL et al. Trying to conceive after an early pregnancy loss: An assessment on how long couples should wait. Obstet Gynecol 2016 Feb; 127:204 PMID: 26942344 http://journals.lww.com/greenjournal/pages/articleviewer.aspx?year=2016&issue=02000&article=00004&type=abstract
  9. Muanda FT, Sheehy O, Berard A Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ 2017 May 1;189:E625-33 PMID: 28461374 http://www.cmaj.ca/content/189/17/E625.full.pdf+html
  10. Schreiber CA, Creinin MD, Atrio J et al. Mifepristone pretreatment for the medical management of early pregnancy loss. N Engl J Med 2018 Jun 7; 378:2161. June 7, 2018 PMID: 29874535 https://www.nejm.org/doi/10.1056/NEJMoa1715726 - Westhoff CL. A better medical regimen for the management of miscarriage. N Engl J Med 2018 Jun 7; 378:2232. June 7, 2018 PMID: 29874544 https://www.nejm.org/doi/10.1056/NEJMe1804945
  11. Naimi AI, Perkins NJ, Sjaarda LA et al Aspirin on Human Chorionic Gonadotropin - Detected Pregnancy, Pregnancy Loss, and Live Birth. Per Protocol Analysis of a Randomized Trial, Ann Intern Med 2021, Jan 26 PMID: 33493011 https://www.acpjournals.org/doi/full/10.7326/M20-0469
  12. Wang YX, Minguez-Alarcon L, Gaskins AJ Association of spontaneous abortion with all cause and cause specific premature mortality: prospective cohort study. BMJ 2021;372:n530 PMID: 33762255 https://www.bmj.com/content/372/bmj.n530
  13. Abortion, Miscarriage, and Breast Cancer Risk NIH Institute and Center Resources http://cis.nci.nih.gov/fact/3_75.htm
  14. Neil S JAMA Insights Women's Health Management of Early Pregnancy Loss. JAMA. Published online April 7, 2023.
  15. NEJM Knowledge+ - van Dijk MM, Kolte AM, Limpens J et al Recurrent pregnancy loss: diagnostic workup after two or three pregnancy losses? A systematic review of the literature and meta-analysis. Hum Reprod Update. 2020 Apr 15;26(3):356-367. PMID: 32103270 PMCID: PMC7161667 Free PMC article. - Homer HA. Modern management of recurrent miscarriage. Aust N Z J Obstet Gynaecol. 2019 Feb;59(1):36-44. PMID: 30393965 Review.