miscarriage
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Introduction
Spontaneous abortion of the products of conception & pregnancy prior to the middle of the 2nd trimester.
Etiology
- chromosomal aberrations in > 50%[3]
- cervical insufficiency is a risk factor
- history of cervical intraepithelial neoplasia treated with LEEP or cervical cone biopsy[15]
- violence NOT linked with miscarriage[2]
- 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
- misoprostol 800 ug vaginally, repeat on day 3 if expulsion of retained placenta incomplete[4]
- 71% success at day 4, 84% at day 8
- failures 16%, with vacuum aspiration needed at day 30
- 200 mg oral mifepristone 24 hours prior to vaginal misoprostol improves success rate[10]
- 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%
- vaginal progesterone of no benefit in preventing miscarriages[7]
- neither anticoagulants nor aspirin of benefit in preventing miscarriage in women with thrombophilia[5]
- preconception use of low-dose aspirin is associated with favorable outcomes in women with prior miscarriage[11]
- live birth rates similar for women who conceive within 3 months of a miscarriage compared with those who waited longer[8]
More general terms
More specific terms
Additional terms
References
- ↑ Stedman's Medical Dictionary 27th ed, Williams & Wilkins, Baltimore, 1999
- ↑ 2.0 2.1 Journal Watch 24(1):2, 2004 Nelson DB Fertil Steril 80:1205, 2003 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14607576
- ↑ 3.0 3.1 3.2 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: https://www.ncbi.nlm.nih.gov/pubmed/15136087
- ↑ 4.0 4.1 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: https://www.ncbi.nlm.nih.gov/pubmed/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: https://www.ncbi.nlm.nih.gov/pubmed/16120864 - ↑ 5.0 5.1 5.2 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 - ↑ 6.0 6.1 Bardos J et al. A national survey on public perceptions of miscarriage. Obstet Gynecol 2015 Jun; 125:1313. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26000502
- ↑ 7.0 7.1 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: https://www.ncbi.nlm.nih.gov/pubmed/26605928
- ↑ 8.0 8.1 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26942344 <Internet> http://journals.lww.com/greenjournal/pages/articleviewer.aspx?year=2016&issue=02000&article=00004&type=abstract
- ↑ 9.0 9.1 Muanda FT, Sheehy O, Berard A Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ 2017 May 1;189:E625-33 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28461374 <Internet> http://www.cmaj.ca/content/189/17/E625.full.pdf+html
- ↑ 10.0 10.1 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: https://www.ncbi.nlm.nih.gov/pubmed/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: https://www.ncbi.nlm.nih.gov/pubmed/29874544 https://www.nejm.org/doi/10.1056/NEJMe1804945 - ↑ 11.0 11.1 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: https://www.ncbi.nlm.nih.gov/pubmed/33493011 https://www.acpjournals.org/doi/full/10.7326/M20-0469
- ↑ 12.0 12.1 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: https://www.ncbi.nlm.nih.gov/pubmed/33762255 https://www.bmj.com/content/372/bmj.n530
- ↑ Abortion, Miscarriage, and Breast Cancer Risk NIH Institute and Center Resources http://cis.nci.nih.gov/fact/3_75.htm
- ↑ Neil S JAMA Insights Women's Health Management of Early Pregnancy Loss. JAMA. Published online April 7, 2023.
- ↑ 15.0 15.1 15.2 15.3 15.4 15.5 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: https://www.ncbi.nlm.nih.gov/pubmed/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: https://www.ncbi.nlm.nih.gov/pubmed/30393965 Review.