​Kembara Xtra - Medicine - Miscarriage

​Kembara Xtra - Medicine - Miscarriage 
The failure or loss of a pregnancy before 13 weeks' gestational age (WGA) is referred to as miscarriage, also known as early pregnancy loss (EPL) or spontaneous abortion (SAb).
Related keywords - Anembryonic gestation: Gestational sac without an embryo detectable on ultrasonography (US) after six weeks of gestation
Embryonic or fetal demise: cervix closed; embryo or fetus present in the uterus without cardiac activity. Incomplete abortion: abortion with retained products of conception, typically placental tissue. Induced or therapeutic abortion: evacuation of uterine contents or products of conception through medical or surgical means. Ectopic pregnancy: pregnancy outside the uterus.
- Septic abortion: a spontaneous or therapeutic abortion worsened by pelvic infection; a common complication of illegally performed induced abortions - Threatened abortion: vaginal bleeding in the first trimester of pregnancy
Missed abortion and blighted ovum are less frequently used in favor of terminology that describe the sonographic diagnosis. Synonym(s): spontaneous abortion.

Epidemiology 

Age of predominance: increases with age, especially after age 35; at age 40, the loss rate is double that of age 20.
Incidence
20–25% of clinical pregnancies experience threatened abortion (first-trimester bleeding).
80% of all clinically recognized pregnancies that terminate in EPL do so within 12 weeks of the last menstrual period (LMP), making it between 10% and 15% of all clinically recognized pregnancies.
About 30% of pregnancies terminate in EPL when both clinical and biochemical (-hCG found) pregnancies are taken into account. One in four women will experience an EPL throughout her lifetime.

Pathophysiology and Etiology 
Trauma Maternal factors: uterine abnormalities, infection (toxoplasma, various viruses, rubella, CMV, herpesvirus), maternal endocrine problems, hypercoagulable condition Chromosomal anomalies (50 percent of cases) Congenital malformations Trauma
Genetics
A substantial chromosomal anomaly is present in approximately 50% of first-trimester EPLs, 50% of which are autosomal trisomies, with the remaining 50% being triploidy, tetraploidy, or 45X monosomies.

Risk Elements 

The majority of EPL instances include individuals who have no known risk factors; nevertheless, risk factors can include:
anomalies in the chromosomes
Maternal aging and uterine anomalies
 Maternal chronic disease, such as antiphospholipid antibodies, uncontrolled diabetes mellitus, polycystic ovarian syndrome, obesity, hypertension, thyroid disease, and renal disease. Smoking, alcohol, cocaine use, infection, and luteal phase malfunction are other potential contributing factors.

Prevention 

The use of aspirin and/or other anticoagulants, bed rest, hCG, immunotherapy, uterine muscle relaxants, or vitamins for general EPL prevention, before or after threatening abortion is detected, is not supported by enough data.
Half of threatened abortion-complicated pregnancies already lack fetal heart function when bleeding starts.
Oral progestogens may lower the chance of EPL in threatening abortions (RR 0.73, 95% CI 0.59-0.92) and raise the rate of live births (RR 1.07, 95% CI 1.00-1.15).
Antiphospholipid Syndrome: In women who have antiphospholipid antibodies and a history of recurrent abortion, the combination of unfractionated heparin and aspirin lowers the chance of EPL.


History A woman of reproductive age who complains of nonmenstrual vaginal bleeding should be evaluated for pregnancy.
Vaginal bleeding: Features (amount, color, consistency, related symptoms), onset (rapid or slow), length, intensity/quantity, and aggravating/precipitating variables Prenatal course: toxic or infectious exposures, family or personal history of genetic abnormalities, past history of ectopic pregnancy or EPL, endocrine disease, autoimmune disorder, bleeding/clotting disorder; document LMP if known; abdominal pain/uterine cramping as well as associated nausea/vomiting/syncope; rupture of membranes; passage of products of conception.

clinical assessment 
Abdominal exam for discomfort, guarding, rebound, and bowel sounds (peritoneal symptoms more probable with ectopic pregnancy) Orthostatic vital signs to estimate hemodynamic stability
 A speculum examination for the visual evaluation of cervical dilatation, blood, and fetuses (confirms the diagnosis of EPL)
 A bimanual exam to check for adnexal discomfort or bulk and uterine size-dates discrepancy

Differential Diagnosis Physiologic bleeding in normal pregnancy (implantation bleeding) Ectopic pregnancy: potentially life-threatening; must be taken into consideration by any woman of reproductive age who experiences abdominal pain and vaginal bleeding
hCG-secreting ovarian tumor; subchorionic hemorrhage; cervical polyps, neoplasia, and/or inflammatory diseases; pregnancy with a hydatidiform mole;

Laboratory Results 

Initial examinations (lab, imaging)
Quantitative hCG is especially helpful if the US has not yet verified an intrauterine pregnancy (IUP). Measurements of the quantitative serum hCG over time can determine if a pregnancy is viable. Seven weeks following LMP, serum hCG should increase by at least 53% every 48 hours.
An untimely increase, a plateau, or a decline in hCG points to an atypical IUP or a potential ectopic pregnancy.
CBC (complete blood count) with differential
Cultures: gonorrhea/chlamydia Rh type
 US exam to assess fetal viability and rule out ectopic pregnancy; transvaginal US (TVUS) and abdominal US require hCG levels of at least 2,000 and 5,500 mIU/mL, respectively.
TVUS criteria for nonviable intrauterine gestation include fetal poles measuring 7 millimeters or larger without cardiac activity, gestational sacs measuring 25 millimeters or smaller without a fetal pole, and IUPs lacking growth for more than a week. With TVUS, a gestational sac of 2 to 3 mm is often visible around WGA 5, a yolk sac by WGA 5.5, and a fetal pole with heart activity by WGA 6.

Tests in the Future & Special Considerations
Follow serum hCG levels weekly until zero in the event of vaginal bleeding without a known IUP and hCG levels under 2,000 mIU/mL.
If levels stagnate, think about ectopic pregnancy or retained fetuses. Consider gestational trophoblastic illness if levels are exceedingly high.
If the initial hCG level prevents IUP from being documented by TVUS, monitor serum hCG in 48 hours to record the proper rise.
Once the hCG level matches the depiction on US (see above), repeat the US.
 In the meanwhile, give the patient ectopic prophylaxis for worsening abdomen pain, fainting, and nausea/vomiting.
Offer methotrexate for the treatment of a probable ectopic pregnancy in a pregnancy with an uncertain site and an hCG rise of 53% in 48 hours.


Other/Diagnostic Procedures
In a healthy pregnancy, fetal heart tones can be audibly detected using a Doppler starting between 10 and 12 WGA.
Fetal heart activity between 7 and 11 WGA is 90-96% indicative of prolonged pregnancy in cases where abortion is threatened.


Discuss your contraceptive options when you receive a diagnosis of EPL because ovulation can take place before your menstrual cycle returns to normal.
Although it may take many weeks for the procedure to be finished, expectant management (sometimes known as "watchful waiting") is 90% effective for partial abortions. Only used in the first trimester, this method works best for women who are showing signs of impending miscarriage.

Medication 

Complete miscarriage rates and surgical evacuation requirements are comparable with expectant management and medicines.
For women who get surgical evacuation, medical therapy, or expectant management, the long-term conception rate and pregnancy outcomes are comparable.
Compared to surgical management, medicinal management has reduced infection rates.
Initial Line
Misoprostol is the most used medication for causing tissue passage during incomplete abortions or embryonic death.
- Off-label use; FDA hasn't accepted it for use in treating early pregnancy failure, despite the World Health Organization (WHO) recognizing it as a life-saving drug for this indication
- Efficacy: Complete evacuation of fetal products in 71% of cases by day 3, and in 84% of cases by day 8.
- Dose, gestational age, and mode of administration all affect effectiveness.
- The WHO regimen of 600 mg sublingually every three hours for up to three doses is an alternative regimen; multidose regimens and oral dosage (including buccal and sublingual) may result in greater side effects. The recommended dose is 800 g vaginally.
- If mifepristone 200 mg is added and administered 24 hours before misoprostol, the efficacy increases to 83.8% (ARR 16.7%, 95% CI 7.1-26.3%).
The most typical side effects include nausea, diarrhea, and cramping in the abdomen. Recommended for stable individuals who decline surgery but do not wish to wait for spontaneous passage of fetuses; pain increases at higher dosages but is controlled with oral analgesics.
Next Line
Following an EPL, Rh immunoglobulin (RhoGAM) 50 g IM should be administered to Rh-negative individuals.
Women who show signs of anemia should take iron supplements.

Referral 
For up to a year, patients should be watched for the emergence of pathologic grieving. The evidence is insufficient to recommend therapy as a means of preventing grief-related anxiety or depression after EPL.


The standard surgical procedure is uterine aspiration, also known as manual vacuum aspiration (MVA) or suction dilation and curettage (D&C) or manual uterine aspiration (MUA).
Septic abortion, excessive bleeding, hypotension, persistent IUP following medical or expectant care, and patient preference are indications.
 When compared to expectant management, surgical intervention results in fewer days of vaginal bleeding, with a lower risk of incomplete abortion and heavy bleeding and a similar risk of infection, but at a higher cost. Risks (all rare): anesthesia (typically local), uterine perforation, intrauterine adhesions, cervical trauma, infection that may lead to infertility or increased risk of ectopic pregnancy. Prioritizing the patient's preferences when choosing management is suitable.
Aspiration is seen to be superior to sharp curettage since it is less unpleasant, takes less time, results in less blood loss, and doesn't require general anesthesia. Vacuum aspiration (either manual or electric) is also preferred over sharp curettage. Suction curettage is preferred by the WHO over hard metal curettage.
Data are insufficient to justify the use of antibiotics prior to aspiration for EPL, despite evidence from induced abortions suggesting that antibiotic prophylaxis with doxycycline 200 mg in a single dose reduces the already low risk of postprocedure infection.

Alternative Therapies 
In comparison to Western medicine alone, Chinese herbal medicine improved sustained viability at 28 weeks, according to a comprehensive review (number required to treat [NNT] = 4.8 pregnancies with combined therapy). The available studies, however, did not adhere to global norms for accurate reporting.

Admission 
If the patient's vital signs are orthostatic, start resuscitation by giving them IV fluids and/or blood if necessary. Patients with hemodynamic instability may need IV fluids and/or blood products to keep their blood pressure steady.

Take Action 

All patients should be given the option of a follow-up appointment in 2 to 6 weeks to check on the status of any bleeding, menstrual cycle recovery, or grieving symptoms, as well as to assess the contraception strategy.

patient observation
It is not necessary to check or monitor serum hCG to 0 if EPL occurs in the context of previously documented IUP and the abortion is terminated with the return of normal menstruation.
Following medical care, use US or serial serum -hCG to confirm full ejection.
 If pregnancy is not desired right away, suggest a reliable form of contraception. Provide preconception counseling if pregnancy is desired; immediate implantation of an intrauterine device is permissible and safe.
There is no proof that waiting a specific number of cycles before trying to conceive again is necessary.

If the patient is having a D&C under general anesthesia, they must eat NPO.

Patient Education: Advise patients to call if they experience significant bleeding (soaking two pads every hour for two hours), fever, pelvic pain, or malaise as these symptoms may point to endometritis or retained sperm.

Once bleeding is under control, the prognosis is favorable. For recurrent miscarriages, the prognosis depends on the underlying cause; subsequent pregnancies have a success rate of up to 70%.

D&C or MUA complications include uterine perforation, hemorrhage, adhesions, cervical trauma, and infection, which might raise the risk of ectopic pregnancy or infertility. Retained products of conception: Bleeding and adhesions are more prevalent with D&C than with MUA, and all complications are uncommon.