Miscarriage

& RPL
2024-2025
Soha AlBeitawi

Infertility & Reproductive Medicine

Specialist
Associate prof.
EBOG, JBOG, MBBS
Learning objectives
1. Be able to diagnose miscarriage & to differentiate between different
types
2. To know the etiology of miscarriage
3. To know the different management options, the indications,
contraindications & complications
4. Be Familiar with surgical instruments used in D&C/E&C
5. Understand the definition of recurrent pregnancy loss (RPL)
6. Know the causes of RPL
7. Know how to approach couples with RPL
8. Know the principles of management of RPL
9. Be able to provide a proper counselling for couples with RPL or after
sporadic miscarriage
 Definition: = the expulsion of POC
before the age of viability
(WHO: 22 wk or wt > 500 gm/ UK: 24 wk)

 20 % of clinically recognized
pregnancies
Abortion vs
Miscarriage
1. Threatened
2. Inevitable
3. Incomplete
4. Complete
5. Missed
6. Septic
7. Recurrent
 Threatened miscarriage
 Bleeding from placental site which is not severe
enough to terminate pregnancy
 S&S:

1. Vaginal bleeding (usually 1 symptom) ±

st

2. Abd pain
3. Closed os
4. Normal size GS
5. + FHB (up t0 97% preg. Continues)

Amount of bleeding may vary from just spotting to a gush

with clots.
Why this bleeding??

1. Sub-chorionic hematoma (not seen often)

2. Implantation (may cause some blood vessel to
bleed
3. Cervix: becomes softer & rich in blood supply
during pregnancy, so any slight trauma can
provoke bleeding
4. Vagina: any infection can cause bleeding in the
form of spotting
 NO specific treatment to stop
bleeding
Inevitable miscarriage

1. Vaginal bleeding (more severe)

2. Abd pain & cramping
3. Dilated cervical os ±
4. Tissue felt in cervix
5. US: + or - FHB
 Incomplete Miscarriage

1. Fetus & membranes are expelled

2. Chorionic tissue remains attached
3. Bleeding continues
4. US : debris in uterine cavity
5. Intrauterine tissue diameter ≥ 15mm
(*)

(*) institute of obs&gyn, Ireland

 Complete Miscarriage
1. Hx of pain & bleeding & passage
of POC
2. Pain & bleeding subsided
3. Os closed
4. US: empty cavity ( ET < 15mm)

** bleeding usually subside within 10 days

Missed Miscarriage
The retention of dead fetus
S&S:
1. Usually Hx of threatened miscarriage
2. Brown discharge
3. Sx of pregnancy disappear
4. Os closed
5. US: NO FHB
** coagulation defect may occur if not evacuated (spont. or
induced) within 28 days
Dx of miscarriage (when missed)
1. Gs ≥ 25 mm w/o YS VISIBLE
2. Fetal pole CRL ≥ 7mm w/o FHB
 If uncertain  repeat scan after 7 days
Septic Miscarriage
 Any miscarriage that got infected
 S&S:

1. Pain
2. Pink vaginal discharge
3. Fever
4. Tachycardia
5. Tender lower uterus
Causes of septic..
1.Delay in evacuation of the uterus
2. Trauma , perforation or cervical
tear
- Infecting organisms: anerobic streptococcus, Coliform
bacillus, Cl. Welchii, Bacteroides fragilis
Closed OS Opened OS
?? ??
?? ??
??
Pregnancy of unknown location
(PUL)

= no signs of intrauterine or ectopic

pregnancy with + pregnancy test:
1. Very early intrauterine pregnancy or
2. Complete miscarriage or
3. Early ectopic
Etiology of miscarriage

 Embryonic:

-chromosomal abnormalities are the most

common cause of spontaneous miscarriage.
**80-90% of 1st trimester miscarriage- 1/3 trisomies
**More than 90% of cytogenic and morphologic errors are
eliminated through spontaneous miscarriage .

The rate of chromosomal abnormalities ↑ with age,

with a steep ↑ at > 35 years.
Etiology of Sporadic miscarriage
 Maternal:
1. Chronic illness: severe HTN, renal disease,
SLE,
2. Acute infection
3. trauma
4. Alcohol, tobacco, cocaine
5. Anatomic abnormalities
6. Endocrine : IDDM, hypothyroidism
7. Immunologic: APS (more 2nd trimester loss)
Complications of miscarriage
1. Infection
2. Coagulation disorder
3. Psychologic trauma
.
Workup
1. BG & RH
2. CBC
3. Factor XIII & fibrinogen (if
needed)
Management Non- sensitized Rhesus (Rh - ) women should receive prophylactic
anti-D (Ig) in the following situations:
1. Ectopic pregnancy,
2. All miscarriages over 12 week’s gestation (including
- ABC…. threatened)
3. All miscarriages were the uterus is evacuated
- Anti –D:250 IU (50 µg) surgically.
4. Threatened miscarriage under 12 weeks gestation when
bleeding is heavy or associated with pain

1. Expectant
2. Medical : misoprostol
3. Surgical ( E&C)

--The risk of immunization before 12 weeks' gestation is negligible when there has been no
instrumentation
Expectant management:
How?? & Whom??
 7-14 days as the first-line management strategy for stable women

with a confirmed diagnosis of miscarriage.

NO (signs of infection, excessive bleeding, pyrexia or abdominal
pain)
 Majority will miscarry within 2-3 wks

 Give oral and written information about what to expect throughout the
process, advice on pain relief and where and when to get help in an emergency
Follow up ??? If ET < 15 mm : complete
 Rescan in 2 weeks if still bleeding If > 15 mm  consider
surgery
 Urine pregnancy test 3 weeks after resolution
Medical management
Acceptable to offer provided that there are NO:
1. Signs of infection
2. Excessive bleeding
3. Pyrexia
4. Abdominal pain
 Misoprostol (cytotec)
• Its use for treatment of early pregnancy failure in
women with prior uterine surgery is safe.

• Bleeding settle down & continue like a period for

up 7-10 days

• Urine Pregnancy test 3 weeks later

Allow analgesia + anti-

emetics
Indications for suction curettage
1. Hemodynamic instability (BP < 90/50, PR
> 100bpm)
2. Persistent excessive vaginal bleeding
3. Severe pain
4. Suspected GTD
5. Anemia (Hb < 10 g/dl)
6. Infected RPOC / Septic (T > 37.5˚c )
7. Maternal wishes
Anesthesia:

1. Local anesthesia (para-cervical block)

with 1% lidocaine
2. Procedural sedation (i.e, propofol,
fentanyl, midazolam)
3. Regional anesthesia (spinal or epidural
nerve blocks)
4. General anesthesia
Complications
of treatment
Cervical preparation
Misoprostol 400mcg vaginally /orally 3 hours prior to
 Surgical: surgery  Significant reduction in dilatation force,
Hmg, uterine & cervical trauma.
1. Uterine perforation 1%
2. Intra-abdominal, Cervical
trauma 0.1%  Medical:
3. Infection (same for all 1. N, V, diarrhea
methods) 2. Hmg
4. Hmg 3. Incomplete miscarriage &
5. RPOC need for surgery
6. Asherman (destruction of strata
basalis)
How to reduce the risk of
complications??
 Doctor for how long I will bleed after
evacuation???

 Bleeding (mild) may last 7-10 days after

evacuation – up to 21 days
Psychological effects
1.Why did the miscarriage occur????
2. Is there anything that I did or didn’t
do that caused miscarriage???
3. Is my next pregnancy end like this???

‫ والذي نفسي بيده إن‬:‫ثم قال‬

‫السقط ليجر أمه بسرره إلى الجنة‬
 How long should i wait before trying
for another baby??

 Once you feel ready

 Preferably until after a normal period
(which is usually 3-4 weeks after a
miscarriage )
 Recurrent
pregnancy loss
(RPL)
 Lossof ≥ 2 pregnancies. [ESHRE 2017]
 1% of couple trying to conceive
Risk factors:
1. Maternal age
2. Paternal age ( > age of 40 )
3. Previous reproductive history
4. Maternal cigarette smoking & caffeine consumption
5. Obesity ( ↑ sporadic & RM)
6. Stress ??
7. Genetic
8. Thrombophilia
9. Anatomical factor
10. Endocrine ??
11. Infection
 Maternal age
Age (years) Miscarria
 Strong independent ge rate
RF for miscarriage. 20-24 11%
 Reflects declining in 25-29 12%
the number & quality 30-34 15%
of remaining oocytes 35-39 25%
- Many cases of RM will be explained 40-44 51%
solely by advancing maternal age
≥ 45 93%
 Reproductive history

 Independent predictor of future pregnancy outcome

 Risk of further miscarriage ↑ after each successive
pregnancy loss:

No loss 9%
1 loss 12%
2 20%
≥3 40%
Genetic factors:
- Fetal aneuploidy  the most important cause of

miscarriage before ???

- 10 wk gestation
- Trisomy the most frequent

- 2-5 % of RM  1 partner carries a balanced

structural chromosomal anomaly
 Carriers of these translocations are phenotypically ????
NORMAL
 But 50-70% of there gametes are unbalanced bcoz

of abnormal segregation at meiosis

 Result in miscarriage or live birth with multiple

congenital malformation ± mental disability
Acquired thrombophilia = Antiphospholipid
syndrome (APS)

= acquired autoimmune disorder associated with

vascular thrombotic events & pregnancy
failure
1. Primary APS
2. Associated with other aid: SLE
Antiphospholipid Antibodies
= family of around 20 AB that are directed against
phospholipid binding plasma proteins
- include:

1. lupus anticoagulant
2. Anticardiolipin Ab
3. Β2- glycoprotein I Ab
- Present in 15% of women with RM
- If untreated  90% risk of further loss
Early in pregnancy Later in pregnancy

Pathophysiology
1. Inhibition
trophoblastic
of Thrombosis of the
utero-placental
function & vasculature
differentiation

2. Activation of
complement pathways 
inflammation
mediated placental
injury
Anatomical factors:
1. Congenital uterine anomalies (uterine septate &
bicornuate)
2. Uterine fibroids, WHY???
3. Cervical weakness
Infection:
 Any severe infection that leads to bacteremia or
viremia can cause sporadic miscarriage
 To cause RM infective agent should persist in genital tract
while asymptomatic

 TORCH : doesn’t meat this criteria

Chronic endometritis
 Persistent inflammation of endometrium &
excessive plasma cells in endometrial stroma
 May impair endometrial receptivity
 Often asymptomatic, or
 Mild Sx:
1. Pelvic pain
2. Dyspareunia
3. AUB
4. Leukorrhea
 Can cause PTL
Management of RPL:
- General advice + (according to etiology):
 Psychological support + regular scans  ↓ miscarriage
rate in unexplained RM
 60-75% chance of successful future pregnancy without
pharmacological intervention in unexplained RM
 ↓ wt, smoking….
 Healthy diet
 Folic acid
 Control chronic illness
Inherited thrombophilia

- A recent systemic review reported no

benefit of LMWH for prevention of PL in
women with hereditary thrombophilia
and RPL . [ESHRE 2017]
 ‫عن معاذ بن جبل‪ ،‬قال‪ :‬قال رسول الله ‪ -‬صلى الله عليه‬
‫وسلم ‪ :-‬ما من مسلمين يتوفى لهما ثالثة‪ ،‬إال أدخلهما الله‬
‫الجنة بفضل رحمته إياهما‪ ،‬فقالوا‪ :‬يا رسول الله! أو اثنان؟‬
‫قال‪ :‬أو اثنان‪ .‬قالوا‪ :‬أو واحد؟ قال‪ :‬أو واحد‪ .‬ثم قال‪:‬‬
‫والذي نفسي بيده إن السقط‬
‫ليجر أمه بسرره إلى الجنة إذا‬