Pregnancy loss

Question 1

What is spontaneous abortion/miscarriage?

Answer 1

Loss of pregnancy before 20 weeks’ gestation

Question 2

What is stillbirth/intrauterine fetal demise?

Answer 2

Loss of pregnancy after 20 weeks’ gestation

Question 3

What is recurrent pregnancy loss?

Answer 3

Two or more miscarriages occurring before 20 weeks’ gestation

Question 4

What are the risk factors of spontaneous abortion?

Answer 4

(Maternal) Reproductive organ abnormalities (i.e. cervical incompetence, uterine adhesions)
Systemic diseases (i.e. diabetes mellitus, hyper/hypothyroidism, genetic disorders, hypercoagulability)
(Fetoplacental) Chromosomal/congenital abnormalities
Trauma
Drugs
Toxins

Question 5

What are the risk factors of stillbirths?

Answer 5

(Maternal) Fetal-maternal hemorrhage, Diabetes mellitus, Hypertensive pregnancy disorders, Uterine rupture, advanced age
(Fetoplacental) Intrauterine growth restriction, placental abnormalities (i.e. abruption, previa), infection, congenital
Unknown
Toxin / Drugs

Question 6

What are the types of abortions and the clinical findings?

Answer 6

Threatened abortion: Vaginal bleeding, no foetal activity, closed cervical os
Inevitable abortion: Vaginal bleeding +/- products of conception, open os
Missed abortion: No bleeding, no products of conception, no foetal activity, closed os
Incomplete abortion: Vaginal bleeding, products of conception, open os, usually > 12weeks
Complete abortion: Vaginal bleeding, products of abortion, closed os, usually < 12 weeks
Stillbirth: No foetal movement, no cardiac activity, open/closed os, > 20 weeks

Question 7

How is pregnancy loss diagnosed?

Answer 7

(<20 weeks) Doppler ultrasound for foetal activity 
Pelvic examination 
Transvaginal ultrasound 
Downtrend beta-hCG 
(>20 weeks) US
Foetal autopsy to determine cause

Question 8

What is the treatment for threatened abortion?

Answer 8

Expectant management
Weakly US
Treat underlying conditions
Rh(D)-negative women should receive Rh(D)-immune globulin

Question 9

What is the treatment for inevitable/missed/incomplete/abortions?

Answer 9

Expectant management
Misoprostol (induce expulsion of products of conception)
Pretreatment with mifepristone 24 hours prior is recommended (improves efficacy than just misoprostol)
Surgical evacuation

Question 10

What is the treatment for complete abortions?

Answer 10

No treatment

Question 11

What is the treatment for stillbirths?

Answer 11

Do not rush delivery unless other risk factors present (i.e. preeclampsia, infection)
Spontaneous labor usually begins within 2 weeks of stillbirth
Emotional support

Question 12

What are the complications of pregnancy loss?

Answer 12

(Septic abortion) Complication of a missed, inevitable, or incomplete abortion in which retained products of conception become infected
(Retained products of conception (RPOC)) → release of thromboplastin into systemic circulation → disseminated intravascular coagulation
(Endometritis)