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MISCARRIAGE - SPONTANEOUS

Spontaneous miscarriage is the loss of fetus before 20 weeks of gestation or delivery of a fetus weighing <500 g, in the absence of elective medical or surgical measures to terminate pregnancy.
Early loss is considered if it occurred before menstrual week 12 while late loss refers to those that occurred from menstrual week 12-20.
It is also known as spontaneous abortion, spontaneous pregnancy loss or early pregnancy failure.

Pharmacotherapy

Management for Septic Miscarriage
Antibiotics (Broad Spectrum, Parenteral)
  • Eg Clindamycin plus Gentamicin with or without Ampicillin, Ampicillin plus Gentamicin and Metronidazole, Levofloxacin and Metronidazole, Ticarcillin- clavulanate, Piperacillin-tazobactam, Imipeem
  • Administered immediately to patients diagnosed with septic miscarriage until the patient has improved and afebrile for 48 hours, then shifted to oral antibiotics  to complete for 10-14 days
  • Various antibiotics for septic miscarriage are available. Please see the latest MIMS for specific prescribing information
Management for Threatened Miscarriage
Anti-D Immunoglobulin
  • May be given to patients who had threatened miscarriage at <12 weeks gestation when bleeding was heavy or associated with pain
  • In patients who are Rh(D) negative and unsensitized, Rh(D) immune globulin should be given immediately following surgical intervention of early pregnancy loss or within 72 hours of early pregnancy loss diagnosis with medical or expectant management planned in the 1st trimester 
  • Intramuscular doses are administered into the deltoid muscle
  • Not recommended in patients who had a complete miscarriage <12 weeks of gestation where there has been no surgical intervention
Progesterone
  • Important hormone for establishing and maintaining pregnancy
  • Immediate administration of progestogen proceeding current pregnancy in patients with ≥3 consecutive miscarriages has shown benefits
  • Studies have shown that progestogens are effective in the treatment of threatened miscarriage with no harmful effects to the mother nor to the newborn (ie  no evidence of increased rates of pregnancy-induced hypertension or antepartum hemorrhage, no increased occurrence of congenital abnormalities)
  • In small studies, Dydrogesterone was shown to be superior than no treatment in continuing pregnancy until 20 weeks of gestation
    • Another study showed that support of corpus luteum with Dydrogesterone decreases pregnancy loss in threatened miscarriage during the first trimester in women with no history of recurrent miscarriage
  • Progesterone therapy for threatened miscarriage is given either orally or vaginally, though the optimal dose and route of therapy has not been determined
Management for Incomplete/Inevitable/Missed Miscarriage
Misoprostol
  • A prostaglandin analogue that may be given orally or vaginally depending on patient’s preference
    • Dosages vary depending on the route of administration and the fetus' gestational age
  • Used for initial medical management of incomplete or missed miscarriage in patients with no signs of infection, excessive bleeding, or abdominal pain
    • Patients may be given single doses of Misoprostol at 600 mcg orally for incomplete miscarriage while for missed miscarriage 800 mcg intravaginally or 600 mcg sublingually 
    • Counsel patients with missed miscarriage that the duration and intensity of lower abdominal cramping and genital blood loss may increase with medical therapy
  • May also be given for cervical priming 3 hours prior to surgical evacuation of retained products of conception

Management for Recurrent Miscarriage with No Identifiable Cause

  • Progestogens may be used for early and late spontaneous recurrent miscarriage
  • Multivitamins and supplementation with folic acid are used though with no confirmed benefit 
Management for Recurrent Miscarriage due to Antiphospholipid Syndrome
Aspirin (Low-dose) Plus Heparin
  • Should be considered in women with antiphospholipid syndrome to prevent further miscarriage
    • Reduces miscarriage rate by 54%
    • Improves live birth rate of women with recurrent miscarriage associated with antiphospholipid antibodies but needs vigilant antenatal surveillance since these pregnancies are still at risk of complications (ie repeated miscarriage, preeclampsia, fetal growth restriction, preterm birth)
  • Heparin therapy during pregnancy may improve live birth rate in patients with second trimester miscarriage associated with inherited thrombophilias
    • Reduction of pregnancy loss is more effective with the addition of unfractionated Heparin than with low molecular weight Heparin
  • Heparin has no potential to cause fetal hemorrhage or teratogenecity but may cause maternal bleeding, hypersensitivity reactions, Heparin-induced thrombocytopenia, and if used long term, osteopenia and vertebral fractures
Others
  • Pain reliever and anti-emetics should be offered to patients undergoing medical management

Non-Pharmacological Therapy

Expectant Management/Spontaneous Resolution
  • Used for 7-14 days as first-line management in patients with confirmed miscarriage
  • May be considered depending on patient’s clinical status, desire to continue pregnancy, and certainty of diagnosis
    • Complete spontaneous expulsion of fetal tissue usually occurs in pregnancies <6 or >14 weeks
    • Has risk of infection or hemorrhage
  • Highly effective in patients with incomplete spontaneous miscarriage with no need for surgical intervention
  • Patient should be advised that complete resolution may take several weeks and that overall efficacy rates may be lower than medical or surgical interventions
    • Follow-up scans may be done every 2 weeks until a complete miscarriage is diagnosed
  • Should not be considered in women at increased risk of hemorrhage and its effects (eg has coagulopathies), has previous traumatic pregnancy (eg stillbirth, miscarriage, antepartum hemorrhage), or has an infection
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