MISCARRIAGE

 A natural loss of the products of pregnancy.

Miscarriage, also known as spontaneous abortion and pregnancy loss, is the natural death of an embryo or fetus before it is able to survive independently. Some use the cutoff of 20 weeks of gestation, after which fetal death is known as a stillbirth. The most common symptom of a miscarriage is vaginal bleeding with or without pain. Sadness, anxiety and guilt often occur afterwards. Tissue and clot-like material may leave the uterus and pass through and out of the vagina. When a woman keeps having miscarriages, infertility is present.

Source: Miscarriage – https://en.wikipedia.org

Both Manual Vacuum Aspiration (MVA) and medical evacuation are equally effective for miscarriage. However, in the follow settings, MVA is preferred:

»     septic miscarriage

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»     anaemia

»     haemodynamic instability

»     second trimester miscarriage

SILENT MISCARRIAGE OR EARLY FETAL DEMISE

GENERAL MEASURES

Counselling.

Evacuation of the uterus.

MEDICINE TREATMENT

Before MVA, to ripen the cervix:

  • Misoprostol, oral/PV, 400 mcg as a single dose.

Medical evacuation:

  • Misoprostol, oral/PV, 600 mcg as a single dose.

       o      Repeat after 24 hours if necessary.

INCOMPLETE MISCARRIAGE IN THE FIRST TRIMESTER

GENERAL MEASURES

Counselling.

Evacuation of the uterus after ripening the cervix.  

MEDICINE TREATMENT

Before MVA, to ripen the cervix:

  • Misoprostol, oral/PV, 400 mcg as a single dose.

Medical evacuation:

  • Misoprostol, oral/PV, 600 mcg as a single dose.
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      o       Repeat after 24 hours if necessary.

MIDTRIMESTER MISCARRIAGE (FROM 13–22 WEEKS GESTATION)

GENERAL MEASURES

Counselling.

Evacuation of the uterus after the fetus has been expelled.

MEDICINE TREATMENT

  • Misoprostol, PV, 400 mcg immediately.

Follow with:

  • Misoprostol, oral, 400 mcg every 4 hours until expulsion of the products of conception.

      o       Duration of treatment must not exceed 24 hours.

Warning

Uterine rupture may occur in women with previous Caesarean sections.

Caution for this group and those of high parity: use 200 mcg of misoprostol or alternative methods such as extra-amniotic saline infusion without misoprostol.

If cervical dilatation already present:

  • Oxytocin, IV.
    • Dilute 20 units in 1 L sodium chloride 0.9%, i.e. 20 milliunits/mL solution, and infuse at 125 mL/hour.
    • Reduce rate if strong contractions are experienced.
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Note:

Check serum sodium if used for more than 24 hours because of the danger of dilutional hyponatraemia.

For analgesia:

  • Morphine, IV, 10 mg 4 hourly.

If Rh-negative:

  • Anti-D immunoglobulin, IM, 100 mcg as a single dose.

REFERRAL

»     Uterine abnormalities.

»    Recurrent miscarriages (3 consecutive spontaneous miscarriages).

»      Suspected cervical incompetence: mid-trimester miscarriage(s) with minimal pain and bleeding.

»     Immunological problems.

»     Diabetes mellitus.

» Parental genetic defects and SLE or other causes of autoimmune disease.

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