Summary
Miscarriage, trivialised by many as the spontaneous loss of a pregnancy that occurs before the fetus can survive outside the uterus, is not a minor issue. Technically, the limit of viability is set at the 24th week of gestation, but this is subject to change in line with developments in neonatal care. Miscarriages have been described as early (under 12 weeks of gestation) or late (13-24 weeks of gestation). Recurrent miscarriage is defined as the occurrence of 3 or more consecutive miscarriages in some texts and as 2 or more miscarriages, consecutive or not, in others. Regardless, it affects 1% of women of reproductive age. Verification of diagnosis, using ultrasound, may be tricky at times and it is better to take the approach of being 'safe than sorry'.
Miscarriage vs Abortion
Aroound a quarter of women who miss a period and have a positive pregnancy test end up with a pregnancy loss. Perhpas more pregnancies are lost as in the absence of testing it is not possible to be. certain of exact numbers. Technically, the loss of pregnancy before it reaches a certain level of maturity is called abortion (dubbed in various names like threatened abortion, inevitable abortion, incomplete abortion, complete abortion), but the word miscarriage is far more frequently understood. There are 100,000+ miscarriages annually in country to like the UK with around 50,000 hospitalizations. The burden of the disease is considerable, and the health costs and personal toll enormous. Apart from the adverse effects on social and psychological well-being, there is mortality associated with miscarriage, most common causes of death being haemorrhage and sepsis.
The most common cause of miscarriage in early pregnancy is believed to be chromosomal abnormality, which some say is a way for nature to protect against the anomalies not compatible with life and life quality. Other less common causes of miscarriage are antiphospholipid syndrome, inherited thrombophilias (antithrombin deficiency, protein C and protein S deficiency, factor V Leiden mutation, and mild hyperhomocysteinemia), and structural congenital abnormalities of the uterus. The risk of miscarriage is also higher in poorly controlled chronic disease including type 1 diabetes, thyroid disease. obesity, etc.
Ultrasound for diagnosis
Vaginal bleeding and the disappearance of pregnancy symptoms cause an alert about the possibility of a miscarriage. The limited information gained via medical history and physical examination for diagnosis of make clinical assessments unnecessary when diagnosis based on ultrasound can be made in the vast majority of cases. Occasionally, a woman with heavy bleeding and signs of cardiovascular collapse, may. need life saving treatment on an urgent basis without an ultrasound scan.
In the current day, transvaginal ultrasound has become the standard for examining women. With suspected miscarriage in early pregnancy confirmed by urinary test, ultrasound can diagnose a normal, healthy, early intrauterine pregnancy with a miscarriage. There can be a risk of diagnostic error so a repeat ultrasound after a few days or by a second observer may confirm viability. Misdiagnosing a normal pregnancy could result in the iatrogenic loss of a desired normal pregnancy. To be certain, blood biochemical markers, human chorionic gonadotropin and progesterone, may be used. It is important to exclude the possibility of an ectopic pregnancy.
Treatment and aftercare
There is nothing wrong with 'wait and watch' if there is no urgency. Surgery is not routinely required to diagnose or treat miscarriage. For women who opt for surgical treatment, it is important to send the product of the uterine curettage to be examined histologically to confirm the diagnosis of intrauterine pregnancy and to exclude a molar pregnancy.
Miscarriage can be prevented by bed rest or by vitamin supplementation, but if there is no harm what's the risk. Women often choose watchful waiting versus active management (medical or surgical) there may be a higher rate of unplanned emergency interventions. The success of medical treatment depends on several factors including the type of miscarriage, the dose of the drug, the route of administration, and the time available to pass the conception products. It may help avoid the need for surgical intervention but it entails the suffering of side effects over a time period. By contrast surgical treatment may be considered definitive and the choice should be informed. Surgical option may be ambulatory without general anaesthesia.
After a miscarriage, normal menstrual periods should resume in 1 to 2 months. Once the bleeding has stopped, the resumption of sexual activity is safe. There are no medical reasons for women to delay trying a new pregnancy. Since most miscarriages are caused by chromosomal abnormalities, women do not have to be screened for other less common causes of miscarriage, unless they experience recurring losses. Miscarriage is a sad and stressful event for women, their partners and families. It represents the loss of a baby. Respect and sensitivity are necessary along with clear explanations of the processes, procedures, and options. Some women may develop anxiety and depression after the loss of a pregnancy and may benefit from further counselling and psychological support.
Conclusion
Trivialised as loss of an immature pregnancy, miscarriage can cause serious morbidity to the mother and the family. There is a need to provide women, their partners and the family with support and counselling. Early pregnancy assessment services with ultrasound must be available round the clock to women with bleeding in the first half of pregnancy. All clinically stable women with a confirmed diagnosis of miscarriage should be given evidence-based information to decide on watchful waiting as a first-line treatment option or surgical treatment to those who prefer this option. Those who have persistent excessive bleeding, hemodynamic instability, evidence of infected retained tissue, and suspected gestational trophoblastic disease need targeted management based on proper guideline recommendations.
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