ORGANUM
Six types:
Threatened miscarriage
Inevitable miscarriage
Complete miscarriage
Miscarriage with infection (sepsis)
Missed miscarriage (empty gestational sac, embryonic loss, early and late fetal loss)
Spontaneous second trimester loss
The first sign of an impending miscarriage is the development of vaginal bleeding in early pregnancy. The uterus is found to be enlarged, and the cervical os is closed. Lower abdominal pain is either minimal or absent. Most women presenting with a threatened miscarriage will continue with the pregnancy irrespective of the method of management.
The patient develops abdominal pain usually associated with increasing vaginal bleeding. The cervix opens, and eventually products of conceptions are passed into the vagina. However, if some of the products of conception are retained, the miscarriage remains incomplete.
Distension of the cervical canal by products of conception can cause hypotension and bradycardia (cervical shock)
An incomplete miscarriage may proceed to completion spontaneously, when the pain will cease and vaginal bleeding will subside with the involution of the uterus. Spontaneous completion of a miscarriage in over 16 weeks gestation is more likely than in those between 8 and 16 weeks gestation, when retention of placental fragements is common.
During the process of miscarriage - or after therapeutic termination of a pregnancy - infection may be introduced into the uterine cavity. The clinical findings of septic miscarriage are similar to the those of incomplete miscarriage with the addition of uterine and adnexal tenderness. The vaginal loss may become purulent and the patient pyrexial. In cases of severe overwhelming sepsis, endotoxic shock may develop with profound and sometimes fatal hypotension. Other manifestations include renal failure, disseminated intravascular coagulopathy and multiple petechial hemorrhages. Organisms which commonly invade the uterine cavity are E.coli, Streptococcus faecalis, Staphylococcus albus and aureus, Klebsiella and Clostridium welchii and perfringens.
In empty gestational sac (anembryonic pregnancy or blighted ovum), a gestational sac of >25mm is seen on ultrasound but there is no evidence of an embryonic pole or yolk sac or change in the size of the sac on rescan 7 days later. Embryonic loss is diagnosed where there is an embryo >7mm in size without cardiac activity or where there is no change in the size of the embryo after 7 days on the scan. Early fetal demise occurs when a pregnancy is identified within the uterus on ultrasound consistent with 8-12 weeks but no fetal heartbeat. These may be associated with some bleeding and abdominal pain or be asymptomatic and diagnosed on ultrasound scan. The pattern of clinical loss may indicate the underlying aetiology; for example, antiphospholipid syndrome tends to present with recurrent fetal loss.
Pregnancy loss occurs between 12 and 24 weeks associated with spontaneous rupture of membrane or cervical dilation despite the presence of of fetal heart activity.