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Clinical Opinion MISCARRIAGE
The majority of miscarriages are diagnosed after a patient complains of vaginal bleeding, cramping or even passage of products of conception. Miscarriage can also be diagnosed at the time of routine, first trimester ultrasound. The risks of miscarriage is unexpectedly high. Approximately 20% to 25% of all pregnancies miscarry. Some experts believe that the likelihood is even higher if very early pregnancies are considered (chemical pregnancies are diagnosed with transitory elevation of hCG associated with only a slight delay in the onset of the next menstrual period). In the late 1960s, when science became able to evaluate chromosomes, a variety of studies were done on the chromosomal constituents of spontaneous abortuses. Chromosomes are the genetic ―building blocks.‖ The range, in the literature, is between 60% and 70% of abortuses tested that were chromosomally abnormal. This suggested the vast majority of lost pregnancies are not normal. Experts have likened miscarriage to ―nature's quality assurance mechanism." It is likely that the majority of the other losses had other abnormalities which were not detectable with gross chromosomal evaluation in the late 1960s, including possible metabolic or non-chromosomally based structural disorders which lead to demise and miscarriage. The genetic constitution of the fetus is determined at the moment of fertilization in the fallopian tube-- when egg meets sperm. In cases where initial cell divisions (meiosis and mitosis) do not proceed normally miscarriage will ensue the majority of times, although some fetuses are live born with a variety of chromosomal abnormalities. The mother has no role in causation of miscarriage. Such things as exercise, casual drinking, intercourse or lack of rest have no role in leading to miscarriage. Oppositely, there is nothing that a patient could have done to prevent miscarriage. Contemporary management strategies often favor medical over surgical management of pregnancy loss in so far as the mother is hemodynamically stable. Medical Management of spontaneous miscarriage at Desert Women’s Care when residual products of conception remain within the uterus (incomplete miscarriage or missed abortion) will include the following steps. First, patient is given prescriptions for 200 mg Mefepristone, 800 ug of Misoprostol, Motrin 800 mg to be taken every eight hours for the first three days then every eight hours as required for cramps and Tylenol #3 to be taken 1 – 2 every four to six hours for cramps in addition to the Motrin as needed. Patient is to take the Mefepristone immediately and to use the Misoprostol twenty-four hours later. Prostaglandin side effects are managed with Acetaminophen for fever and immodium for diarrhea. Transvaginal Ultrasound is scheduled for one week. Successful medical management includes absence of gestational sac, endometrial thickness less than 30 mm and relief of heavy bleeding. Failure of medical management is defined as presence of a gestational sac, endometrial thickness greater than or equal to 30 mm or persistent heavy bleeding. Women failing medical management may either take a second dose of Misoprostol or be scheduled for Suction D&C. If all tissue has been passed spontaneously (complete miscarriage), treatment with methergine 0.2 mg three times daily for five to seven days may be sufficient to cause the uterus to cramp and expel residual blood clots and slow bleeding. Prepared by Richard H. Demir, MD 2011 all rights reserved Clinical Opinion It is necessary to maintain pelvic rest for several weeks so as not to cause ascending infection in the immediate post miscarriage period. Because pregnancy has occurred, it is necessary to determine your Rh status and to treat you prophylactically with RhoGAM one ampule intramuscularly should you be found to be Rh negative and antibody negative. This treatment will likely prevent sensitization of your immune system to RhoD negative antigens. This means that subsequent pregnancies will most likely not be at risk for Rh Disease, although this can never be guaranteed. Miscarriage is a common event that has no adverse predictive significance for a subsequent pregnancy— this means that a single miscarriage does not increase the likelihood of a miscarriage in the next pregnancy. Therefore, having a miscarriage does not make a woman less likely to have a successful pregnancy on her next attempt. Additional information is available at WebMD or other similarly accessible patient oriented sources of information. Prepared by Richard H. Demir, MD 2011 all rights reserved


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