Preparation Course

InaCOG part 1

Module 1:
Miscarriage and
Recurrent miscarriage
Tujuan instruksional umum :
Peserta didik dapat memahami dan menjelaskan tentang
kejadian keguguran dan keguguran berulang

Tujuan instruksional khusus :

• Peserta didik dapat menjelaskan definisi dan terminologi
dari keguguran dan keguguran berulang
• Peserta didik dapat menjelaskan patogenesis dari
keguguran
• Peserta didik dapat menjelaskan faktor-faktor dari janin
ataupun maternal yang dapat memicu terjadinya
keguguran
• Peserta didik dapat memahami dan menjelaskan
klasifikasi klinik dari keguguran
• Peserta didik dapat menjelaskan penegakkan diagnosis
keguguran
• Peserta didik dapat menjelaskan aspek komplikasi dari
keguguran (sepsis dan aloimunisasi)
• Peserta didik dapat menjelaskan konsep etiologi dari
keguguran berulang
Definition or terminology

Abortion or Miscarriage is a loss or termination of a pregnancy with a fetus aged younger

than 20 weeks’ gestation or weighing <500 g.
It was contradictory because the mean birthweight of a 20-week fetus approximates 330 g,
whereas 500 g is the mean for 22 weeks

The National Centre for Health Statistics and the World Health
Organization
Definition or terminology

Miscarriage is defined as the spontaneous loss of pregnancy

before the fetus reaches viability.

The term therefore includes all pregnancy losses from the time
of conception until 24 weeks of gestation
Definition or terminology

Early pregnancy loss is a nonviable, intrauterine pregnancy (IUP) within the first 12 weeks of
gestation that consists of either an empty gestational sac or one containing an embryo or
fetus without fetal heart activity

The American College of Obstetricians and Gynaecologists, 2019

Recurrent pregnancy loss is women with repetitive miscarriage

First trimester miscarriage - pathogenesis
More than 80% of spontaneous miscarriage – less than 12 weeks of gestation

Death of the embryo or fetus 🡪 hemorrhage into basal decidua 🡪 tissue necrosis 🡪contraction 🡪
uterine contraction and expulsion

No fetal echo

No fetal heart activity

empty sac embryonic or fetal death

First trimester miscarriage - incidence

15-25%

57%
First trimester miscarriage – fetal factors
The association between euploid vs aneuploid miscarriage to gestational age

Advance gestation miscarriage associated with euploid embryo

First trimester miscarriage – fetal factors
The association between aneuploid miscarriage to maternal age

Advance maternal age associated with aneuploid embryo

First trimester miscarriage – fetal factors

The most common chromosome abnormalities in miscarriage

Trisomy 50-60% Trisomy of chromosome 13, 16, 18, 21 and 22 Chromosomal non-disjunction
Balance translocation
Monosomy 9-13% 45, X0 (Turner syndrome), autosomal monosomy Chromosomal non-disjunction
Triploidy 11-12% Dignyc triploidy (maternal derived) Failure to produce haploid
oocyte
Fertilization of diploid oocyte by
haploid sperm
Diandric triploidy (paternal derived) Fertilization of haploid oocyte by
two haploid sperm
Maternal factors
Medical disorder
Thyroid disorder, diabetes mellitus, SLE, malignant disease, exposure to
teratogenic substances

Surgical procedure
Ovarian surgery, uterine surgery
Abdominal trauma

Nutrition
Obesity

Behavior
Persistent smoking, alcohol consumption, recreational drugs

Environment factors
Endocrine disrupting chemical (DDT, bisphenol A, phthalate, etc.), radiation,
chemotherapy
Spontaneous miscarriage clinical classification
To diagnose early pregnancy loss
Spontaneous miscarriage clinical classification
Septic abortion

With spontaneous or induced abortion, organisms may invade

myometrial tissues and extend to cause parametritis, peritonitis,
and septicemia.

Classic clinical findings include fever, lower abdominal pain,

uterine tenderness, and foul vaginal discharge

Most bacteria causing septic abortion are part of the normal

vaginal flora.
Anti-D Immunoglobulin

Spontaneous or induced abortion, 2 percent of D-negative women will become alloimmunized if not
provided passive iso-immunization

The American College of Obstetricians and Gynaecologists recommends:

300-μg intramuscular dose of anti-Rho (D) immunoglobulin for all gestational ages

Graduated doses: a 50-μg or 120-ug dose is given for pregnancies ≤12 weeks and a 300-μg one for
those ≥13 weeks

This is administered immediately following surgical evacuation

For medication abortion or expectant management, the injection is given within 72 hours of
pregnancy failure diagnosis
Recurrent miscarriage: Definition or terminology

Kejadian keguguran sebanyak dua kali atau lebih sebelum usia kehamilan 24 minggu (ESHRE)
Kejadian keguguran sebanyak tiga kali atau lebih berturut-turut sebelum usia kehamilan 24 minggu (RCOG)

Kejadian keguguran sebanyak paling tidak dua kali (ASRM)

Konsensus keguguran berulang-HIFERI POGI 2018

Recurrent miscarriage: Definition or terminology

Primary RPL refers to multiple losses in a woman who has never delivered a liveborn

Secondary RPL refers to multiple pregnancy losses in a patient with a prior live birth

Secondary RPL have better prognosis

Why after 2 or 3 miscarriages?

50%

30%

15% 15%

chance for having

another miscarriage

no. of miscarriage
1o 2o 3o 4o
Recurrent miscarriage: etiology
The circles of protection
Uterine cavity
Cervical structure

Autoimmune disorders

Thrombophilia
Diabetes mellitus
Thyroid disorder

Maternal
Sumapradja K. 2020 supporting system
QUIZ

Mrs. A. 24 years old, primigravida, present to your outpatient clinic with chief complaint of vaginal bleeding. There is
no abdominal pain. Her LMP was happen 2 months ago. She had positive pregnancy test 3 weeks ago.
Her vital signs still in normal limit
No abdominal tenderness.
Speculum examination shows closed ostium with light bleeding comes from the external os. No cervical mass.
Transvaginal was done and it shows intra-uterine gestational sac and yolk sac. Fetal echo still cannot be identified.
Gestational diameter was 2.0 cm. No subchorionic bleeding was identified.
QUIZ
1. What will be your diagnosis?
A. Threatened abortion
B. Incomplete abortion
C. Missed abortion
D. Complete abortion
E. Inevitable abortion

2. What will be your next plan?

A. Do laboratory check for hCG level
B. Do laboratory check for progesterone level
C. Repeat US check for the present of fetal echo
D. Repeat US check for the present of sub chorionic hemorrhage
E. Terminate the pregnancy
TERIMA KASIH