European Journal of Cardiovascular Medicine

Miscarriage is defined as the loss of an intrauterine pregnancy before 24 weeks of gestation by the Royal college of Obstetrics and Gynaecology^.11 It is defined by the World Health organization as the expulsion of a foetus or embryo weighing 500 grams or less, and the of gestational age less than 22 completed weeks of pregnancy. ² Miscarriage can be classified as Early or first trimester, when the pregnancy loss occurs before 12 weeks of gestation and late or second trimester, when the pregnancy loss occurs between 12 and 24 weeks of gestation.³ According to the recent data from National Family Health Survey, carried out in 2019 – 2021 in India, miscarriages occurs in approximately 7 % of pregnancies.⁴

There are many factors which are associated with increased risk of miscarriage like chromosomal abnormalities, foetal malformations, placental abnormalities, infections, antiphospholipid antibodies, advanced maternal and paternal age, abnormal parental genetic makeup, previous miscarriage, environmental causes, multiple pregnancy, chronic illness, thyroid disorders,  uncontrolled diabetes, trauma, uterine malformations, high maternal BMI , regular or high alcohol consumption and thrombophilia but still the underlying aetiology remains poorly understood in many cases.^5-11  Adverse pregnancy outcomes like miscarriage and still birth are poor maternal health indicators . Miscarriage and its management not only cause physical complications such as haemorrhage and infection but also causes mental, psychosocial trauma and is still considered a cultural taboo. Hence can negatively impact a woman’s physical, mental and emotional well being.¹²

There are many global and national programs that are working to reduce the  pregnancy related risk and make motherhood safe but still miscarriages and, complications due to miscarriage and its management do occur mainly in developing countries hence understanding it's cause remains crucial. This study aims to explore the characteristics of pregnant women undergoing miscarriages and its complications in India.

The study was conducted as a prospective observational study in the department of Obstetrics and Gynaecology, Mallareddy Narayana multispeciality hospital, Suraram, Hyderabad, over a period of 2 years from July 2021 to July 2023 after obtaining approval from the institutional ethical committee. Written and informed consent to participate in research and to publish their data was taken from each study participant.

Inclusion criteria

1. Women who were admitted and treated for first and second trimester missed abortion, inevitable abortions, incomplete abortions and complete abortions upto 20 weeks gestational age. Diagnosis was confirmed by ultrasound scan.
2. Women with threatened abortions who progressed to inevitable/ incomplete abortions.

Exclusion criteria

1. Women in whom pregnancy was terminated in view of anomalous foetus or in accordance with MTP act of India.
2. Women diagnosed with ectopic pregnancy and molar pregnancy.

The sampling frame was bounded by the above inclusion and exclusion criteria. This was time based study and all the patients falling in the sampling frame were included in the study. A detailed history regarding age, parity, socioeconomic status, consanguineous marriage, presenting complaints of patient like pain abdomen, bleeding per vagina, duration and amount of bleeding and expulsion of any products of conception, obstetric parameters like previous miscarriages and previous life birth, details of medical disorders, lifestyle details like active/passive smoking, alcohol/toddy consumption was noted. Menstrual history was noted and gestational age was calculated from the first day of last menstrual period. Physical examination including general examination, abdominal and vaginal examination was done. Vitals of the patient including temperature, pulse rate, respiratory rate and blood pressure were recorded. Height and weight were recorded using standardized methods for anthropometric measurements and BMI was computed according to Quetelet index.

Investigations were sent for estimation of haemoglobin, blood group analysis and HbA1c estimation. Fasting blood samples were sent for thyroid function test and fasting blood glucose levels, and 2 hours post meal blood sample was sent for estimation of post meal blood sugar level. Ultrasound scan was done and diagnosis of miscarriage was confirmed. Missed miscarriages, inevitable miscarriage, incomplete miscarriage and complete miscarriage were managed according to the latest accepted evidence based norms of the RCOG. Post procedure vitals were noted. Women were observed for any complications like excess bleeding, uterine perforation, infection, fever, retained placenta, retained products of conception. All mothers with rhesus negative blood type were administered 300 µg of Anti Rh Immunoglobulin. Appropriate antibiotic cover was given in accordance with hospital protocols and patients were discharged in stable condition. Patient was followed up for further 3 months to note any complications. Data was recorded in excel sheet and data was analysed statistically.

Research involving Human Participants

1. All procedures performed on the patient were in accordance with the ethical standards of the Institutional and National Research Committee and with the 1975 Helsinki declaration and its latest amendment in 2000 and other comparable ethical standards.

2. All treatment protocols followed were in accordance with the latest accepted Evidence Based Medicine Norms of the RCOG.

3. Foetal sex was neither detected nor informed in accordance with the PNDT Act 1994.

4. All surgical evacuations were governed by the MTP Act 1971 and its amendment.

A total of 250 participants were included in the study.

Table 1. Age of the study participants

Table 2. Parity of the study participants

Table 3. Socioeconomic status of the study participants

Table 4. BMI of the study participants

Table 5. Consanguineous/ non consanguineous marriage

Table 6. Total number of miscarriages

Table 7. Type of miscarriages

Table 8. Gestational age at miscarriage (weeks)

 Table 9. Previous miscarriage and  previous live birth in the study participants

Table 10. Haemoglobin value in the study participants

Table 11. Medical disorders in the study participants

Table 12. Exposure to smoking and alcohol

 Table 13. Complications of miscarriages

In this study we found that 44.8% of the miscarriages occurred in the age group between 20-24 years. 10.4% of the couples had a consanguineous marriage, 43.6% of the study participants were nullipara and 50.8% belong to upper lower socioeconomic status. 21.6 % of the miscarriages were in the gestational age of 8-9 weeks. 53.6% of the miscarriages were missed miscarriages.49.6% of the study particiapants had previous live birth, whereas 29.6% had previous miscarriages. 23.6% of the women were overweight and 12% were found to have obesity. 22% of the study participants had medical disorders; nearly 72.8% were anaemic and 12.4% had hypothyroidism. Complications due to miscarriage were seen 26% of the study participants.

As per the report of abortion surveillance done in The United States 2021, women in age group 20-24 and 25-29 years accounted for the highest percentage of abortions.^13,14 which is in accordance with this study. The risk of abortion is strongly linked to maternal age. Socioeconomic status has been well established with individual’s health and it plays an important part in health and life expectancy of pregnancy and has an impact on pregnancy outcome^15,16.  Low income and maternal deprivation in general is associated with poor housing, nutrition, and healthcare access, which in turn negatively affects the general health physically and mentally.^17,18 This study showed that 50.8% of the study participants belonged to upper lower socioeconomic status.This study showed that the 22% of the study participants has medical disorders like diabetes mellitus type 2, thyroid disorders and hypertension, which is also suggested by other studies which states medical conditions like diabetes mellitus and hypertension has negative reproductive outcome. ^19-23

In this study 61.6% of the study participants were exposed to passive smoking and 8.8% were toddy consumers. This is supported by other studies which suggests smoking, tea and alcohol consumption is negatively associated with reproductive outcome in females.^24-29 This study showed 23.6% of study participants were overweight and 12% of the study participants were obese. Overweight and obese pregnant women are at a strongly increased risk of miscarriage, whether they conceived after natural conception or assisted reproductive measures.³⁰ Obese and overweight patients has a significantly increased endometrial expression of haptoglobin and also displayed a significant increase in endometrial expression of transthyretin and beta- globulin, which are inflammatory factors. This may provide evidence for occurring endometrial inflammatory reactions in the endometrial linings of obese women and may contribute to their higher risk of miscarriage.³¹

Obesity is associated with high serum leptin levels due to leptin produced by the adipose tissue, which acts at the level of the ovary and of the endometrium where it inhibits both human granulosa and thecal cell steroidogenesis, and interferes with the development of the dominant follicle and oocyte maturation, consequently alters endometrial epithelium receptivity . Leptin, behind modulating endometrial receptivity, also exerts a regulatory role in remodeling the endometrial epithelium and stimulating proliferation and apoptotic cell pathways.³² Anaemia in pregnancy is defined as haemoglobin < 11 g/dl according to the WHO. ³³ It is the most prominent haematological abnormality during gestation and it is a global health problem affecting nearly half of all pregnant women.³⁴ This study shows that 72.8% of the study participants were anaemic.  But existing evidence focusing on anaemia during early pregnancy and miscarriage risk is scarce and the results are inconclusive.^35,36,37

A large case-control study conducted in Finland with 22,271 pregnant women³⁸  and another prospective study conducted in 817 middle-aged Sri Lankan women³⁹ found no additional risk of miscarriage when Hb < 10 g/dL and Hb < 11 g/dL during the first trimester, respectively. On the contrary, a large-scale population-based cohort study including 3,971,428 Chinese women reported an increased risk of miscarriage for women with severe anaemia prior to pregnancy (Hb < 70g/dL).⁴⁰ 

Miscarriage not only affects the reproductive and physical health of a woman but also negatively affects her mental well being. Preconceptional counselling to improve the health of a woman, correction of anaemia, optimization of medical disorders and BMI will improve the reproductive outcome. Establishment of preconception clinic, dedicated abortion care clinics, recurrent pregnancy loss clinics, post abortal follow up care and bereavement care services should form a important component of abortion care system.

Miscarriage is a major social and health issue mainly in the developing countries. Public health education about importance of preconception health and lifestyle modification, optimizing modifiable risk factors will play an important in reducing the occurrence of miscarriages and improve the overall reproductive outcome and wellbeing of a woman.

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