Miscarriage ( abortion Early pregnancy loss - PowerPoint PPT Presentation

Loading...

PPT – Miscarriage ( abortion Early pregnancy loss PowerPoint presentation | free to view - id: 43e85f-MGRmZ



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Miscarriage ( abortion Early pregnancy loss

Description:

Miscarriage ( abortion Early pregnancy loss Dr. R. EL-Gantri Associated Professor Obst. & Gyne. Department Definition: Spontaneous termination of pregnancy before ... – PowerPoint PPT presentation

Number of Views:2242
Avg rating:3.0/5.0
Slides: 32
Provided by: 6297378
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Miscarriage ( abortion Early pregnancy loss


1
Miscarriage ( abortion Early pregnancy loss
  • Dr. R. EL-Gantri
  • Associated Professor
  • Obst. Gyne. Department

2
Definition
  • Spontaneous termination of pregnancy before
    viability of fetus ( before 24 week gestation).
  • Incidence 15
  • Early pregnancy loss if it occurs before 12
    weeks (80)
  • Late pregnancy loss if it occurs between
    13 to 24 weeks (12)

  • ( usually there is a fetus)

3
  • Early pregnancy loss classified into
  • Blighted ova no
    fetus on U/S examination (Empty gestational sac)

  • Fetal tissues absent on histological
    examination
  • Early fetal demise
    fetus present on U/S examination

  • fetal tissues present on histological
    examination
  • Factors influence rate of spontaneous
    miscarriage
  • Maternal age gt 35 years
  • Gravidity
  • Previous miscarriage
  • Multiple pregnancies

4
Etiology
  • Abnormal conceptus as genetic abnormalities
    (50-60), structural abnormalities
  • Endocrine abnormalities (10- 15)
  • Cervical incompetence (8-10)
  • Uterine anatomic abnormalities (1-3)
  • Immunological (5)
  • Infections (3-5)
  • Structural abnormalities
  • Unknown reasons (lt 5)

5
  • 1- abnormal conceptus
  • Blighted ovum means an empty gestational
    sac without embryo development.
  • Most miscarriage occurs before 8
    weeks gestations and are blighted ovum
  • and result from error in
    maternal and/ or paternal meiosis

  • super fecundation of an egg by two sperms

  • chromosomal division without cytoplasmic division

6
  • The abnormalities of development may be due to

  • Chromosomal abnormalities

  • Structural abnormalities

  • Gene defects (absence of specific enzyme)
  • I- The chromosomal abnormalities
  • Are found in approximately 80 of
    blighted ovum and 5-10 of the miscarriage in
  • which the a fetus is present.
  • These are the most frequent and
    important causes of early pregnancy loss

7
The chromosomal abnormalities include
  • ? autosomal trisomy The non-disjunction defect
    is found approximately in
  • 60 of
    blighted ovum with abnormal karyotypes.
  • most
    non-disjunction occurs during 1st mitotic
    division
  • The affected
    chromosomes are 16 (32)

  • 22
    (10)

  • 21 (8)
  • ? Triploidy occurs in 12-15 of
    chromosomal abnormalities
  • double paternal
    chromosomes (69 chromosomes)
  • partial molar
    of pregnancy occurs in 5
  • ? Monosomy X represents 25 of miscarriage with
    chromosomal abnormalities (45X)

8
  • ? Structural rearrangement the abnormality
    consists of unbalanced translocation

  • accounts 3-5 of miscarriage with abnormal
    chromosome

  • 3 of couples will be carrier

  • karyotyping is required
  • II- structural abnormalities as NTD, uncommon
    cause of miscarriage
  • III- Gene defect -difficult to determine
    because of facilities to identify the individual
  • gene defects.
  • -Example as
    autosomal dominant disorders and X-linked
    dominant
  • disorders.

9
II- Endocrine causes
  • Corpus luteum is essential for maintenance of
    pregnancy during the first 8 weeks.
  • Surgical removal of it? miscarriage within
    4- 7 days
  • Parenteral progesterone may prevent
    abortion but the evidence of progesterone
    deficiency as a cause of miscarriage is
    unsatisfactory.
  • In the past, progesterone have been used
    among women with recurrent miscarriage with good
    results.
  • It is possible that corpus luteum
    deficiency could be a cause of early pregnancy
    loss
  • Use pf progesterone is over used in miscarriage.

10
III-Uterine abnormalities
  • A- Uterine malformations
  • - result from a failure of normal fusion
    of the Mullerian ducts, as bicronuate uterus,
  • septate or subseptate, and uterus
    didelphys.
  • - May result in miscarriage in 10- 15
  • B- Intra-uterine synechiae ( Asher man's
    syndrome) in which there is either partial or
    complete adhesion between walls of uterus leading
    to partial or complete obliteration of the
    uterine cavity.
  • Usually occur as a result of intrauterine
    infections following


  • Retained parts of conception

  • post-abortal or postpartum
    curettage

  • repeated pregnancy loss

11
C- Cervical incompetence
  • ? Is a well recognized cause of miscarriage in
    late second trimester
  • ? The clinical feature are
  • -
    painless cervical dilatation (main presentation)
  • -
    increase vaginal discharge
  • -
    speculum examination shows bulging membrane with

  • cervical dilatation
  • ?Causes Trauma to cervix is the main
    etiological factor
  • - vigorous
    mechanical dilatation of cervix
  • - trauma
    during delivery
  • - cone
    biopsy
  • - cervical
    amputation
  • Congenital rare

12
? Diagnosis of cervical incompetence
  • 1- History and examination
  • 2- During pregnancy U/s examination

  • Finding short cervix

  • internal os dilated up to 2cm

  • funnel shaped cervix
  • 3- Non pregnancy
  • passing Hegar dilator
    number 8 through internal os
  • hysterosalpingography

13
? Treatment
  • Placing suture ( cervical cerclage) around the
    cervix at 14- 16 weeks gestation
  • Two types of sutures
  • McDonald
  • Shrodkar
  • ? Complications of cerclage
  • - Rupture of
    membrane
  • - Infections
  • - further trauma
    to cervix
  • ? Time of removal of cerclage at 38 weeks

14
D- Infection
  • ? uncommon cause of miscarriage
  • ? acute maternal infections as peyelitis,
    appendicitis can lead to general toxic illness
    with high temperature that stimulates the uterine
    activity ? miscarriage.
  • ? early diagnosis treatment will control most
    of infection and forestall the occurrence of
    miscarriage
  • ? syphilis can cross the placenta ? IUFD and
    miscarriage
  • ? other infections as Rubella, Toxoplasmosis,
    Listeriosis, CMV, and Mycoplasma can lead to
    miscarriage

15
E- Immunological causes
  • Immunological rejection of fetus can cause
    recurrent miscarriage
  • May be due to failure of the normal immune
    response in mother
  • An example is anti-phospholipids antibody
    syndrome responsible for 3-5 of recurrent
    miscarriage
  • F- toxic factors
  • Anesthetic gases, smoking, alcohol, and drug
    abuse can cause miscarriage
  • G- Trauma
  • amniocentesis, CVS, IUCDs, and abdominal surgery

16
Types of miscarriage
  • 1- Threatened miscarriage
  • Referred as vaginal bleeding before 24
    weeks gestation when there is a viable fetus
    without evidence of cervical dilatation and pain.
  • 2- Inevitable, if the cervix becomes dilated, the
    bleeding increases and there is pain.
  • 3- Incomplete, if there is partial expulsion of
    product of product of conception ( usually the
    fetus) with retention of some parts ( usually
    placenta).
  • 4- Complete, complete expulsion of product of
    conception.
  • 5- Missed miscarriage, the embryo dies in utero
    but is not passed
  • 6 Septic, infection may occur following any type
    of abortion and may spread to pelvis or even
    leads to septicemia.

17
  • 7- Recurrent miscarriage, referred as three or
    more consecutive abortion
  • Clinical features of miscarriage
  • 1- Threatened miscarriage
  • - vaginal bleeding
    (usually slight)
  • - slight abdominal
    cramps
  • - internal os is
    closed
  • - viable fetus on
    U/S examination
  • 2- Inevitable miscarriage
  • - bleeding becomes
    heavy with clots
  • - lower abdominal
    pain
  • - cervix dilated
    bulging membrane

18
3- Incomplete miscarriage
  • - heavy vaginal bleeding may lead to
    hypo-volaemic shock
  • - lower abdominal pain some times
    sever
  • - history of passing something (POC)
  • - cervix dilated
  • - Retained parts of conception on U/S
    examination
  • 4- Complete miscarriage
  • - bleeding minimal
  • - no pain
  • - cervix closed
  • - empty uterus on U/S examination

19
Differential diagnosis
  • Ectopic pregnancy
  • Hydatiform mole ( molar pregnancy)
  • Local causes as cervical erosion, cervical
    polyp, etc.
  • Clinical assessment
  • A- History includes
  • personal history
  • complains as vaginal
    bleeding, pain
  • GA Nigel's rule
  • medical history

20
B- Examination
  • General assessment for any signs of
    shock
  • Abdominal examination for

  • abdominal tenderness

  • size of uterus large wrong date


  • multiple pregnancy

  • molar
    pregnancy


  • fibroids

  • smaller wrong date

  • non-
    viable fetus

21
Pelvic examination
  • Should be carried out in all cases
  • If the vaginal bleeding is slight ? speculum
    examination for


  • - any vaginal
    infection

  • - cervical lesion
  • If the bleeding is heavy ? digital examination to
    assess

  • - cervical tenderness
    ? Ectopic

  • - state of cervix

  • - any POC felt inside
    cervix

  • ?

  • to be removed
    manually


  • ?

  • relieve pain
    decrease bleeding

22
C- Investigation
  • Serum B-HCG may be required to confirm
    pregnancy
  • Ultra-sound examination
  • Abdominal U/S GS will be seen
    normally if SBHCG 3000mIU/ml
  • Trans-vaginal more accurate
  • GS
    will be seen normally if SBHCG 1000mIU/ml
  • NB if fetal heart seen on U/S examination,
    pregnancy will continue in 98.

23
Management
  • 1- Threatened miscarriage
  • - Reassurance of patients
  • - Rest for few days until the
    bleeding has settled down
  • - may require progesterone
    supplementation
  • - folic acid
  • anti D if RH negative
  • 2- Incomplete miscarriage
  • - assessment of general
    condition
  • - blood sample for blood group,
    RH factor, and CBC
  • - removal of POC if felt in
    cervical canal
  • - ergometrine 0.5mg IV or IM to
    ? blood loss

24
  • - evacuation of uterus UGA followed by
    gentle curettage
  • - ergometrine 0.5mg IV will encourage
    uterine contraction
  • -anti D if RH negative
  • - if there is hypo-volaemic shock, may
    require blood transfusion
  • Septic miscarriage
  • Occurs as a result of ascending infection
    following miscarriage.
  • If not treated, infection may spread throughout
    pelvis ? septicemia and septic shock
  • Signs
  • pyrexia
  • abdominal pain, and
    tenderness
  • persistent vaginal
    bleeding
  • offensive vaginal
    discharge

25
Investigation
  • Routine basic investigations as BL. Group, RH
    factor, CBC, BS, urea electrolytes, etc
  • Cervical swab
  • U/S examination for retained parts
  • Treatment
  • Iv. Broad spectrum antibiotic
  • IV fluids blood transfusion if needed
  • Analgesia
  • Evacuation of uterus
  • Anti D

26
Complications of septic miscarriage
  • Septicemia, and septic shock
  • Acute renal failure
  • Chronic pelvic infection
  • Infertility
  • Missed miscarriage
  • clinical features
  • - Disappearance of symptoms of
    pregnancy
  • -Size of uterus lt duration of
    gestation
  • - U/S shows no signs of fetal life
  • -PT will remains positive as long
    as the placental tissues survive then ? -ve
  • Treatment
  • there is no urgency in treating missed
    miscarriage because

  • spontaneous miscarriage mostly occurs

  • coagulation defects due to dead fetus syndrome
    are rare

27
  • Many women prefer to have pregnancy termination
  • If pregnancy less than 12 weeks termination by

  • suction curettage

  • mifepristone ( anti-progesterone)
  • If pregnancy gt 12 weeks, termination by

  • induction of labor with prostaglandin

  • (extra-amniotic)

  • mifepristone

28
  • Recurrent miscarriage
  • Management includes
  • 1-Careful history and examination
  • 2- trans-vaginal U/S
  • 3- HSG and/or hysteroscopy
  • 4- karyotyping
  • 5-blood tests for infections
  • 6- antiphospholipid antibodies
  • Treatment according to the cause

29
Induced abortion
  • Induced abortion is not considered in
    medical terms alone but it arouses strong
    personal emotions and involves religious and
    ethical considerations.
  • Indications termination of pregnancy may be
    medically indicated to safe life of patients
  • as in malignant diseases of
    cervix, breast and sever cardiac disease.
  • Also fetal malformation may
    require termination.

30
Q question
  • 1- what is miscarriage and the types?
  • 2- how to diagnose different types of miscarriage
    ?
  • 3 what are the complications ?
  • How to treat patient ?

31
  • Good luck
About PowerShow.com