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Miscarriage Early pregnancy loss

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Title: Miscarriage Early pregnancy loss


1
Miscarriage Early pregnancy loss
  • Dr Chro Najmaddin Fattah
  • MBChB, DGO, MRCOG, MRCPI, MD
  • Obst. Gyne. Department

2
Definition
  • Spontaneous miscarriage is the most common
    complication of early pregnancy before 24 week
    gestation 820 clinically recognized
    pregnancies 1326 all pregnancies
  • 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
  • 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
Ultrasound Findings of EPL
  • Anembryonic Pregnancy No fetal pole with mean
    sac diamter gt25 mm (transabdominal) OR gt18
    mm (transvaginal) lt4 mm growth in 7 days (No
    yolk sac, with mean sac diameter gt25mm)
  • Embryonic Demise No cardiac activity with CRL
    7mm

Mishell DR, Comprehensive Gynecology 2007
5
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)

6
Abnormal conceptus
  • Means an empty gestational sac without embryo
    development. (Blighted ovum )
  • Most miscarriage occurs before 8 weeks
    gestations.
  • Result from Error in maternal and/ or
    paternal meiosis
  • chromosomal division without cytoplasmic
    division

7
  • 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 empty sac(
    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

8
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)

9
  • ? Structural rearrangement the abnormality
    consists of unbalanced translocation accounts
    3-5 of miscarriage with abnormal chromosome
  • 3 of couple s will be carrier karyotyping
    is required
  • II- structural abnormalities as Nural tube
    deffect (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.

10
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
    miscarriage 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.

11
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

12
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

13
? 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

14
? 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

15
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

16
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

17
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.

18
  • 7- Recurrent miscarriage, referred as three or
    more consecutive miscarriage
  • 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

19
  • 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

20
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
  • medical history

21
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

22
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 RPOC
    felt inside cervix

  • ?
  • to be
    removed manually

  • ?
  • relieve pain
    decrease bleeding

23
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 1500mIU/ml
  • NB if fetal heart seen on U/S examination,
    pregnancy will continue in 98.

24
Management Options
  • Do Nothing Expectant management
  • Do Something Medical management
  • Do Surgery Surgical management

Sotiriadis A, Obstet Gynecol 2005 Nanda K,
Cochrane Database Syst Rev 2006
25
Comparison of Outcome by Method Management of
Early Pregnancy Loss
  • Factor Comparison of Methods
  • Success rate Surgical gt Medical Medical
    Expectant
  • Resolution Surgical gt Medical gt Expectant
    within 48 hrs
  • Infection risk Expectant Medical
    Surgical .23

Nanda K, Cochrane Database Syst Rev 2006 Nielsen
S, Br J Obstet Gynaecol 1999 Shelly JM, Aust.
NZ J Obstet Gynaecol 2005 Sotiriadis A, Obstet
Gynecol 2005 Tinder J, (MIST) BMJ, 2006
26
Do Nothing Expectant Management
  • Overall success rate
    81
  • Success rates vary by type of miscarriage
    Incomplete/inevitable abortion 91
    Embryonic demise 76
    Anembryonic pregnancies 66

Luise C, Ultrasound Obstet Gynecol 2002
27
Medical Management
  • Success Rates
  • Placebo
    1660
  • Single dose misoprostol 2588
    400800 mcg
  • Repeat dose x 1 if incomplete 8088 at 24 hours
  • Success rate depends on type of miscarriage
    100 with incomplete abortion 87 for all
    others

Wood SL, Obstet Gynecol 2002 Bagratee JS, Hum
Reproduct 2004 Blohm F, BJOG Int J Obstet
Gynecol 2005
28
Medical Management Requirement for Therapy
  • lt13 weeks gestation
  • Stable vital signs
  • No evidence of infection
  • No allergies to medications used
  • Adequate counseling and patient acceptance
    of side effects

29
Misoprostol
  • Prostoglandin E1 analogue
  • FDA approved for prevention of gastric ulcers
  • Used off-label for many Ob/Gyn indications
    Labor induction Cervical ripening Medical
    Miscarriage (with mifepristone)
    Prevention/treatment of postpartum hemorrhage
  • Can be administered by oral, buccal, sublingual,
    vaginal and rectal routes

Chen B, Clin Obstet Gynecol 2007
30
Surgical Management Early Pregnancy Loss
  • Suction dilation and curettage (DC)
  • Who should have surgical management? Unstable
    Significant medical morbidity Infected Very
    heavy bleeding Anyone who WANTS immediate
    therapy

31
Management
  • 1- Threatened miscarriage
  • - Reassurance of patients
  • - Rest for few days until the
    bleeding has settled down
  • - May require progesterone
    supplementation
  • - Folic acid
  • 2- Incomplete miscarriage
  • - Assessment of general
    condition
  • - Blood sample for blood group,
    RH factor, and CBC
  • - Removal of RPOC if felt in
    cervical canal
  • - Ergometrine 0.5mg IV or IM to
    ? blood loss

32
  • - 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

33
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

34
Complications of septic miscarriage
  • Septicemia, and septic shock
  • Acute renal failure
  • Chronic pelvic infection
  • Infertility
  • Missed miscarriage
  • clinical feature - 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

35
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

36
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.

37
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 ?

38
Thank you
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