Miscarriage ( abortion Early pregnancy loss

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Miscarriage ( abortionEarly pregnancy loss

• Dr. R. EL-Gantri
• Associated Professor
• Obst. Gyne. Department

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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)

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• 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

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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)

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• 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

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• 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

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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)

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• ? 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.

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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.

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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

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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

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? 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

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? 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

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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

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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

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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.

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• 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

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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

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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

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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

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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

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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.

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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

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• - 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

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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

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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

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• 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

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• 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

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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.

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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 ?

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• Good luck