TBL (Miscarrriage)

7/31/2019 TBL (Miscarrriage)

1/36

Miscarriage

Andy Lim Yew Ann


2/36

Definition of Miscarriage

Pregnancy that ends spontaneously before thefetus has reached a viable gestational age.

Legal definition of miscarriage in UK:

Spontaneous loss of pregnancy at or before 24weeks of gestation.


3/36

Clinical Forms of Miscarriage

Types of Miscarriage Definition Clinical Presentation

Threatened MiscarriageVaginal bleeding with a

viable pregnancy

Per vaginal bleeding and

pain

Speculum: Cervical os closed

Inevitable MiscarriageBleeding with cervical

dilation without passage offetal tissue


painSpeculum: Cervical os open

Complete MiscarriageSpontaneous passage of all

products of conception

Pain and bleeding has

resolved

Speculum: Cervical os closed

Incomplete MiscarriageRetained products of

conception


painSpeculum: Cervical os open,

products of conception

located in cervical os

Missed Abortion

Intrauterine fetal demise

without passage of tissue

With or without pain and

bleeding


4/36

Causes of Miscarriage

Chromosomal Abnormalities

(Maternal age>35 years old)

Trisomies ( Downs syndrome),

Triploidies and tetraploidies

Monosomy X (Turners syndrome)

Translocation and inversion

Endocrine Disorders Diabetes, hyperthyroidim, luteal phase

deficiency, polycystic ovarian syndrome

Abnormalities of the Uterus Uterine septa, endometrial adhesions(post-

curettage or Ashermans sundrome)

Infections Salmonella typhi, malaria, cytomegalovirus,

Brucella, toxoplasmosis, Mycoplasma

hominis. Chlamydia trachomatis and

Ureaplasma urealyticum

Chemical Agents Tobacco, anaesthetic gases, arsenic,

benzene, solvents, lead, mercury,

pesticides, cadmium

Immunological Disorders Antiphospholipid syndrome,

thrombophilia (Hereditary)


5/36

Signs and Symptoms of Miscarriage

Symptoms

Vaginal bleeding

Crampingabdominal pain

Fading of pregnancysymptoms

No fetal movement

Signs

Cervix may bedilated

Fetal tissue may befelt at cervical os

Uterine size may besmaller than

menstrual dating


6/36

Ultrasonography Findings of

Miscarriage

No heartbeat in an embryo larger than5mm/ earlier ultrasound revealed fetal

heartbeat, subsequent u/s no heartbeatdetected

Gestational sac larger than 8mmand has no yolk sac

Gestational sac larger than 16mmand has no embryo

Transvaginal Ultrasound

A: Gestational

sacB: Crown

lump length

C: Amniotic

sac

D: Yolk sac


7/36

Definition of Recurrent Miscarriage

Three or more spontaneous consecutive

pregnancy losses before week 20.


8/36

History & Physical examination


9/36

Questions to Ask

Uterine instrumentation ?

Are the menstrual cycles regular ?

Is there galactorrhea ? History of congenital abnormalities or

karyotypic abnormalities ?

Any exposure to environmental toxins ? Any history of venous or arterial thrombosis ?


10/36

Hirsutism ?


11/36

Uterine malformation ?


12/36

Cervical laceration ?


13/36


14/36

Investigation


15/36

Karyotyping


16/36

Sonohysterography


17/36


18/36


19/36

Hysterosalpingogram


20/36


21/36


22/36

Hysteroscopy


23/36


24/36


25/36


26/36


27/36

MRI


28/36

Other investigation

Anticardiolipin antibodies and lupus

anticoagulant

Thyroid function test and thyroid peroxidase

(TPO) antibodies

Culture and serology

Hypercoagulable state

Progesterone level

Endometrial biopsy


29/36

Pathogenesis of Septic Abortion


30/36

Introduction of Foley Catheter

To Vaginal Orifice

Infection of Uterine Lining

Septic Abortion

(Abortion that is complicated by infection)

Circulatory System RenalSystem Gastro-IntestinalSystem Respiratory System ImmuneSystem

Positive

hematoma

(abnormal

hematologicexamination

specifically

hemoglobin and

hematocrit)

Blood in urine

Acidic (ph of 5.8)

Difficulty andpainful urination

Possible renal

failure

Loss of appetite

Difficulty in

swallowing

Loss of weight

hemoglobin

oxygen carrying

capacity

CO2

stimulation for

breathing

Hyperventilation

WBC

Positive infection


31/36

Indications for Therapeutic

Abortion


32/36

Maternal condition

History of dilated cardiomyopathy in previous pregnancies

Myocarditis, Pericarditis, Heart Failure

Hypercoagulability

Marfan syndrome, when ascending aorta is wider than 5 cm

Eisenmenger's Syndrome

Pregnancy induced fatty liver

History of esophageal varicosities hemorrhage

Uncontrollable autoimmune hepatitis Renal failure

Hypertension which is not controllable with permitted drugs during pregnancy

Any of the pulmonary diseases that leads to pulmonary hypertension even to a milddegree (emphysema, fibrosis, diffuse bronchiectasis)

Active uncontrollable SLE which has involved a major organ Vasculitis

Pemphigus vulgaris and severe generalized psoriasis and advanced melanoma Multi-drug resistant epilepsies

Multiple sclerorosis in which the patient is disabled

Myasthenia gravis

Some type of motor neuron diseases like amyotrophic lateral sclerosis (ALS) which isintensified following by pregnancy and will seriously endanger mother life


33/36

Fetal Condition

Osteogenesis imperfecta Osteochondrodysplasia

Osteopetrosis and infantile neuroaxonal dystrophy

Bilateral renal agenesis

Polycystic kidney

Multicystic dysplastic kidney

Potter syndrome

Congenital nephrotic syndrome and hydropsSevere bilateral hydronephrosis Alpha thalassemia and hydrops fetalis

Thrombotic disorders

Trisomy 13, 18, 3, 16, 8

Anencephaly

Cat cry syndrome

Holoprosencephaly

Syringomyelia Cranioschisis

Meningoencephalocele

Meningohydroencephalocele

Thanatophoric dysplasia

Cyclopia with holoprosencephaly

Ichthyosis congenita

Schizencephaly


34/36

Counselling

Objectives of Counselling :

To educate the patient about Recurrent Pregnancy

Loss

What are the causes ?

Who is at risk ?

How to prevent / manage?

To provide care and support for the patient Help the patient to cope with their emotional distress

and prevent them from developing psychiatric disorder

Genetic causes


35/36

Genetic causes

Perform karyotype of parents with family or personal history of genetic abnormalities.

Perform karyotype of the abortus in recurrent cases.

Provide genetic counseling for families with recurrent loss or familial history of genetic disease.

In patients with a high risk for recurrent, chromosomally abnormal conceptus, discuss the optionsof adoption, gamete donation, and PGD.

Immunologic causes

Perform APLA testing if indicated.

If APLA levels are elevated, counseling with a hematologist and a specialist in maternal fetalmedicine is recommended.

Aspirin and heparin therapy may be given to patients who are diagnosed with APS.

Anatomic causes

Imaging may include HSG, hysteroscopy, ultrasonography, and/or MRI.

Surgical correction may be required.

Infectious causes

Cervical cultures should be obtained during the evaluation of infertility.

Empiric antibiotics should be given before invasive testing, such as HSG.

Environmental causes

Encourage life-style changes and counseling for preventable exposures.

Endocrine factors

Perform thyroid-stimulating hormone (TSH) screening in symptomatic patients.

Thrombophilic disorders

Aspirin and heparin therapy may be given for proven diagnoses.


36/36

Thank You =)

Documents

TBL (Miscarrriage)