MISCARRIAGE

PRESENTERSZEESHAN AHMED LODHI

AND RIZWAN ANWER

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

EARLY MISCARRIAGE : before 12wks LATE MISCARRIAGE: from 13 to 24wks

DEFINITION

1 Advanced maternal age2 Chromosomal abnormalities3 Endocrine disorders4 Uterine abnormalities5 Cervical incompetence

RISK FACTORS OF MISCARRIAGE

6 Infections 7 Drugs and Chemicals8 Psychological disorders9 Trauma10 Multiple pregnancies

Following are the types of miscarriage based on clinical presentation and investigation finding:

Threatened miscarriage Inevitable miscarriage Incomplete miscarriage Complete miscarriage Missed miscarriage

TYPES

Pregnancy complicated by bleeding before 24wks and symptoms indicate a miscarriage could be possible

Slight bleeding Abdominal

cramps Cervical os

closure Viable fetus on

U/S

THREATENED MISCARRIAGE

Cervix has dilated but Products of conception (POC) have not been expelled and symptoms indicate that a miscarriage could not be stopped.

Heavy bleeding with clots

Considerable lower abdominal pain

Cervical os open Intrauterine

pregnancy on U/S

INEVITABLE MISCARRIAGE

Some, but not all POC have been passed. Retained product may be the the part of fetus, placenta or membrane.

Heavy bleeding that may lead to shock

Severe abdominal pain

Cervical os open Retained POC on

U/S

INCOMPLETE MISCARRIAGE

All POC have been passed out without surgical or medical intervention.

Minimal or resolved bleeding

No pain Cervical os closed Empty uterus on

U/S

COMPLETE MISCARRIAGE

Uterus retains POC for two months or more after the death of fetus.

It can lead to coagulopathies.

With or without bleeding

Pain or no pain Cervical os closed Gestational sac

present. Fetal pole present

but no fetal heart beat.

MISSED MISCARRIAGE

HISTORY EXAMINATION * General * Abdominal * Pelvic with speculum and digital

APPROACH

CBC , BHCG , Hb typing , U/S In cases of recurrent miscarriages: * karyotyping * hormonal (progesterone, TSH) * infections (TORCH) * immunological (anticardiolipin Ab,

lupus anticoagulant etc)

INVESTIGATIONS

MANAGEMENT

Depending on clinical presentation and

patients choice:

◦EXPECTANT (Do nothing)

◦MEDICAL (Do something)

◦SURGICAL (Do everything)

Watchful waiting Most of the cases pass POC within 2 to 6

weeks Avoids side effects and complications of

surgery I/c risk of unplanned surgery Follow up

EXPECTANT APPROACH

INDICATIONS: Fetal parts are greater than 14wks in size >10wks pregnancy patients elects D&C and

her cervix is closed Some conditions like DIC in which surgery or

anasthesia is contraindicated

MEDICAL APPROACH

PROSTAGLANDINS: Misoprostol (in oral n vaginal forms) Gemeprost (vaginal form) PROGESTERON ANTAGONIST: Mifepristone (used in combination

with prostaglandin to I/c success rate)

DRUGS

Non invasive Drugs are administered orally or injected No anasthesia

ADVANTAGES

Bleeding lasts longer Require multiple visits to doctor Women may see the contents of their womb

as they are passed Chances of incomplete evacuation. May require Surgery.

DISADVANTAGES

INDICATIONS: Patient’s preference Infected retained tissue Excessive bleeding Cervix is closed &sac is >5cm Patients has miscarried twice before Patient is incapable of followups

SURGICAL APPROACH

VACUUM ASPIRATION: Also called D&E. Uses aspiration to

remove uterine content through the cervix. DILATATION & CURETTAGE: Uses sharp curette to scrape off POC from

uterine lining.SURGERY HAS ITS ADVATAGE OF SUCCESS

RATE OF ABOUT 95 – 100 %

PROCEDURE OF SURGERY

CERVICAL TRAUMA SUBSEQUENT CERVICAL INCOMPETENCE UTERINE PERFORATION INTRAUTERINE ADHESIONS POST OPERATIVE PELVIC INFECTION OCCASIONAL SUBFERTILITY

DISADVANTAGES

Cervical trauma Cervical incompetence Uterine perforation Intrauterine adhesions Post op pelvic infection subfertility

COMPLICATIONS OF SURGERY

COUNSELLING

Sympathy, explanation and reassurance are mandatory

Follow up by a senior member of staff , this will lead to discussion about a future pregnancy or contraception