MISCARRIAGESMISCARRIAGES

Dr. TARIG MAHMOUDDr. TARIG MAHMOUDMD SUDANMD SUDANHAIL UNIVERSITY KSAHAIL UNIVERSITY KSA

CAUSES OF EARLY BLEEDING IN CAUSES OF EARLY BLEEDING IN PREGNANCYPREGNANCY

MiscarriagesMiscarriagesEctopic pregnancyEctopic pregnancy

Hydatidiform moleHydatidiform mole

MISCARRIAGE / ABORTIONDefinition : Termination of pregnancy before viability. OR: Expulsion of a fetus or an embryo weighing 500 gm or less Incidence: 15 - 20% of pregnancies total reproductive losses are much

higher if one considers losses that occur prior to clinical recognition.Classification: 1. spontaneous: occurs without medical or mechanical means. 2. induced abortion

PATHOLOGYPATHOLOGY Haemorrhage into the decidua basalis. ▼Necrotic changes in the tissue adjacent to the bleeding. ▼Detachment of the conceptus. ▼The above will stimulate uterine contractions resulting In expulsion.

RISK FACTORS

Maternal age - more than 35years. Increased gravidity. Previous history of miscarriage. Multiple pregnancy

CAUSES OF MISCARRIAGE

Fetal causes: Abnormal conceptus: Chromosomal e.g. Trisomy. Structural e.g. Neural tube defect. Genetic e.g. X- Linked diseases.

CAUSES OF MISCARRIAGE

Maternal causes:

1. Immunological: Alloimmune response: failure of a normal immune response in the mother to accept the fetus for a duration of a normal pregnancy. Autoimmune disease: antiphospholipid antibodies especially lupus anticoagulant (LA) and the anticardiolipin antibodies (ACL)

2. uterine abnormality: congenital: septate uterus → recurrent abortion. cervical incompetence: - Congenital - aquired ▼ second trimester abortions. - fibroids (submucus): → • disruption of implantation and development of the fetal blood supply.• rapid growth and degeneration with release of cytokines.• occupation of space for the fetus to grow..

3. Endocrine : -Poorly controlled diabetes (type 1/type 2).

- hypothyroidism and hyperthyroidism.- Luteal phase Deficiency : Decreased level of progesterone which

secreted by corpus luteum so endometrium is poorly or improperly hormonally prepared for implantation and is therefore inhospitable for implantation.

4. Infections (maternal/fetal): as TORCH infections, Ureaplasma urealyticum, listeria

5. Environmental toxins: alcohol, smoking, drug abuse, ionizing radiation……

TYPES OF MISCARRIAGE

Threatened miscarriage .Inevitable miscarriage.Incomplete miscarriage.Complete miscarriage.Missed miscarriage.Septic miscarriage.Recurrent miscarriage.

CLINICAL FEATURES/MANAGEMENTThreatened miscarriage - Short period of amenorrhea. - Uterus corresponding to the duration. - Mild bleeding (spotting). - Mild pain. - P.V.: closed cervical os. - Pregnancy test (hCG): + ve. - US: viable intra uterine fetus.Management-reassurance.-Rest.-Repeated U/S

Clinical feature: - Period of amenorrhea. - heavy bleeding accompanied with clots (may lead to shock). - Severe lower abdominal pain. - P.V.: opened cervical os + product inside the cervical canal.

–Management -I.V fluids. -Blood if need. - Digital evacuation if possible. - Ergometrine & syntocinon. - evacuation of the uterus (medical/surgical).

INEVITABLE MISCARRIAGE

Clinical feature: - Partial expulsion of products - Bleeding and colicky pain continue. - P.V.: opened cervix… retained products may be felt through it. - US: retained products of conception.

TreatmentSurgical evacuation. (if the size of the uterus less than 12wks.).Medical evacuation. (if the size of the uterus more than 12wks.), prostaglandins , syntocinon.

INCOMPLETE MISCARRIAGE

COMPLETE MISCARRIAGE - Expulsion of all products of conception. - Cessation of bleeding and abdominal pain. - P.V.: closed cervix. - US: empty uterus.TreatmentAntibiotic Analgesia

Feature: - gradual disappearance of pregnancy Symptoms Signs. - Brownish vaginal discharge. - Milk secretion. - Pregnancy test: negative but it may be + ve for 3-4 weeks after the death of the fetus. - US: absent fetal heart pulsations.Complications - Hypofibrenogenaemia

Treatment- Wait 4 weeks for spontaneous expulsion - evacuate if: Spontaneous expulsion does not occur after 4 weeks. Infection. DIC. - Manage according to size of uterus

- Uterus < 12 weeks : dilatation and evacuation.

- Uterus > 12 weeks : try Oxytocin or PGs.

MISSED MISCARRIAGE

RECURRENT MISCARRIAGE

Definition: Three or more consecutive miscarriage.Causes: 1)Chromosomal abnormality.2)Immunological factors- antiphospholipids

antibodies.3)Cervical incompetence: 2nd trimester

miscarriage. a) Congenital. b)Acquired-(cervical injury, con biopsy)..

DIGNOSIS OF RECURRENT MISCARRIAGE

From the history : Painless. decreased gestational

age

Investigation: Hagar dilator(No.8). HSG.During pregnancy: Funnel shape, short

cervix .Management: Cervical cerclage.

SEPTIC MISCARRIAGEFollowing an incomplete miscarriage due to ascending infection.Or following criminal abortion.Clinical picture:Clinical picture:- Offensive bloody vaginal discharge.- Increased body temperature.- Lower abdominal pain (pelvic peritonitis) generalized peritonitis.- Increased pulse rate, dehydration, toxicity.InvestigationInvestigation :High vaginal swab for c/s + CBC.Treatment:Treatment:- Antibiotic, iv fluids,blood transfusion.- Evacuation of retained product.

In all form of miscarriages general clinical assessment should be

made: vital signs, abdominal examination, vaginal examination.

All needed investigations + / - u/s Management should be according to

clinical Type & gestational age.

COUNSELLING

Patients who have suffered miscarriages should be offered counseling to ensure that they understand that most miscarriages are non recurrent.

They should also be provided with the necessary psychological support where necessary.

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