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Transcript
Miscarriage Dr Mariem Gweder DHR MSc MRCOG DOGUS Definition Miscarriage = Spontaneous abortion Spontaneous loss of a fetus before the 24th week of pregnancy. WHO definition: loss of an embryo or fetus weighing 500 grams or less, (20 to 22 weeks or less. (Pregnancy losses after the 20th week are called preterm deliveries.) Incidence Occurs in about 15% to 20% of all clinical pregnancies, 60% to 70% occur during the first trimester. Most miscarriages occur during the first 7 weeks of pregnancy. The rate of miscarriage drops after the detection of fetal heart. Classifications Clinical / ultrasonic Threatened Miscarriage: bleeding seen, cervix closed, the fetus is viable. Inevitable Miscarriage : the cervix has already dilated, but the fetus has yet to be expelled. This usually will progress to a complete miscarriage. Complete Miscarriage: is when all products of conception have been expelled. Endometrium is less than 15mm thick on US. Incomplete Miscarriage: part of conception is passed, cervical os is open, and the retained part is more than 15mm thick Delayed or missed miscarriage: the embryo or fetus has died, but the os is closed. Anembryonic pregnancy (blighted ovum) An empty gestational sac, the embryo is either absent or stopped growing Complications Septic miscarriage: missed or incomplete miscarrige becomes infected. Recurrent pregnancy loss: three consecutive miscarriages. Causes & Risk factors First trimester Chromosomal abnormalities: majority of cases -Advanced maternal age: more likely to occur in older women highest after 40 -Woman suffering RPL, -H/O birth defects. Causes & Risk factors ??Progesterone deficiency may be another cause. No study has shown that first-trimester progesterone supplements reduce the risk Polycystic ovary syndrome.: metformin significantly lowers the rate but insufficient evidence of safety, Maternal disease: Hypothyroidism, autoimmune diseases, APL, uncontrolled diabetes Infections,: TORCH, acute febrile illness, pylonephritis. Smoking, Recreation drugs, Alcohol, Antidepressants Physical trauma, exposure to environmental toxins, Multiple pregnancy Causes Second trimester (PTL) Uterine malformation: Up to 15% Uterine fibroids Cervical problems (cervical incompetence) Diagnosis Symptoms Examination Ultrasound: confirmation BHCG Microscopically Genetic for abnormal chromosomes Symptoms The most common symptom is vaginal bleeding with or without abdominal cramps Up to 30% of women will have first trimester bleeding or spotting Low back pain or abdominal pain (dull, sharp, or cramping) Tissue or clot-like material that passes from the vagina Examination General examination: vital signs Abdominal examination : fundal level Pelvic exam, cervical dilatation or effacement, blood clot, POC in the cervical os Abdominal / vaginal ultrasound : gestational age, fetal heart, retained products. Investigations Blood type (if Rh-negative, anti-D immune globulin is needed. Complete blood count (CBC): HB to determine blood loss, WBC and differential to rule out infection HCG to confirm pregnancy HCG (quantitative) to rule out ectopic pregnancy HVS and Blood C/S if septic Management If in shock or heavy bleeding act as emergency: A B C No treatment -Threatened : bed rest has no proven benefit. -Complete Only Counsel Anti-D if needed Follow up:(weekly) Management options For - Incomplete abortion, - Anembryonic (empty sac) -Missed abortion “Early Pregnancy Assessment Unit” Options: Expectant (Conservative) Medical or Surgical Expectant (conservative) No treatment “wait & see” (65–80%) will pass naturally within two to six weeks. avoids the side effects and complications of medications and surgery risk of mild bleeding, need for unplanned surgical treatment, and incomplete miscarriage Medical management Mifepristone (anti-progesterone) oral, followed by (3648h) - Misoprostol: vaginal or oral tabs: repeat in 4-6 hrs if required - Success rate 95% will complete within a few days. Indications: - Patient choice Second trimester: Surgical evacuation is unsafe First trimester : >10 weeks, before D&C & cervix is closed (Misoprostol 400 mcg to ripen the cervix 3-4 hrs prior to dilatation) Contraindication to surgery or anaesthesia ,DIC Advantages: Fewer risks and complications Less cost Greater patient satisfaction Surgical treatment Vacuum aspiration or Traditional (D&C or E&C) Fast Less bleeding, Less pain Convenient for karyotype analysis (cytogenetic or molecular), The patient is febrile (>37.50 C) ◦ After appropriate antimicrobial management The patient or your health facilities are incapable of appropriate follow up Complications: injury to the cervix (e.g. cervical incompetence) perforation of the uterus, Asherman's syndrome: scarring of the endometrium Septic miscarriage Occurs when the tissue from a missed or incomplete miscarrige becomes infected. Unsafe abortion: gram negative, E.Coli Streptococci Staphylococci Bacteroides Chlostridium Perfringens STIs: Niesseria Gonorrhea Chlamydia Trochomatis Presentation: Prolonged or heavy vaginal bleedin offensive vaginal discharge Fever hypotension Hypothermia, oliguria Septic shock may lead to kidney failure and disseminated intravascular coagulation(DIC). chronic pain, PID, and infertility Risk of septicaemia and maternal death. Septic miscarriage management Intravenous fluids Broad-spectrum IV antibiotics should be given until the fever is gone. D&C or misoprostol Recurrent pregnancy loss(RPL) Recurrent miscarriage (habitual abortion) three consecutive miscarriages. 1% of miscarriages Causes Chromosomal: balanced translocation or Robertsonian translocation in one of parents Endocrinal Thrombophilia, Antiphospholipid syndrome Anatomical: cong anomalies, fibroids Cervical incompetence Work up Ultrasound: 2D, 3D, Sonohysterography Hysterosalpingogram (HSG) Hysteroscopy Karyotyping Women with unexplained recurrent miscarriage have an excellent prognosis for Future pregnancy After miscarriage The tissue passed should be sent to histopathology to exclude molar pregnancy. Possible to become pregnant immediately. However, it is recommended that women wait one normal menstrual cycle before trying to become pregnant again. Anti-D for RH negative. Counseling, support, explanation Follow up Summary Miscarriage mostly occurs in first trimester Majority of cases are due to chromosomal abnormalities Classification is clinical and ultrasonic Proper counseling is needed Patient choice should be considered in management options. Questions???