Miscarriages
Dr. Sarah Safdar
PGR - I
Unit – II, LWH
Definition
“Miscarriage is defined as the loss of a
intrauterine pregnancy before 24
completed weeks of gestation”
WHO def...
Types :
• Sporadic/Spontaneous
• Recurrent
Spontaneous Miscarriages
• Expulsion of a fetus before 24 completed weeks of
gestation or an embryo weighing 500 g or less...
Etiology
• Fetal
• Placental
• Maternal
• Unknown in 25% of cases
1) Fetal causes
• Chromosomal abnormalities
i) Aneuploidy ~ 50%
a. Trisomy
b. Monosomy
c. Triploidy/Tetraploidy
ii) Struct...
Causes……
2) Placental
Haemorrhage in decidua basalis or necrotic tissue in tissue
adjacent to bleeding
Hydropic degenerati...
Causes……
 Uterine Anomalies
– Bicornuate and subseptate uterus
– Cervical incompetence(most common Cause of 2nd
trimester...
Causes…….
 Infections
– More commonly associated with isolated abortions
– Any acute illness like typhoid fever, malaria,...
Causes…..
 Other Maternal ailments :
Chronic ailments
 40 yrs
Smoking
Diabetes
Hypertension
Renal disease
Thyroid ...
 Fetal Sex,Multiple Pregnancy,Maternal
age and Parity
4) Unproved Causes ~ 25 %
 Progesterone deficiency
 Immunological...
Presentations Of Spontaneous
Miscarriages
o Threatened
o Inevitable
o Incomplete
o Complete
o Missed
o Septic
Threatened Miscarriage Inevitable Miscarriage
P/V
bleeding
Fresh Blood,small in amnt Fresh blood ,more in amount wd
sum cl...
Outcome
Incomplete Complete
P/V bleeding Heavy bleeding wd passage of
clots & tissue
May b asymptomatic WD Hx of
bleeding & RPOC’s...
Missed Miscarriage
P/V bleeding When present,old blood,small in amount
Pain Usually absent at the time of diagnosis
Others...
%• Complications of
surgical evacuation :
• Tearing or laceration of cervix
• Perforation of uterus leading to
bowel perfo...
Septic Miscarriages
P/V bleeding Bleeding variable in amount,foul smelling,vaginal discharge in
case of infection
Pain Cra...
Recurrent Miscarriages
• Three or more consecutive miscarriages
• TYPES OF RMC
• Primary RMC :
where there have been no pr...
RMC Subtypes
• All pregnancy losses, no viable pregnancy
• Viable pregnancy followed by pregnancy losses
• Pregnancy losse...
Causes Of Recurrent Miscarriages
Genetic
Anatomical
Infective
Endocrine
Immunological
Genetic
• Parental Chromosomal aneuploidy
– balanced reciprocal translocation
– robertsonian translocations
– Pericentric ...
• Other genetic Factors
– euploidy
– single gene defect
– molecularr mutations
• Peripheral blood karyotyping
• Specialize...
Anatomical Factors : Septate Uetrus
• Most common
• Poorest outcome
• Miscarriage > 60 %
• Fetal survival with untreated c...
Submucosal Fibroids
• The mechanism -
– Their position
– Poor endometrial receptivity
– Degeneration with increasing
cytok...
Investigation and Treatment
• HSG,Laparoscopy,Hysteroscopy,MRI,CT & 3
D USG
Surgery :
• Hysteroscopy
Procedure of choice
S...
Cervical Incompetence
• Associated wd MC after 12-14 wks or PM labour
• Silent dilatation of cervix without painful cont
D...
Infective factors
• Syphilis : recurrent late 2nd
trimester MC
» Routine screening
» Prophylaxis wd penicillins
• Bacteria...
Endocrine Factors
• Systemic Endocrine Diseases
• Luteal Phase Defect
• PCO & Hypersecretion of LH
Luteal Phase Defect
– Progesterone is essential for
implantation and maintenance of
pregnancy
• A defect in Corpus luteum...
PCO & Hypersecretion of LH
• Polycystic ovary morphology itself does not predict an
increased risk of future pregnancy los...
Investigations :
• Thyroid Function Tests- T3 ,T4, TSH
• S.Prolactin
• Glucose tolerance test
• HbA1c
• S.FSH
• S.LH
• S.P...
Treatment
• Luteal-phase insufficiency
– luteal-phase support with progesterone
– There is insufficient evidence to evalua...
Autoimmune & Thrombophilic Defects
Autoimmune :
Autoimmune Alloimmune
(directed to self) (directed to foreign
tissues/cell...
• Systemic Lupus Erythmatosus (SLE)
-Risk for loss is 20%,mostly in 2nd
and 3rd
trimester of pregnancy and associated with...
Diagnosis :
CLINICAL
1) Thrombolic events :
arterial,venous,small vessel
2)Pregnancy loss-
» ≥3 losses at <10wks gestation...
LABS
1) Lupus Anticoagulant
2) Anticardiolipin antibodies(IgG or IgM)
Any lab test results must be observed on at least 2
...
• Treatment for APA
1. Low Molecular weight Heparin
– 3000 IU S/C twice a day
– Expensive treatment
1. Un-fractionated Hep...
Investigation
Treatment
• 50 % of Miscarriages ~No Cause
• Prognosis is good
• ReAssurance & Psychological Support
• 75 % of live births...
• MiSCARRIAGES DON’T OCCUR IN A
UTERUS BUT IN A WOMAN,AND
MISCARRIAGES DO NOT OCCUR SOLELY
IN A WOMEN BUT IN A FAMILY
Support should Includes
• Care in Specialist clinic
• Psychological support
• Easy access to named contact
• Close monitor...
• Should be offered to all patients wd RPL
• Explanation of possible causes & prognosis
• After 3 consecutive early preg l...
Your Main Title
Miscarriages,,!!!
Miscarriages,,!!!
Miscarriages,,!!!
Upcoming SlideShare
Loading in...5
×

Miscarriages,,!!!

1,790

Published on

First presentation of my Post graduate training

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,790
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
152
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Miscarriages,,!!!

  1. 1. Miscarriages Dr. Sarah Safdar PGR - I Unit – II, LWH
  2. 2. Definition “Miscarriage is defined as the loss of a intrauterine pregnancy before 24 completed weeks of gestation” WHO definition “The expulsion of fetus or an embryo weighing 500 g or less and also a gestational age limit of less than 22 completed weeks of pregnancy”
  3. 3. Types : • Sporadic/Spontaneous • Recurrent
  4. 4. Spontaneous Miscarriages • Expulsion of a fetus before 24 completed weeks of gestation or an embryo weighing 500 g or less spontaneously • Incidence = 15%(1 in 6) • Actual incidence is difficult to assess because  Some women abort without knowing that they have been pregnant  Some women have vaginal bleeding after variable amenorrhea but not having confirmed evidence of pregnancy  Spontaneous origin by deliberate interference
  5. 5. Etiology • Fetal • Placental • Maternal • Unknown in 25% of cases
  6. 6. 1) Fetal causes • Chromosomal abnormalities i) Aneuploidy ~ 50% a. Trisomy b. Monosomy c. Triploidy/Tetraploidy ii) Structural chromosomal abnormalities ( common in recurrent M) • Developmental defects(NTDs,cleft palate,cyclopia,amniotic bands,syrinomelia & caudal regression)
  7. 7. Causes…… 2) Placental Haemorrhage in decidua basalis or necrotic tissue in tissue adjacent to bleeding Hydropic degeneration in plcental villi 3) Maternal  More common in second trimester  Mostly associated wd recurrent miscarriages  These includes  Uterine Anomalies  Infections  other maternal causes
  8. 8. Causes……  Uterine Anomalies – Bicornuate and subseptate uterus – Cervical incompetence(most common Cause of 2nd trimester abortions) – Uterine myomas – Asherman syndrome
  9. 9. Causes…….  Infections – More commonly associated with isolated abortions – Any acute illness like typhoid fever, malaria, pyelonphritis & appendicitis can cause miscarriage Bacteria : L monocytogenes,Compylobacter,Mycoplasma,ureaplasma Spirochetes : Treponema Pallidum Parasites : Toxoplasma gondii Viruses : Cytomegalovirus,Rubella,Herpes,Coxsackie
  10. 10. Causes…..  Other Maternal ailments : Chronic ailments  40 yrs Smoking Diabetes Hypertension Renal disease Thyroid disease
  11. 11.  Fetal Sex,Multiple Pregnancy,Maternal age and Parity 4) Unproved Causes ~ 25 %  Progesterone deficiency  Immunological causes  Radiations  Direct or indirect trauma
  12. 12. Presentations Of Spontaneous Miscarriages o Threatened o Inevitable o Incomplete o Complete o Missed o Septic
  13. 13. Threatened Miscarriage Inevitable Miscarriage P/V bleeding Fresh Blood,small in amnt Fresh blood ,more in amount wd sum clots Pain Painless Typical L pains Others Cervical Shock syndrome Abdominal Ex Fundal ht = dates Fundal ht = dates P/S Fresh blood coming thru cervix Bag of membrns bulging thru cervix P/V Cervical os closed Cervical os open Ix FCA present on USG FCA may or may not b present Rx Bed Rest,Avoid Coitus,Hormonal Rx, Antibiotics Evacuation of uterus
  14. 14. Outcome
  15. 15. Incomplete Complete P/V bleeding Heavy bleeding wd passage of clots & tissue May b asymptomatic WD Hx of bleeding & RPOC’s passage earlier Pain Crampy lower abd pain May gv Hx of pain Earlier Others Hypovolemic shock Abdominal Ex Fundal Ht < dates FH < dates P/S POC’s present in cx or vagina Cervical os may appear close P/V Cervical os open,POC may be felt in uterus Cervical os may appear close or open Ix RPOC’s on USG Empty uterus on USG Rx Evacuation No Rx
  16. 16. Missed Miscarriage P/V bleeding When present,old blood,small in amount Pain Usually absent at the time of diagnosis Others Absent fetal movements,& FCA Regression of pregnancy symptoms Abdominal Ex Fundal Ht < dates P/S Old discolored blood if present P/V Cervical os closed Ix FCA absent,Spalding & Robert’s sign in advanced preg Rx <12 wks ~ Suction & evacuation >12 wks Expulsion F/b Curettage
  17. 17. %• Complications of surgical evacuation : • Tearing or laceration of cervix • Perforation of uterus leading to bowel perforation • Bladder perforation • Damage to broad ligament • Infection • Asherman syndrome
  18. 18. Septic Miscarriages P/V bleeding Bleeding variable in amount,foul smelling,vaginal discharge in case of infection Pain Crampy lower abd pain Others Pyrexia,Tachycardia,dehydration,electrolyte imbalance,abdominal distension,paralytic illeus,septic shock Abdominal Ex Tenderness,guarding.rigidity in lower abd,abdominal distension,paralytic ileus P/S Blood/pus coming through cervix P/V Cervical os may be open or closed,pelvic tenderness,uterine mobility restricted,adenexal mass Ix POC’s within the uterus,tubo-ovarian mass Rx Ab,fluid & electrolyte correction,blood transfusion,evacuation of uterus.,laparotomy
  19. 19. Recurrent Miscarriages • Three or more consecutive miscarriages • TYPES OF RMC • Primary RMC : where there have been no previous live birth • Secondary RMC ; where atleast one successful pregnancy have been occurred previously Ectopic, molar, and biochemical pregnancies not included.
  20. 20. RMC Subtypes • All pregnancy losses, no viable pregnancy • Viable pregnancy followed by pregnancy losses • Pregnancy losses interspersed with viable pregnancies
  21. 21. Causes Of Recurrent Miscarriages Genetic Anatomical Infective Endocrine Immunological
  22. 22. Genetic • Parental Chromosomal aneuploidy – balanced reciprocal translocation – robertsonian translocations – Pericentric chromosomal inversion • Recurrent aneuploidy – Inc tendency to nondisjunction – Mostly seen in IVF embryos
  23. 23. • Other genetic Factors – euploidy – single gene defect – molecularr mutations • Peripheral blood karyotyping • Specialized genetic counselling
  24. 24. Anatomical Factors : Septate Uetrus • Most common • Poorest outcome • Miscarriage > 60 % • Fetal survival with untreated cases 6 to 28 % • The mechanism – Not clearly understood – Poor blood supply – poor implantation
  25. 25. Submucosal Fibroids • The mechanism - – Their position – Poor endometrial receptivity – Degeneration with increasing cytokine production
  26. 26. Investigation and Treatment • HSG,Laparoscopy,Hysteroscopy,MRI,CT & 3 D USG Surgery : • Hysteroscopy Procedure of choice Septum excision, polypectomy • Laparoscopic myomectomy For fibroids • Laparotomy • Likelihood of live births in untreated pts is as high as 66 % • Open pelvic surgery wth RMC ~ Infertility
  27. 27. Cervical Incompetence • Associated wd MC after 12-14 wks or PM labour • Silent dilatation of cervix without painful cont Dx: Previous Hx of mid-trimester MC Ix : TVS Rx : Cervical cerclage after 12-14 wks Mcdonald/Shirodkar
  28. 28. Infective factors • Syphilis : recurrent late 2nd trimester MC » Routine screening » Prophylaxis wd penicillins • Bacterial Vaginosis » Recurrent 2nd trimester loss » Metronidazole • Regular sterile speculum EX • Regular high n low vaginal swabs • Low dose antibiotic for repeated positive results
  29. 29. Endocrine Factors • Systemic Endocrine Diseases • Luteal Phase Defect • PCO & Hypersecretion of LH
  30. 30. Luteal Phase Defect – Progesterone is essential for implantation and maintenance of pregnancy • A defect in Corpus luteum impaired progesterone production. • LPD cannot be diagnosed during pregnancy; a consistently short luteal phase duration is the most reliable diagnostic criterion.
  31. 31. PCO & Hypersecretion of LH • Polycystic ovary morphology itself does not predict an increased risk of future pregnancy loss among ovulatory women with a history of recurrent miscarriage who conceive spontaneously • Hyperinsulinemia & level of Plasminogen Activator↑ Inhibitor activity – implicated as the proximate cause of incidence of loss(30-50%)among PCOS women • METFORMIN treatment can reduce or eliminate risk of miscarriage in PCOS women
  32. 32. Investigations : • Thyroid Function Tests- T3 ,T4, TSH • S.Prolactin • Glucose tolerance test • HbA1c • S.FSH • S.LH • S.Progesterone
  33. 33. Treatment • Luteal-phase insufficiency – luteal-phase support with progesterone – There is insufficient evidence to evaluate the effect of progesterone supplementation in pregnancy to prevent a miscarriage • PCOS, hyperandrogenism, hyperinsullinemia – insulin-sensitizing agents (METFORMIN) • overt diabetes mellitus – prepregnancy glycemic control • hypothyroidism – thyroid hormone replacement
  34. 34. Autoimmune & Thrombophilic Defects Autoimmune : Autoimmune Alloimmune (directed to self) (directed to foreign tissues/cells) -Systemic Lupus Erythmatosus An Abnormal maternal -Antiphospholipid Syndrome immune response to fetal or placental antigen.
  35. 35. • Systemic Lupus Erythmatosus (SLE) -Risk for loss is 20%,mostly in 2nd and 3rd trimester of pregnancy and associated with antiphospholipid antibodies. • Antiphospholipid syndrome (APA) – 5 - 15 % of women with RPL may have APA APA likely induce microthrombi at placentation site. Altered vascularity affects developing embryo, induces MISCARRIAGES
  36. 36. Diagnosis : CLINICAL 1) Thrombolic events : arterial,venous,small vessel 2)Pregnancy loss- » ≥3 losses at <10wks gestation » fetal death after 10wks » premature birth at <34wks associated with severe preeclampsia or placental insufficiency.
  37. 37. LABS 1) Lupus Anticoagulant 2) Anticardiolipin antibodies(IgG or IgM) Any lab test results must be observed on at least 2 separate occasions 8 wks apart.
  38. 38. • Treatment for APA 1. Low Molecular weight Heparin – 3000 IU S/C twice a day – Expensive treatment 1. Un-fractionated Heparin is better option 2. Low dose Aspirin 3. Steroids? Mainly for anti nuclear antibodies – 10 – 20 mg prednisolone / day
  39. 39. Investigation
  40. 40. Treatment • 50 % of Miscarriages ~No Cause • Prognosis is good • ReAssurance & Psychological Support • 75 % of live births in unexplained RPL
  41. 41. • MiSCARRIAGES DON’T OCCUR IN A UTERUS BUT IN A WOMAN,AND MISCARRIAGES DO NOT OCCUR SOLELY IN A WOMEN BUT IN A FAMILY
  42. 42. Support should Includes • Care in Specialist clinic • Psychological support • Easy access to named contact • Close monitoring including  USG  APPropriate reassurance  helpful & caring staff
  43. 43. • Should be offered to all patients wd RPL • Explanation of possible causes & prognosis • After 3 consecutive early preg losses ~ 60-70% chances of next successful pregnancies • Even after 6 miscarriages~the chance of successful preg is still 45 % Counselling
  44. 44. Your Main Title
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×