Types of miscarriage Indications of miscarriage Methods of miscarriage

1. TERMINATION OF PREGNANCY
Dr. Farwa Ashfaq (PGT)
Dr. Muqqadas (HO)
Ref: NICE Guidelines

2. DEFINITION
 Deliberate removal of embryo/fetus from uterus
before stage of viability

3. FETAL INDICATION

4. MATERNAL INDICATION

5. TYPES OF MISCARRIAGE

7. INDUCED ABORTION
 Abortion act 1967:
-must be performed within an NHS hosp./ approved
clinic.
-CMO must be informed.
-two RMPs must certify that operation is being
performed for grounds specified in the act.
 Amendments by HFEA in 1990:
5 categories:
1. continuance of pregnancy  risk to life of
woman.
2. TOP is necessary to prevent grave injuries to
physical and mental health of pregnant lady.

8. 3.pregnancy has not exceeded 24 weks risk of
mental and physical harm to mother.
4. pregnancy has not exceeded 24 weks  risk of
mental and physical harm to children.
5. Physical / mental abnormality of fetus.

9. PRE-ABORTION MANAGEMENT
 Counseling andd discussion of method being used.
 Full medical history
 USG to confirm intrauterine pregnancy and its GA.
 Blood group, cbc, pt-aptt
 Chlamydia screening all +ve should have STI
screening, contact tracing and treatment of both
partners
 Contraceptive cunseling
 Antibiotic prophylaxis in case of surgical methods.

10. PERI-ABORTION PROPHYLAXIS
 Metronidazole 1g rectally/ 800mg orally prior to or
at time of abortion
PLUS
Doxycycline 100mg 1 x BD x 7 days from day of
abortion
 OR
Metronidazole 1g rectally/ 800mg orally prior to or at
time of abortion
PLUS of abortion
Azithromycin 1gm PO x stat at time of abortion

11. METHODS
 Expectant
 Medical
 Surgical
D&E
Vaccum aspiration (electrical/manual)

12.  Upto 9 weeks- early medical termination
 Upto 10-11 weeks- MVA
 From 6-16weeks- vacuum aspiration under
local/GA
 Above 14 weeks- D&E (cx preparation)
 9+ to 24weeks- Medical Method
UNLISCENCED Regimen: for <9weeks mifepristone
200mg PO f/b misoprostol 800mg vaginally/
sublingually 36-48hrs later.
2nd dose of 400ug of misoprostol after 4 hrs.
For 9-24weeks- repeat max of 4 doses 3hrs apart(
depends on vaginal bleeding)

13. COMPLICATIONS
 RPOCs (confirmed on scan): surgical evacuation
 Haemorrhage (1 in 1000to 4 in 1000 at 20+weeks)
 Uterine perforation
 Uterine Rupture (mid- trimester miscarriage)
 Cervical trauma( cx preparation reduces risk)
 Failed Abortion
 Post- abortion infection
 Future reproductive outcome(small risk of
subsequent miscarriage/preterm labour)

14. RHESUS PROPHYLASIS
 For all non sensitized Rh-ve women, anti-D Ig
shoulde be given within 72 hrs.
250 IU before 20 weeks of gestation
500IU thereafter
no ati-D if medical TOP is done before 10 weeks.
But for surgical TOP it should be given. (RCOG)
 Pre- abortion contraceptive counseling should be
done
 f/up in case of emergency otherwiswe routine f/up
after surgical abortion is not necessary.

15. ECTOPIC PREGNANCY
 3 management options depends on clinical
condition and future fertility requirement.
EXPECTANT
offered to women with small <3 cm non ruptured
ectopic pregnancy without FCA and BHCG <
1500IU/L.
success rate 76-88%

16. SURGICAL
main treatment for Tubal pregnancy especially with
significant bleeding.
RCOG and NICE recommends laproscopic approach
whenever possible.
 2 options: salpingectomy/ salpingostomy
salpingostomy should be offered if C/L tube is already
damaged/removed and female wants to conserve
fertilty may require further medical Tx or
salpingectomy.
 Salphingectomy is done if:
adnexal mass > 35mm
significant pain
ectopic pregnancy with FHR +ve on scan
BHCG > 5000IU/L
hyovolemic shock

17.  MEDICAL
if patient is hemodynamically stable
-asymptomatic
-unruptured small ectopic <35mm and no FCA
-no intrauterine pregnancy on scan
-able to continue f/up visits
Methotrexate Regimen:
inj. Methotrexate 50mg/m2 OR 1g/kg x IM
serial BHCG levels until <20IU/L
More than 1 dse is required in 14-26% cases.

18. ANOMALOUS FETUSES
 1st trimester: vaccum/ D&E
 Medical treatment acc to FIGO protocol in 2nd and
3rd trimester.

20. THANK YOU