early trimester miscarriages

1. Early trimester
miscarriages
Dr HinaAamir
Gynaesho

2. Definition of miscarriages
Early trimester miscarriage refers to loss of
pregnancy before 13 weeks of gestation or
12 completed weeks of pregnancy.
Spontaneous miscarriages –commonest
cause
20% of clinical pregnancies equating to
approx 14,000 miscarriages per annum in
ireland

3. Types of miscarriages
Threatened miscarriage
Missed miscarriage
Incomplete miscarriage
Complete miscarriage
Recurrent miscarriage
Other early pregnancy disorders which
must be ruled out :
Ectopic pregnancy
Hydatidiform mole

4. Causes of miscarriages
 Chromosomal abnormalities
such as tirsomies, monosomy X , translocation , tetraploidies
 Maternal factors:
age>35 yrs
 Endocrine disorders
as diabetes, hypothyroidism , luteal phase deficiency, PCOS,
 Abnormalities of uterus ,
bicornuate uterus
 Infections
such as salmonella typhi, malaria, cytomagaolvirus, brucella,
toxoplasmosis, mycoplasma hominis, chylamydia trachomatis, ureaplasma
urealyticum
 Chemical agents
such as tobacco, anaesthetic gases, arsenic, benzene, solvents ,
ethylene oxide , formaldehyde, pesticides, lead, murcury,cadmium,.
 Psycological disorders
 Immunological disorders
antiphospholipid syndrome, thrombophilia

5. History taking
 Ask about the LMP
 Amount of bleeding , color, passage of clots,or
any tissue products
 Abdopelvis pain ,site, character, severity
 Past obstetric history
 Past h/o PID, pelvic surgery
 Any contraception such as IUCD
 Any past ho miscarriages ,ectopic pregnancy
 Past medical history such as diabetes
 Social history such as smoking ,consumption of
alcohol

6. Examination
 GENERAL PHYSICAL EXAM
• Pallor
• Tachycardia
• Shock
• Collapse
 Abdominal exam
• Tenderness
• Any adnexal mass palpable
• Guarding or rigidity ,enlarged uterus
 PER SPECULUM EXAM
• Source of bleeding
• Amount of bleeding, cervical os open or close or any products of
conception seen

7. Investigations
FBC
 Blood group and hold
Rhesus status
Beta HCG
Progesterone levels if needed
Referral to early pregnancy unit for
ultrasound to look for the location and
viability of conceptus

8. Referal to EPAU
 Those with a H/O a positive pregnancy test
and:
 Vaginal bleeding or abdominal pain
 Previous ectopic pregnancy
 Previous tubal surgury
 Previous miscarriage
 Iucd in situ
 Persistant bleeding post evacuation of the
ERCP were there is a suspicion of the
problems
 Other clinical conditions as stated in the
hospital protocol

9. miscarriage
Gestational sac >20 mm No embryo or yolk sac
miscarriage
embryo> 7 mm No cardiac activity
Transvaginal ultrasound

10. miscarriage
Gestational sac >25 mm No embryo or yolk sac
miscarriage
Embryo >8mm No cardiac activity
Transabdominal ultrasound

11. Ultrasound Terminology
Viable intrauterine pregnancy
Pregnancy of uncertain viability
Early pregnancy loss
Incomplete miscarriage
Complete miscarriage
Pregnancy of unknown location

12. Management of miscarriage
/ectopic pregnancy

13.  Conservative management:
• Effective and acceptable method provided there
are no signs of infection(vaginal discharge),
excessive bleeding, pyrexia or abdominal pain .
• Women should be counselled on what to expect ,
the likely amount of blood loss, what analgesics to
take.
• Follow up scans arranged at 2 weekly intervals
until a diagnosis of complete miscarriage made.

14.  Medical management
• Misoprostol
• Highly effective prostaglandin analogue po or pv
• Protocol adminstration- 600 micro gram at least 3 hourly
 Side effects
• Nausea
• Vomiting
• Cramping
• Diarrhoea
• Success rate 80-90%
• Out patient medical management should be reserved to
women with a MGSD less then 50 mm as increased bleeding
may be encountered. In case of pregnancy with IUCD in-situ
the device should be removed before.

15. Surgical management of
miscarriage
 Surgical uterine evacuation (ERPC) should be offered to women
that prefer that. Misoprostol 400 micro gram can be used for
cervical priming
 Clinical indication for ERPC
• Persistent excessive bleeding
• Haemodynamic trophoblastic disease
• Evidence of retained tissue
• Suspected gestational trophoblastic disease
• Surgical evacuation must be performed using suction curattage and be
preferably managed
 Side effects –
• Complications of anaesthetic agents
• Uterine perforations 1%
• Cervical tears
• Intra-abdominal trauma
• Haemorrhage infection

16.  Histological examination of tissue
• Products of conception should be sent for histological
examination to confirm the diagnosis of miscarriage and
helps excludes ectopic pregnancy
 Rhesus anti- D prophylaxis
 Non- sensitised RH negative women
 Ectopic pregnancy or miscarriages over 12 weeks gestation
including threatened
 All miscarriages were the uterus is evacuated surgically

17. Psychological aspects of
miscarriage
 Support, follow-up and access to formal counselling were
necessary