Miscarriage

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Miscarriage

  1. 1. Bleeding in Early Pregnancy Dr Irfan Ziad
  2. 2. CASE 1.1 “My period is 2 weeks late and I am bleeding.”A 23-year-old nulliparous woman has had 6 weeks of amenorrhoea.She has not been using any contraception. She normally has a regularmenstrual cycle every 28 days. A pregnancy test is positive. She hasnoticed slight vaginal spotting.
  3. 3. WHAT IS THE LIKELY DIFFERENTIAL DIAGNOSIS? Miscarriage Ectopic Pregnancy Molar Pregnancy
  4. 4. Six weeks of amenorrhoea and a positive pregnancytest,after regular menstrual cycles,indicate an earlypregnancy . These small amount of bleeding is a signthat the patient is threatening to have a miscarriage.
  5. 5. MISCARRIAGEis a pregnancy loss under 24 weeks
  6. 6. ABORTION
  7. 7. AetiologyChromosomal abnormality  Trisomies (Down’s syndrome)  Triploidies and tetraploidies  Monosomy X (Turner’s syndrome)  Translocation (hereditary)
  8. 8. AetiologyEndocrine Disorder  Diabetes  Hypothyroidism  Luteal phase deficiency  Polycystic ovarian syndrome
  9. 9. AetiologyAbnormalities of the uterus  Uterine septa (bicornuate uterus)  Endometrial adhesions (post curettage or Asherman’s syndrome)
  10. 10. Aetiology Others Tobacco, anaesthetic gases, arsenic, benzene, solvents, ethylene oxide, formaldehyde, pesticide, lead, mercury, cadmium Psychological disorders Antiphospholipid syndrome Thrombophilia (hereditary)
  11. 11. CASE 1.1 “My period is 2 weeks late and I am bleeding.”A 23-year-old nulliparous woman has had 6 weeks of amenorrhoea.She has not been using any contraception. She normally has a regularmenstrual cycle every 28 days. A pregnancy test is positive. She hasnoticed slight vaginal spotting.
  12. 12. What additional features in the history wouldyou seek to support a particular diagnosis? How much blood? How’s the pain? Do you pass out anything?
  13. 13. What clinical examination would you performand why? Haemodynamic status General exam, vitals, conjunctival colour Abdominal Exam To assess uterine size, to exclude acute abdomen Per Speculum To see if os is open , any fetal tissues, cervix. VE and bimanual exam Assess os, Elicit cervical excitation and adnexal mass in ectopic pregnancy
  14. 14. Threatened Miscarriage Pain : None/ Slight Bleeding : Slight-moderate Os : CloseUltrasound intrauterine gestational sac, : fetal heart activity, intrauterine bleeding, haematoma
  15. 15. Inevitable Miscarriage Pain : Considerable Bleeding : Heavy Os : OpenUltrasound is important in determining the : absence or persistence of conception products inside uterine cavity
  16. 16. Complete Miscarriage Pain : Slight Bleeding : Slight-moderate Os : Open, then close afterwardsUltrasound Empty uterus :
  17. 17. Silent Miscarriage Pain : Absent Bleeding : Slight, chronic Os : CloseUltrasound failure to identify fetal heart beat : Gestational sac >20mm in diameter and no embryonic/fetal part can be seen 6 mm embryo with no heart activity on TVS
  18. 18. Molar Pregnancy Pain : Slight/None Bleeding : Slight-moderate Os : CloseUltrasound Classic “snow-storm” : appearance of vesicles Honeycomb appearance
  19. 19. Ectopic Pregnancy Pain : Present Bleeding : Slight Os : Close/tenderUltrasound Empty uterus : May see adnexal mass
  20. 20. Summary
  21. 21. CASE 1.1 “My period is 2 weeks late and I am bleeding.”A 23-year-old nulliparous woman has had 6 weeks of amenorrhoea.She has not been using any contraception. She normally has a regularmenstrual cycle every 28 days. A pregnancy test is positive. She hasnoticed slight vaginal spotting.
  22. 22. What investigations would be most helpful andwhy? Urine pregnancy test A quick test but may be unreliable FBC To assess Hb, TWC Blood group and GSH To check rhesus status, and to prepare for tranfusion Ultrasound To locate the fetus, to assess viability and to look for POC Histology Any tissues expelled should be investigated to exclude molar or ectopic pregnancy
  23. 23. Ultrasound assessmentLook for pregnancy within the uterusPresence of fetal heart  Should be present 6 weeks  If CRL< 6mm or MSD<20mm with no yolk sac/fetus – rescan  Uncertain viability and unknown locationPresence of yolk sacAdnexal massesFree fluid/ endometrial thickness
  24. 24. 5.5 weeksGestation sac and contents
  25. 25. Yolk sac ( left)6.5 weeks Fetus is 3mm long A fetal heartbeat
  26. 26. 8.5 weeksYolk sac still visible
  27. 27. 12 weeksNow we can see the baby
  28. 28. “Evennot beexpert useto confirm if aagreed criteria, it may with possible of TVS using pregnancy is intrauterine or extrauterine in 8–31% of cases at the “ first visit. Condous G, Okaro E, Bourne T. The conservative management of early pregnancy complications: a review of the literature. Ultrasound Obstet Gynecol 2003;22:420–30
  29. 29. What is the role of serial B-hCG assessment inpredicting pregnancy outcome?
  30. 30. “ RCOG Study Group concluded thatisaccess to serial serum B-hCG estimation essential, “ with results available within 24 hours. Recommendations from the 33rd RCOG Study Group. In: Grudzinskas JG, O’Brien PMS, editors. Problems in Early Pregnancy: Advances in Diagnosis and Management. London: RCOG Press; 1997. p. 327–31
  31. 31. B-HCG Pregnancy hormone Should approximately double in the first trimester every 48 hours>1500 iu/l Ectopic pregnancy will usually be visualised with TVSPlateau below Pregnancy of unknown1000 iu/l location and miscarriage are both possible outcomes
  32. 32. Does serum progesterone assay have a role in predicting pregnancy outcome?
  33. 33. “ When ultrasound findings progesterone levelsof unknown location, serum suggest pregnancy below 25nmol/l are associated with pregnancies “ subsequently confirmed to be non-viable Hahlin M, Thorburn J, Bryman I. The expectant management of early pregnancy of uncertain site.Hum Reprod 1995;10:1223–7. 20. Banerjee S, Aslam N, Woelfer B, Lawrence A. Elson J, Jurkovic D. Expectant management of pregnancies of unknown location:a prospective evaluation of methods to predict spontaneous resolution of pregnancy. BJOG 2001;108:158–63.
  34. 34. Should all women with early pregnancy loss receive anti-D immunoglobulin?
  35. 35. Non-sensitised rhesus (Rh) negative womenAnti-D should receive anti-D immunoglobulin in the following: ectopic pregnancy All miscarriages over 12 weeks of gestation (including threatened)All miscarriages where the uterus is evacuated (whether medically or surgically) Royal College of Obstetricians and Gynaecologists. Use of Anti-D Immunoglobulin for Rh Prophylaxis. Guideline No. 22. London: RCOG; 2002.
  36. 36. Which women should be screened for genital tract infection?
  37. 37. “ Screening forshould be considered in women trachomatis, infection, including Chlamydia “ undergoing surgical uterine evacuation. Royal College of Obstetricians and Gynaecologists. The Care of Women Requesting Induced Abortion. Evidence-based Clinical Guideline No.7.London:RCOG Press; 2004.
  38. 38. When should surgical uterine evacuation be used?
  39. 39. Indications for Surgical uterine evacuation : Patient’s preference Persistent excessive bleeding, Haemodynamic instability, Evidence of infected retained tissue Suspected gestational trophoblastic disease Royal College of Obstetricians and Gynaecologists. The Care of Women Requesting Induced Abortion. Evidence-based Clinical Guideline No.7.London:RCOG Press; 2004.
  40. 40. How should surgical uterine evacuation be performed?
  41. 41. “ Surgical uterine evacuation forcurettage should be performed using suction & miscarriage “ Royal College of Obstetricians and Gynaecologists. The Care of Women Requesting Induced Abortion. Evidence-based Clinical Guideline No.7.London:RCOG Press; 2004.
  42. 42. A Cochrane review concluded that vacuum aspirationis preferable to sharp curettage in cases of incomplete miscarriage. The advantages include: Decreased blood loss Less pain Shorter duration of procedure Royal College of Obstetricians and Gynaecologists. Use of Anti-D Immunoglobulin for Rh Prophylaxis. Guideline No. 22. London: RCOG; 2002.
  43. 43. Complications of Surgical uterine evacuation : Perforation Haemorrhage intrauterine adhesions Intra-abdominal trauma Royal College of Obstetricians and Gynaecologists. Use of Anti-D Immunoglobulin for Rh Prophylaxis. Guideline No. 22. London: RCOG; 2002.
  44. 44. “usingincidence of serious morbidity The a similar surgical technique in induced abortion is 2.1% with a “ mortality of 0.5/100 000. Joint Study of the Royal College of General Practitioners and the Royal College of Obstetricians and Gynaecologists. Induced abortion operations and their early sequelae.J R Coll Gen Pract 1985;35:175–80
  45. 45. What is the advantages of prostaglandinadministration prior to surgical abortion?
  46. 46. “ significant reductions in dilatation force, haemorrhage and “ uterine/cervical trauma.There is no randomised evidence to guide practice in cases of first-trimester miscarriage,particularly in the presence of an intact sac
  47. 47. Should prophylactic antibiotics be given prior to surgical evacuation?
  48. 48. “ There is insufficient evidence to recommend routine antibioticprophylaxis prior to surgical uterine “ evacuation. Antibiotic prophylaxis should be given based on individual clinical indications A randomised trial of prophylactic doxycycline in curettage for incomplete miscarriage did not demonstrate an obvious benefit
  49. 49. What are the alternatives to surgical uterine evacuation for miscarriage?
  50. 50. Medical methodsare an effective alternative in the management of confirmed first-trimester miscarriage.
  51. 51. Efficacy rates vary widelyfrom 13% to 96%,influenced by many factors
  52. 52. Higher success rates were associated with Incomplete miscarriage (70–96% success rate) High-dose misoprostol (1200–1400 micrograms), Prostaglandins administered vaginally and clinical follow-up without routine ultrasound. Hinshaw HKS. Medical management of miscarriage. In: Grudzinskas JG, O’Brien PMS, editors. Problems in Early Pregnancy: Advances in Diagnosis and Management. London: RCOG Press; 1997. p. 284–95.
  53. 53. Misoprostol prostaglandin analogue cheap, highly effective active orally and vaginally No significant difference in successful outcome May bleed up to 3 weeksUsed in combination with mifepristoneS/E: Diarhhoea, abd pain, nause, headache
  54. 54. Cervagem GameprostInserted into the vaginaS/E: vaginal bleeding or uterine painnausea, vomiting, lower abdominal pain, backacheheadache, slight fever, flushing, chills
  55. 55. “Vaginal misoprostol for the termination of second and third trimester of pregnancy “ appears as effective as cervagem, butinformation about maternal safety is limited.
  56. 56. effective regimens for missed miscarriages•a higher dose of prostaglandin with longer duration of use•or, alternatively, priming with antiprogesterone.
  57. 57. Incomplete miscarriageCan be managed with prostaglandin alone No statistical difference in efficacy between surgical and medical evacuation for incomplete miscarriage and for early fetal demise at gestations less than 71 days or sac diameter less than 24mm.
  58. 58. Threatened miscarriage No specific management Reassurance Rest Sedation weekly ultrasound examination
  59. 59. Expectant managementis another effective method to use in selected cases of confirmed first- trimester miscarriage.
  60. 60. Expectant managementWatch and waitSerial scans and HCGMore successful in incomplete miscarriage 28% success if intact sac 94% if incomplete May have prolonged bleedingCan convert at anytime to medical/surgical
  61. 61. Concerns have been raised about theinfective risks of non-surgical management But published data suggest a reduction in clinical pelvic infection and no adverse affects on future fertility.
  62. 62. Septic miscarriageComplicated by infection - delayed evacuation
  63. 63. Septic miscarriageImmediate complication 1.localized endometritis 9.septicaemia 2.spreading endometritis 10. septic shock 11. renal failure 3.salpingitis 12. DIC 4.salpingo-oophritis 13. tetanus 5.pelvic peritonitis 14. gangrene 6. pelvic abscess 7.tuboovarian abscess 8.generalized peritonitis
  64. 64. Septic miscarriageLate complication• Chronic pelvic inflammatory disease• Pelvic adhesion• Ectopic pregnancy• infertility
  65. 65. Septic miscarriageGenital swab I/V broad spectrum antibiotics to cover g(+)ve, g(-)ve and anaerobic organism change antibiotics according to culture and sensitivity resultRemove the septic focus ERPOC Laparotomy and drainage for pelvic abscess TAH for septic uterus and uterine perforation
  66. 66. What are the advantages of arranginghistological examination of tissue passed at the time of miscarriage?
  67. 67. Tissue obtained at the time of miscarriage should be examined histologically to confirm pregnancy and to exclude ectopic pregnancy or unsuspected gestational trophoblastic disease.
  68. 68. CASE 1.2 A 32-year-old patient, Mrs. A, immigrated to the UnitedStates several years ago. Following the birth of their first daughter, Mrs. A has had three miscarriages betweeneight and 12 weeks gestation, the most recent one being one month ago.
  69. 69. What are the recommended investigations of couples with recurrent first-trimestermiscarriage and second-trimester miscarriage?
  70. 70. Investigations would include the following:•chromosomal analysis of the products of conception;•chromosomal analysis of both parents – a chromosomalabnormality (e.g.balanced translocation) will bediagnosed in one of the partners in 5–7per cent of casesof recurrent abortion;•maternal blood for anticardiolipin antibodies and lupusanticoagulant
  71. 71. Should I be given some kinda drug to avoid getting another miscarriage?
  72. 72. “Aspirin alone or in combination with heparin is being prescribed for women with unexplainedRecurrent miscarriage,with the aim of improving pregnancy outcome.” KaandorpSP,GoddijnM,vanderPostJA,HuttenBA,VerhoeveHR,Hamu lyákK,etal.Aspirinplusheparinoraspirinaloneinwomenwithrecurrent miscarriage.NEngl J Med2010;362:1586–96.
  73. 73. Recent Data suggest that the use of empirical treatment in women with unexplained recurrent miscarriage is unnecessary and should be resisted. KaandorpSP,GoddijnM,vanderPostJA,HuttenBA,VerhoeveHR,Hamu lyákK,etal.Aspirinplusheparinoraspirinaloneinwomenwithrecurrent miscarriage.NEngl J Med2010;362:1586–96.
  74. 74. In the absence of any identifiable cause,what are my chances of achieving an ongoing pregnancy on the next occasion?
  75. 75. There is a 60–70% likelihood ofsuccessful pregnancy if no cause is found for recurrent miscarriage
  76. 76. Is there potential benefit from support and follow-up after pregnancy loss?
  77. 77. “All professionals should be aware of the psychological sequelae associated with pregnancy loss and should provide support,follow-up and access to formal counselling when necessary. “

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