3. Causes
(1) Chromosomal abnormality
-( maternal age > 35 years old)
-> 50% of Miscarriage in first trimester.
e.g.: Trisomy (Down's Syndrome)
Monsomy X (Turner's Syndrom
Triploids and tetraploides
4. (2) Immunological causes
Anti phospho lipid syndrome.
Anti cardio lipin anti bodies.
(3) Infections
CMV, Toxoplasmosis, syphilis and
other febrile illness like Malaria.
(4) Maternal diseases
DM, HTN , Chronic renal diseases thyroid
diseases.
5. (5) Congenital of acquired abnormalities
of female internal organ.
(Double uterus, Septate uterus, cervical incompetence,
uterine fibroid)
(6) Drugs
Cytotoxic drugs, caffeine, al cohol, tobacco and cocaine.
(7) Over distension of the uterus
eg: Multiple gestation.
(8) Psychological disorders.
(9)Hormonedeficiency.progesterone,leu
tinizing hormone
7. (1) Threatened
miscarriage
Definition:-
painless vaginal bleeding accruing any time between
implantation and 24 weeks gestation.
* Cervix is closed
Clinical Picture:-
Signs and Symptoms of early pregnancy
Mild vaginal bleeding.
Pain slight or absent.
Cervix is closed.
Pregnancy test is + ve
U/S show a living fetus.
8. Management:-
-Investigation:-
HB% and urine general. Blood grouping and RH
factor.
U/S for fetus.
-Bed rest.
-Treat the cause if present.
-Anti D if mother Rh – ve
Prognosis:-
- in 50% bleeding will stop and pregnancy will continue
9. (2) Inevitable Miscarriage
Clinical Picture:-
-Vaginal bleeding is excessive with clots.
-Supra pubic colicky pain radiated to the back.
-Cervix is opened. Products of concepts may be
felt in the cervical canal
Management:-
-Resuscitation (I/V Fluid, Blood transfusion and
analgesia ) Ergometrine or Syntocinon.
1->12 weeks medical prostaglandins ,oxytocin
2-<12-surgical Evacuation of the uterus.
-Anti D gamma globulin if mother RH – ve . -
10. (3) In complete miscarriage
Retention of a part of the product of conception inside the
uterus.
Clinical Picture:-
-Excessive bleeding.
-Abdominal pain.
-Dilated cervix.
-Product of conception in uterus, cervix or vagina.
-The patient may be pale or shocked.
-u/s show some material still remaining in the uterus.
Management:- as the same as inevitable
11. (4) Complete Miscarriage
All the product of conception has been expelled from the
uterus.
Clinical Picture:-
-Pain and bleeding are usually stop.
-Cervix is close.
-U/S show an empty uterus. -
Management:-
-No further treatment.
-Anti D if mother RH – ve.
-Anti biotic if needed.
-observe the patient for 2 – 3 hours.
12. (5) Missed miscarriage
Is retention of dead fetus for 4 wks or more before
24weeks of gestation and failure of the uterus to expel
it.
Clinical Picture:-
-History of normal pregnancy.
-Painless recurrent Vaginal bleeding of dark brown blood.
- loss of normal pregnancy symptoms.
-Uterus doesn't increase in size or decrease.
-No fetal movement and No FHS.
Investigation:-
-HCG levels drop in7-10 days and become ->ve
-U/S show fetal death
13. Treatment:-
-Evacuation of the uterus either:
Medically (Misoprostol 600 – 800 mg/vagina )
surgically: suction curettage.
-Anti D if needed.
-Anti biotic.
Complication:-
-Infection.
-DIC
14. Septic abortion
It is a miscarriage that is complicated
with sepsis.
Clinical Presentation:-
-The Patient is very ill, febrile and
anemic.
-Sever abdominal tenderness.
-offensive vaginal discharge.
-Shock may be present either due to
bleeding or sepsis.
Leucocytosis and anemia
15. Septic abortion
Infection of the uterine cavity
following abortion leads to
SEPTIC ABORTION. Most cases
result from CRIMINAL
interference with non-sterile
instruments, but may follow
spontaneous miscarriage
17. Symptoms
1. A history of abortion, often
criminal.
2. Pelvic infection and septicaemia.
3. Fever with rigors.
4. Rapid thready pulse and low BP.
5. Dehydration.
18. Symptoms cont…..
6. Pelvic tenderness with foul
discharge from the uterus and
bleeding.
7. Neutrophil leucocytosis is found on
the blood count.
8. Reduced hemoglobin (anaemia).
19. Treatment
1. Admission to hospital
2. Blood culture
3. Hb, TWBC (and differential),
urine.
4. H.V.S.
5. Hydration with I.V. fluids and
blood transfusion if necessary.
20. Treatment cont……
6. Adequate doses of antibiotics
should be started at once: a
combination of amoxicillin,
Clindamycin, and Metronidazole
may be used. Change the
antibiotics according to culture
results.
21. Treatment cont…..
7. If the products of conception
are retained the uterus should
be evacuated. This should be
done at once if there is severe
bleeding, otherwise it is
preferable to wait to allow the
antibiotics to take effect.
22. Recurrent Miscarriage
Definition: (Three consecutive
spontaneous miscarriages)
Causes:
1. Chromosomal abnormalities.
(found in up to 3-5%)
2. Uterine abnormalities (bicornuate
and subseptate)
3. Polycystic ovaries.
23. Recurrent misc. causes cont….
4. Midfllicular LH/FSH defects
hypersecretion of LH
5. 15% of women with 1st trimester
recurrent miscarriage and 30% of
women with 2nd trimester misscarriage
may have Antiphospholipid antibodies
(APL).
6. 20% have thrombophilic defects.
7. Bacterial vaginosis.
8. Incompetent cervical os (2nd trimester
miscarriage)
26. Investigations cont…..
8. Selective investigations:
Thyroid function tests ( TFT )
Renal function tests (RFT)
screening for Diabetes Mellitus
ARE DONE IF INDICATED.
9. TORCH have no value in the
investigations for Recurrent
miscarriage.
27. Treatment of Rec. misc.
1. Parenteral karyotyping
2. Surgical correction of uterine
abnormalities
3. Cervical circulage for int. os
incompetence
4. Medical treatment or laparoscopic
drilling for polycystic ovaries.
28. Treatment cont.
5. Thromboprophylaxis thrombophilia
using unfractionated heparin (UH), or
low molecular weight heparin (LMWH),
or low dose Aspirin.
6. High Vaginal swab (HVS) and treatment
according to the specific organism (e.g.
Metronidazole and/or Clindamycin
29. Cervical inCompetence
Mid trimester miscarriage
Cause
-Congenital.
-Acquired:
Instrumental delivery,
Excessive dilatation in D and C.
Cervical surgery
Treatment:-
Surgically by cervical cerclage
31. INDUCED ABORTION
MEDICAL
HEART FAILURE.
RENAL FAILURE
CANCER + RADIATION
HEPATIC FAILURE
MALIGNANT
HYPERTENSION.
FETAL MALFORMATION
Mental diseases
RX:
MEDICAL BOARD.
CONSENT WRITTEN
DO IT IN A GENERAL
HOSPITAL
32. Diagnosis of Miscarriage
History:-
-amenorrhea , vaginal bleeding, abdominal pain and + ve
pregnancy test.
-Maternal age, medical disorder.
-Previous history of miscarriage. -
Examination:-
-General Examination.
-Speculum Examination.
-Ultra sound.
Laboratory investigation. -
-Full blood count.
-Blood group and Rh type.
-HCG. -
-Progestron
33. Management
(A) Surgical
(1) Vaginal evacuation
1- Suction
For 7 – 12 weeks gestation.
Procedure:-
-Evacuation of the bladder. -
-lithotomy Position .
-anaesthia.
-Sterilization
-Bimanual Examination
-Sims Speculum.
-Dilatation. -
-Suction: Canula and – ve pressure.
34.
35.
36.
37. 2- Dilatation and evacuation
The same as suction till the dilatation
of the cervix
Then:
-Ergometrin I/V.
-Evacuation: Ovum forceps.
-Curettage.
