This document discusses miscarriage, ectopic pregnancy, and recurrent miscarriage. It defines miscarriage as pregnancy loss before 24 weeks and notes the most common sign is vaginal bleeding. For ectopic pregnancy, it describes the risk factors, symptoms, and treatments which include expectant management, medical treatment with methotrexate, or surgical treatment. Recurrent miscarriage is defined as 3 or more consecutive losses and investigations and treatments are discussed including aspirin, heparin, surgery for anatomical issues, and psychological support.

1. Miscarriage & Ectopic

2.  Miscarriage is a pregnancy that ends spontaneously before 24 weeks’
gestation
 The most common sign of miscarriage is vaginal bleeding
 10–20% of clinical pregnancies
 the risk increasing with maternal age

3. Classification

4. Aetiological factors
• Chromosomal abnormalities.
• Medical/endocrine disorders.
• Uterine abnormalities.
• Infections.
• Drugs/chemicals.

5. Investigations
 Transabdominal/TVUSS
If the crown–rump length is 7.0 mm or more with a transvaginal ultrasound scan and
there is no visible heartbeat
If the mean gestational sac diameter is 25.0 mm or more using a transvaginal
ultrasound scan and there is no visible fetal pole
 Hemoglobin and ‘Group and Save’ (or crossmatch if patient
is severely compromised)
 measure to assess degree of vaginal loss
 rhesus status

6. Management
 Expectant
 Medical
 Surgical

7. Expectant
 After a spontaneous miscarriage where the pain and bleeding resolve,
a repeat ultrasound scan is not required to confirm completion.
 Women may be advised to take a urinary pregnancy test after 3
weeks and attend if it is positive.
 Women undergoing expectant management may require unplanned
surgery if they start to bleed heavily

8.  administration of a single, or repeated, vaginal or sublingual dose of the
prostaglandin E analogue misoprostol
 Side effect of misoprostol : rigors , vomiting and diarrhoea
 no need for routine scan follow-up
 although a post-treatment pregnancy test is recommended
 Srgical treatment is required if : heavy bleeding or failure (10% failure )

9. Surgical
 persistent excessive bleeding
 haemodynamic instability
 patient choice
 manual vacuum aspiration
 Pre-evacuation ripening of cervix with misoprostol to decrease trauma and
bleeding
 Risks : uterine perforation, postoperative pelvic infection and cervical
trauma and subsequent cervical incompetence

10. Recurrent miscarriage
 Recurrent miscarriage is defined as the loss of three or more consecutive
pregnancies
 it affects 1% of couples
 Risk factors
advancing maternal and paternal age,
Obesity
balanced chromosomal translocations
Uterine structural anomalies
Antiphospholipid syndrome (APS).

11. Investigations for recurrent miscarriages
consider …..
 Antiphospholipid antibodies
All women with recurrent first-trimester miscarriage and all women with one or more
second-trimester miscarriage should be screened before pregnancy for antiphospholipid
antibodies
Thrombophilia
Women with second-trimester miscarriage should be screened for inherited thrombophilias
including factor V Leiden, factor II (prothrombin) gene mutation and protein S
 Fetal karyotyping
Cytogenetic analysis should be performed on products of conception of the third
and subsequent consecutive miscarriage

12.  Maternal and paternal karyotyping
should be performed in couples with recurrent miscarriage where testing of products of
conception reports an unbalanced structural chromosomal abnormalities
 Imaging anatomical abnormalities ( septum )
All women with recurrent first-trimester miscarriage and all women with one or more
second-trimester miscarriages should have a pelvic ultrasound to assess uterine
anatomy

13. Management of recurrent miscarriages
 Aspirin and low-dose heparin can reduce the miscarriage rate in women with
APS by 50%.
 Balanced translocations may be overcome by preimplantation genetic
diagnosis or gamete donation.
 Congenital uterine abnormalities, including uterine septum and cervical
incompetence, may be amenable to surgery
 No evidence of benefit of progesterone, corticosteroids or metformin
 Most couples have normal investigations and the value of psychological
support and serial ultrasound scans during pregnancy

14. ECTOPIC PREGNANCY

15.  Implantation of a pregnancy outside the normal uterine cavity and Over 98%
implant in the Fallopian tube (tubal ectopic )
One in 80 pregnancies are ectopic
other places like cs scar , abdominal , ovarian, cervical .
 A heterotopic pregnancy is the simultaneous development of two pregnancies:
one within and one outside the uterine cavity (1% of IVF pregnancies)

16. Risk factors for ectopic pregnancy
 Fallopian tube damage due to pelvic infection (e.g.
Chlamydia/Gonorrhoea), previous ectopic pregnancy and previous tubal
surgery
 Functional alterations in the Fallopian tube due to smoking and
increased maternal age and progesterone only methods of contraception
 Previous abdominal surgery (e.g. appendicectomy, caesarean section)
 subfertility and IVF
 use of intrauterine contraceptive devices
 endometriosis
 conception on oral contraceptive/ morning after pill.

17. Symptoms of ectopic pregnancy
 Subacute Abdominal pain
 Early pregnancy vaginal bleeding
 Acute abdominal pain (ectopic rupture or abortion )
 shoulder tip pain
 Hypovolemic shock
 Abnormal rising BHCG

18. Investigations
 Vaginal ultrasound
 Serum BHCG (suboptimal rise )
By transvaginal ultrasound : empty uterus , adnexial mass , or adnexial
gestational sac , fetal echo and maybe fetal heart seen , free fluid
suggestive of rupture ectopic and hemoperitoneum , cervical motion
tenderness .
Evaluation of Hb and Rh status is needed

19. Management of ectopic pregnancy
Expectant
Medical (methotrexate )
Surgical

20. Expectant
 This option is suitable for patients who are haemodynamically stable
and asymptomatic (and remain so)
 The patient requires serial hCG measurements until levels are
undetectable

21. Medical treatment
 Intramuscular methotrexate (50 mg/m2)
 minimal symptoms
 adnexal mass <40 mm in diameter
 serum hCG concentration under 3,000 IU/l.
 No fetal heart
 bhcg follow-up ( days 4.7.11. then weekly ) until it became
undetectable
 (levels need to fall by 15% between day 4 and 7, and continue to fall
with treatment)

22. Medical treatment
 advise women to avoid sexual intercourse during treatment and to avoid
conceiving for 3 months after methotrexate treatment because of the risk of
teratogenicity
 Avoid alcohol and direct sun-light
 Contraindications to methotrexate
(1) chronic liver renal or hematological disorder
(2) active infection
(3) immunodeficiency;
(4) breastfeeding
(5) Any criteria not suitable for medical treatment of ectopic

23. Surgical treatment
 In unstable or sever symptomatic cases , high Bhcg or positive fetal heart
 Operation of choice is laparoscopic salpingectomy (removal of the tube )
 Salpingotomy (opening of the tube ) sometimes done if the other tube is
destroyed or absent …. Carries higher risk of recurrence with nearly the
same future fertility rate as salpingengectomy
Don’t forget anti D ;)