Presented by: Nur Insyirah Abdullah Ahmad Zeiree Abdullah

The WHO defines miscarriage (abortion) as expulsion or extraction of a fetus or an embryo weighing 500gm or less from its mother womb before 22 weeks of pregnancy. The viability of pregnancy varies from 24-28 weeks.

The incidence of clinically evident miscarriage ranges from 10-15 % of all pregnancies However, when very early pregnancies, in the 14 days period following conception even before a woman misses her period are considered, the miscarriage rate will be between 45 to 55% It may manifest as heavy period

Miscarriage

Spontaneous

Induced

Threatened

Inevitable

Incomplete

Complete

Missed

Septic

Recurrent

Vaginal bleeding Associated within dull aching lower abdominal pain VE: closed cervical os USG:presence of fetal cardiac activity Up to 1/3 of these women progress to inevitable miscarriage

Vaginal bleeding Lower abdominal pain associated with open cervical os Product of conception often palpable through the os

History of passage of POC as fleshy masses in addition to vaginal bleeding and pain Hemorrhage with symptoms of shock

History of pain and passage of products followed by absence of pain and bleeding or minimal bleeding if present VE:cervical os is closed Uterine size is less than POA With progress of time, pregnancy test become negative and symptoms of pregnancy disappear

Fetus/embryo has died but is retained in the uterus for a period of time without symptoms of miscarriage Uterine size is less than the POA Minimal vaginal bleeding ( streak of dark altered blood) USG finding:2 types 1)Empty gestational sac with absent embryonic pole 2)Gestational sac with an embryonic pole without cardiac activity visualised

The term used when there have been more than 3 successive spontaneous miscarriages

Spontaneous miscarriage or n induced abortion is complicated by infection either ascending from the lower genital tract or iatrogenically introduced while performing induced abortion

Matenal medical disorder

Infection Systemic factors Excessive maternal smoking and alcohol

Psychological factors Fetal factors Local factors Etiology of miscarriage Maternal factors Bicornuate uterus,septate uterus ,double uterus

Cervical insufficiency

Uterine abnormalities Paternal factors

Immunological factors

Presence of submucous myoma

Miscarriage Threatened

Uterine size Corresponding

Symptoms Bleeding Pain

Cervix Closed

USG Live fetus Retrochoreal hemorrhage

Inevitable

Same or less

Bleeding Pain

Open with palpable products

Open Closed Closed

Absent cardiac activity Retrochoreal hemorrhage

Retained product seen Empty cavity Empty gestational sac in blighted ovum or fetus without cardiac activity in early fetal demise

Incomplete Complete Missed

Smaller Smaller Smaller

Heavy bleeding Sign of shock No bleeding Absent or minimal bleeding

History : amenorrhea,UPT,early pregnancy bleeding,pain General examination: vital sign,palm,conjunctiva for anemia Vaginal examination and speculum examination Ultrasound FBC GXM,ABO,Rhesus incompatibility BUSE,renal profile RBS Lupus anticoagulant,anticardiolipin Serial serum B-hCG Thyroid function test High vaginal swab

General measurement Resuscitation Secure airway Breathing Circulation:BP,PR,SPO2,set large bore IV lines Monitor vital signs: anticipate for hypovolemic shock Transfuse if hb< 8 g/dl If Rh-ve,anti-D should be considered

Threatened abortion Pelvic ultrasound examination=whether fetus present,if so whether cardiac activity is observed Reassurance and emotional support Repeat ultrasound examination 1 week later to confirm a growing fetus and to reassure the family

Inevitable miscarriage Need hospitalization Analgesic for pain control Pelvic ultrasound examination Evacuate the uterine cavity with suction or manually with ovum forcep Administration of misoprostol vaginally in doses up to 400mcg

Incomplete miscarriage Resuscitation Analgesic Correct the hypovolemia with crystalloid/cross compatible cross matched blood Broad spectrum antibiotics Once the patients condition stabilized the remaining POC is evacuated from uterus

Complete miscarriage USG:ensure empty of uterine cavity,rule out possiblity of an extrauterine pregnancy Serial B-hCG level

Missed abortion Uterus smaller than POA USG: need to confirm Can wait for spontaneous expulsion but would involve mother anxiety,pain of expulson,develop serious complication eg:DIC and infection Evacuate POC surgically or medical methods(combination of mifeprestone and misoprostol)

First trimester Suction curettage Dilatation and evacuation Mifeprestone 200600mg orally followed by misoprostol 400600mg orally MTX 1.5 mg/square meter of body surface area IM followed by 400mg misoprostol vaginally 1 week later

Second trimester Dilatation and evacuation

Incomplete miscarriage Excessice bleeding Infection Depression Anxiety disorder Recurrent miscarriage Ashermans syndrome

Ahmad Zeiree Bin Abdullah

Recurrent miscarriage means having three or more miscarriages in a row. It affects about one in every hundred couples trying for a baby.

Blood clotting problems

APS Factor V leiden deficiency Factor II defiency Protein S deficiency

Abnormal chromosomes
Unbalanced translocation

Cervical incompetence
Dilate too early(2nd trimester)

Abnormally shaped uterus

DM and thyroid problems

PCOS

Infection

Immune problems

Antiphospholide syndrome Investigation: Antiphospholopid antibodies test

Clear diagnosis : 2 (+) test in 2 separate occasion Treatment : i) Low dose aspirin in early pregnancy ii) Heparin injection if fetal heart rate detected by scan

Investigation: Blood test usually for inherited blood disorder called trombophilia included - Factor V leiden - Factor II - Gene mutation - Factor S
Treatment: Heparin injection in next pregnancy

Investigation: -tissue test from fetal and 50% results are not clear -blood test for parent to check of balanced translocation.

Treatment: No treatment but special genetic counseling

Abnormally shaped uterus

1st pelvic ultrasound scam

hysteroscopy

laparoscopy

3D pelvic ultrasound scan

Treatment Surgery can correct the abnormalities but there is no evidence of improvement in reducing recurrent miscarriage

Hard to diagnose No reliable test outside of pregnancy Usually diagnose by regular scan during pregnancy

Cervical stich -operation under general or epidural anesthesia to keep the cervix close during pregnancy at 14 weeks

-removed towards end Of pregnancy

Pre implantation genetic diagnosis Imunotherapy Progesteron supplement Steroid HcG supplement Metformin supplement Suppresion of high level of LH

Still controversial!!

Usually patients will be very dissappointed because they dont know the reason. So the doctor must explain carefully it is actually good news because do not having major problems and the chance of having next normal pregnancy is good.