Miscarriage1

Based on Gynecology by ten teachers

1. MISCARRIAGE PRESENTERS ZEESHAN AHMED LODHI AND RIZWAN ANWER

2. Spontaneous loss of pregnancy at or before 24 weeks of gestation. EARLY MISCARRIAGE : before 12wks LATE MISCARRIAGE: from 13 to 24wks DEFINITION

3. 1 Advanced maternal age 2 Chromosomal abnormalities 3 Endocrine disorders 4 Uterine abnormalities 5 Cervical incompetence RISK FACTORS OF MISCARRIAGE

4. 6 Infections 7 Drugs and Chemicals 8 Psychological disorders 9 Trauma 10 Multiple pregnancies

5. Following are the types of miscarriage based on clinical presentation and investigation finding: Threatened miscarriage Inevitable miscarriage Incomplete miscarriage Complete miscarriage Missed miscarriage TYPES

6. Pregnancy complicated by bleeding before 24wks and symptoms indicate a miscarriage could be possible Slight bleeding Abdominal cramps Cervical os closure Viable fetus on U/S THREATENED MISCARRIAGE

7. Cervix has dilated but Products of conception (POC) have not been expelled and symptoms indicate that a miscarriage could not be stopped. Heavy bleeding with clots Considerable lower abdominal pain Cervical os open Intrauterine pregnancy on U/S INEVITABLE MISCARRIAGE

8. Some, but not all POC have been passed. Retained product may be the the part of fetus, placenta or membrane. Heavy bleeding that may lead to shock Severe abdominal pain Cervical os open Retained POC on U/S INCOMPLETE MISCARRIAGE

9. All POC have been passed out without surgical or medical intervention. Minimal or resolved bleeding No pain Cervical os closed Empty uterus on U/S COMPLETE MISCARRIAGE

10. Uterus retains POC for two months or more after the death of fetus. It can lead to coagulopathies. With or without bleeding Pain or no pain Cervical os closed Gestational sac present. Fetal pole present but no fetal heart beat. MISSED MISCARRIAGE

11. HISTORY EXAMINATION * General * Abdominal * Pelvic with speculum and digital APPROACH

12. CBC , BHCG , Hb typing , U/S In cases of recurrent miscarriages: * karyotyping * hormonal (progesterone, TSH) * infections (TORCH) * immunological ( anticardiolipin Ab , lupus anticoagulant etc) INVESTIGATIONS

13. MANAGEMENT Depending on clinical presentation and patients choice: EXPECTANT (Do nothing) MEDICAL (Do something) SURGICAL (Do everything)

14. Watchful waiting Most of the cases pass POC within 2 to 6 weeks Avoids side effects and complications of surgery I/c risk of unplanned surgery Follow up EXPECTANT APPROACH

15. INDICATIONS: Fetal parts are greater than 14wks in size >10wks pregnancy patients elects D&C and her cervix is closed Some conditions like DIC in which surgery or anasthesia is contraindicated MEDICAL APPROACH

16. PROSTAGLANDINS: Misoprostol (in oral n vaginal forms) Gemeprost (vaginal form) PROGESTERON ANTAGONIST: Mifepristone (used in combination with prostaglandin to I/c success rate) DRUGS

17. Non invasive Drugs are administered orally or injected No anasthesia ADVANTAGES

18. Bleeding lasts longer Require multiple visits to doctor Women may see the contents of their womb as they are passed Chances of incomplete evacuation. May require Surgery. DISADVANTAGES

19. INDICATIONS: Patient’s preference Infected retained tissue Excessive bleeding Cervix is closed &sac is >5cm Patients has miscarried twice before Patient is incapable of followups SURGICAL APPROACH

20. VACUUM ASPIRATION: Also called D&E. Uses aspiration to remove uterine content through the cervix. DILATATION & CURETTAGE: Uses sharp curette to scrape off POC from uterine lining. SURGERY HAS ITS ADVATAGE OF SUCCESS RATE OF ABOUT 95 – 100 % PROCEDURE OF SURGERY

21. CERVICAL TRAUMA SUBSEQUENT CERVICAL INCOMPETENCE UTERINE PERFORATION INTRAUTERINE ADHESIONS POST OPERATIVE PELVIC INFECTION OCCASIONAL SUBFERTILITY DISADVANTAGES

22. Cervical trauma Cervical incompetence Uterine perforation Intrauterine adhesions Post op pelvic infection subfertility COMPLICATIONS OF SURGERY

23. COUNSELLING Sympathy, explanation and reassurance are mandatory Follow up by a senior member of staff , this will lead to discussion about a future pregnancy or contraception