Early trimester
miscarriages
Dr Hina Aamir
Gynae sho
Definition of miscarriages
Early trimester miscarriage refers to loss of
pregnancy before 13 weeks of gestation or
12 completed weeks of pregnancy.
Spontaneous miscarriages –commonest
cause
20% of clinical pregnancies equating to
approx 14,000 miscarriages per annum in
ireland
Types of miscarriages
Threatened miscarriage
Missed miscarriage
Incomplete miscarriage
Complete miscarriage
Recurrent miscarriage
Other early pregnancy disorders which
must be ruled out :
Ectopic pregnancy
Hydatidiform mole
Causes of miscarriages Chromosomal abnormalities
such as tirsomies, monosomy X , translocation , tetraploidies
Maternal factors:
age>35 yrs
Endocrine disorders
as diabetes, hypothyroidism , luteal phase deficiency, PCOS,
Abnormalities of uterus ,
bicornuate uterus
Infections
such as salmonella typhi, malaria, cytomagaolvirus, brucella, toxoplasmosis, mycoplasma hominis, chylamydia trachomatis, ureaplasmaurealyticum
Chemical agents
such as tobacco, anaesthetic gases, arsenic, benzene, solvents , ethylene oxide , formaldehyde, pesticides, lead, murcury,cadmium,.
Psycological disorders
Immunological disorders
antiphospholipid syndrome, thrombophilia
History taking
Ask about the LMP
Amount of bleeding , color, passage of clots,orany tissue products
Abdopelvis pain ,site, character, severity
Past obstetric history
Past h/o PID, pelvic surgery
Any contraception such as IUCD
Any past ho miscarriages ,ectopic pregnancy
Past medical history such as diabetes
Social history such as smoking ,consumption of alcohol
Examination GENERAL PHYSICAL EXAM• Pallor
• Tachycardia
• Shock
• Collapse
Abdominal exam • Tenderness
• Any adnexal mass palpable
• Guarding or rigidity ,enlarged uterus
PER SPECULUM EXAM• Source of bleeding
• Amount of bleeding, cervical os open or close or any products of conception seen
Investigations
FBC
Blood group and hold
Rhesus status
Beta HCG
Progesterone levels if needed
Referral to early pregnancy unit for
ultrasound to look for the location and
viability of conceptus
Referal to EPAU
Those with a H/O a positive pregnancy test and:
Vaginal bleeding or abdominal pain
Previous ectopic pregnancy
Previous tubal surgury
Previous miscarriage
Iucd in situ
Persistant bleeding post evacuation of the ERCP were there is a suspicion of the problems
Other clinical conditions as stated in the hospital protocol
miscarriage
Gestational sac >20 mm No embryo or yolk sac
miscarriage
embryo> 7 mm No cardiac activity
Transvaginal ultrasound
miscarriage
Gestational sac >25 mm No embryo or yolk sac
miscarriage
Embryo >8mm No cardiac activity
Transabdominal ultrasound
Ultrasound Terminology
Viable intrauterine pregnancy
Pregnancy of uncertain viability
Early pregnancy loss
Incomplete miscarriage
Complete miscarriage
Pregnancy of unknown location
Management of miscarriage
/ectopic pregnancy
Conservative management:
• Effective and acceptable method provided there
are no signs of infection(vaginal discharge),
excessive bleeding, pyrexia or abdominal pain .
• Women should be counselled on what to expect ,
the likely amount of blood loss, what analgesics to
take.
• Follow up scans arranged at 2 weekly intervals
until a diagnosis of complete miscarriage made.
Medical management
• Misoprostol
• Highly effective prostaglandin analogue po or pv
• Protocol adminstration- 600 micro gram at least 3 hourly
Side effects
• Nausea
• Vomiting
• Cramping
• Diarrhoea
• Success rate 80-90%
• Out patient medical management should be reserved to women with a MGSD less then 50 mm as increased bleeding may be encountered. In case of pregnancy with IUCD in-situ the device should be removed before.
Surgical management of
miscarriage
Surgical uterine evacuation (ERPC) should be offered to women that prefer that. Misoprostol 400 micro gram can be used for cervical priming
Clinical indication for ERPC
• Persistent excessive bleeding
• Haemodynamic trophoblastic disease
• Evidence of retained tissue
• Suspected gestational trophoblastic disease
• Surgical evacuation must be performed using suction curattage and be preferably managed
Side effects –
• Complications of anaesthetic agents
• Uterine perforations 1%
• Cervical tears
• Intra-abdominal trauma
• Haemorrhage infection
Histological examination of tissue
• Products of conception should be sent for histological
examination to confirm the diagnosis of miscarriage and
helps excludes ectopic pregnancy
Rhesus anti- D prophylaxis
Non- sensitised RH negative women
Ectopic pregnancy or miscarriages over 12 weeks gestation
including threatened
All miscarriages were the uterus is evacuated surgically
Psychological aspects of
miscarriage Support, follow-up and access to formal counselling were
necessary
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