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