Gynecology L1
Miscarriage and early pregnancy lossVaginal bleeding in early pregnancy is always a cause for concern . It may occur in cases of miscarriage or ectopic pregnancy , or with a cervical lesion such as a polyp or carcinoma . On many occasions no certain cause of early bleeding may be found .
Miscarriage :
- Is a pregnancy that ends spontaneously before the 24th week of pregnancy(before the fetus has reached a viable gestational age) .- Observation suggests that 10 – 20 % of clinically recognized pregnancies end in early miscarriage , but the loss of very early embryos is greater than this .
The most common time for clinically evident abortion to occur is between 7 and 13 wks .
Aetiological factors :
Despite along list of aetiological factors , the cause of a particular miscarriage is often uncertain .1. Malformation of the zygote :
A common cause of miscarriage is an abnormality of the fetus severe enough to cause fetal death . About 70% of these are caused by chromosomal abnormalities , for which either parent may be responsible , although they often arise from spontaneous , unexplained mutation in the zygote itself .
Types of chromosomal abnormalities :
Autosomal trisomies ( the most common ) with incidence 30 – 35 % ex: trisomy 21 , 18 , 13 .Triploides and tetraploidies .
Monosomy X ( Turner syndrome ) .
Translocation in 1.5 % .
- The incidence increase with increase maternal age .
2. Immunological rejection of fetus :
a. Investigations of maternal immune response to her pregnancy have now focused on the complex interaction of immune and endocrine factors acting at endometrial level .
- Hypotheses on immunodystrophism in which cytokines are being evaluated in the context of implantation & embryonic growth will examine the relationships between migrating trophoblast and the large granular lymphocytes ( which have natural killer cell activity and under endocrine control) .
b- Immunological disorders :
1. Congenital ( thrombophillia ) .
2. acquired ( antiphospholipid syndrome ) .
3. Chronic medical diseases :
chronic renal failure , congenital heart disease , Tuberculosis ( TB ) , sickle , cell disease .4. Endocrine disorders :
- Diabetes if the disease is not adequately controlled .- Hypothyroidism , luteal insufficiency ( insufficient production of progesterone by the corpus luteum before the placenta is fully formed will lead to inadequate development of the deciduas and miscarriage ) , and polycystic ovarian syndrome .
5. Infections :
a. Causing congenital abnormality like : Cytomegalovirus infection , rubella , toxoplasmosis , vaccinia and listeriosis .b. Acute febrile illness like : malaria , Salmonella typhi , measles , brucella , and mycoplasma hominis .
6. Uterine abnormalities : Mainly 2nd trimester loss ) : which include :
a. Uterine septa .b. bicornuate uterus .
c. Endometrial adhesions ( post curettage or asherman"s syndrome ) .
d. Big fibroid which is closely related to the cavity .
e. Cervical incompetence : Previous lacerations of the cervix involving the internal Os may be due to over vigorous surgical dilatation of the cervix or cone biopsy or very rarely the cervical weakness is of congenital origin .
So the unsupported membranes bulge through the cervix and rupture , miscarriage follows .
7. Trauma :
a. Direct trauma to uterus as gun shot .
b. Indirect like surgical removal of ovary containing corpus luteum of pregnancy .
8. Chemical agents :
Like tobacco , anesthetic gases , Arsenic compound , benzene , pesticides , lead , formaldehyde , and mercury .9. Drugs :
Prostaglandins ( PGs ),PG analogue ex misoprostol , ergot derivatives ( methergene ) , and cytotoxic agent .10. Psychological upset :
11. Sever malnutrition , especially vitamin E deficiency .Pathological – Anatomy :
In the first trimester of pregnancy the attachment of the chorion to the decidua is so delicate that separation may follow strong uterine contractions produced by any cause . The resulting haemorrhage into the choriodecidual space leads to further separation .In other cases fetal death precedes uterine contractions , which may occur some days later , or due to inadequate placentation , there's defect in transformation of the spiral arteries and a reduced trophoblastic penetration into the decidua .
- The decidua basalis remain in the uterus , and in the majority of cases the embryo , with its membranes & most of the decidua capsularis , expelled .
- In some cases the gestation sac is retained in the uterus for days or weeks as a missed miscarriage . The embryo is reabsorbed and layers of blood clot collect around it to form a " carneous mole " .
By 12th week , the placenta is a definite structure , and if it happens after this time the process of miscarriage is similar to that of labour .
Bleeding and painful contractions are followed by dilatation of the cervix , rupture of the membranes and expulsion of the fetus and placenta .
If all the conceptus is expelled normal uterine involution follows , but frequently part of the placenta is retained with some blood clot .
Modern Pregnancy loss classification :
Type loss
Typical gestation ( weeks )
Fetal heart activity
Principal ultrasound finding
Beta HCG level
Biochemical loss
< 6
Never
Unknown location
Low then fall
Early pregnancy loss
6 – 8
Never
Empty sac
Initial rise then fall
Late pregnancy loss
> 10
Lost
Crown-rump length and fetal heart activity identified .
Rise then static or fall
Clinical varieties of miscarriage :
- The following terms are used to describe varieties of miscarriage :
1. Threatened 5. Septic
2. Inevitable 6. Missed
3. Complete 7. recurrent .
4. Incomplete .
1. Threatened miscarriage :
Vaginal bleeding occurs without dilatation of the cervix and with very little or no pain .- Incidence : 25% of all pregnancy complicated by threatened abortion .
- Prognosis : If the bleeding heavy , or increases , the prognosis is bad , but the miscarriage should not be regarded as inevitable until cervical dilatation begins .
- There may be repeated short episodes of bleeding without the miscarriage becoming inevitable .
Management :
The diagnosis usually based on clinical history& examination , and by ultrasound ( usually transvaginal one ) , which is used to differentiate miscarriage from other type of early pregnancy complication as ectopic pregnancy or molar pregnancy , also to know the type of miscarriage .Also the ultrasound examination can determine the size of the fetus and show it the fetal heart is beating ; it can also give some clue to dilatation of the cervix , and to see subchorionic haematoma if present .
There's no specific treatment and the essential task is to establish that the miscarriage is threatened and is not becoming inevitable .
- The patient may need to restrict some forms of activity , bed rest , avoidance of sexual intercourse until warning signs are disappeared .
- Clinical surveillance including weekly ultrasound examination , and an evaluation of serum measurements of the beta subunit of hCG , progesterone and pregnancy associated placental protein A( PAPP-A) .
- Progesterone therapy : Its role is contraversial , It's relax smooth muscle ( myomterial muscles ) , but it may increase the risk of incomplete miscarriage .
- HCG injection may have a role in treatment of threatened miscarriage ( by support the corpus luteum of pregnancy and stimulate it to produce more progesterone ) .
2. Inevitable miscarriage :
The process is now irreversible . The cervix is open , there's more bleeding and rhythmical and painful uterine contractions continue .
- The uterus usually expels its contents unaided .
All examinations are carried out with careful aseptic technique . Analgesics such as pethidine may be required . If haemorrhage become sever or the miscarriage is not quickly completed ergometrine or syntometrine , phostaglandins is required and inevitable miscarriage can be complete or incomplete and the surgical evacuation either by suction curettage or by sharp curettage .
In all cases inevitable miscarriage anti-D gammaglobulin 500 Mg is injected intramuscularly unless the woman is known to be rhesus positive .
3. Complete miscarriage :
When all the uterine contents have been expelled spontaneously there is cessation of pain, scanty blood loss and a firmly contracted uterus. ,On examination : closed cervical OS . If there is no more active bleeding , or if an ultrasound scan shows an empty uterine cavity , no further treatment is required . ( expectant management ) , the patient should be observed for any further bleeding and examine the product of conception .
Objectiv
The students should be know about:
This life threatening condition ,which is commonly seen in our gynecology emergency department .
How can differentiate the miscarriage from other early pregnancy complications .
Aetiological factors.
Pathological-Anatomy.
Clinical varieties of miscarriage &their management.
Modern classification of miscarriage.
Miscarriage and early pregnancy loss L2
Continue (L2)- Incomplet miscarriage :
This term means that some of products of conception , usually chorionic or placental tissue , are retained .
Clinical features :
Typical symptoms include :
Vaginal bleeding ( usually heavy ) .
Lower abdominal pain .
Patient may be presented in shock state ( low blood pressure , increase pulse rate , pallor , and cold extremities ) .
On examination : The uterus is still found to be enlarged and the cervix is open , and parts of products of conception may be seen through the cervix .
History of passing pieces of product of conception .
By ultrasound examination : The retained products can be seen .
Management :
The chief dangers are haemorrhage and sepsis , and they continue until the uterine cavity is empty .- Sever vaginal bleeding associated with shock may necessitate blood transfusion by a flying squad before the woman is moved from the home to hospital .
Intramuscular ergometrine , 0.5 mg , is given immediately and placental debris in the cervical canal is removed under direct vision , using a speculum and ring forceps .
The transfusion is continues until the blood pressure reaches a level safe enough for transfer of the woman to hospital .
There the uterus is evacuated under anesthesia ( by either suction curettage or sharp curettage ) . prophylactic antibiotic such as ampicillin is wise .
- In some cases , the bleeding is not severe but it continues intermittently for several weeks and the uterus remains enlarged .
* Surgical evacuation of the uterus is then essential with histopathological examination of the products , some of these cases due to a placental polyp .
* or medical treatment : By misoprostol ( PGE1 ) analogue with advantage of avoiding surgery , it can be used in a dose of 600µg orally or 400 µg sublingually ( as a single dose ) with success rate of 66 – 100 % .
Gastrointestinal side effects :
Due to stimulatory effect of misoprostol on the gastrointestinal tract which include : vomiting , nausea , diarrhea , abdominal pain , dyspepsia , flatulence , sometime constipation , these side effects are common in oral route than other routes.
+ the mifepristone ( RU 486 ,antiprogesterone agent) increase successful rate of misoprostol . Mifepristone also binds to the glycocorticoid receptor and blocks the action of cortisol , thus is contraindicated in any patient on corticosteroids or who has suspected adrenal insufficiency , it’s not available in
Many countries because is expensive.
* or use gemeprost vaginally ( PGE1 analogue ) .
* The medical treatment should be avoided in cases of :
a) haemodynamic instability .
b) pelvic sepsis .
c) hypersensitivity to PG .
d )Sickle cell anaemia.
e)Gluacoma.
Expectant management :is a valid option for incomplete miscarriage ,its choice depends on :clinical assessment of the patient 's condition, when U/S assessment of the uterine cavity is suggestive of retained products with an anterio-posterior diameter of 15 mm or less genuine retained products are less likely to be confirmed histologically , hence such cases are best managed expectantly .
Anti-D gammaglobuline 500 microgram is injected intramuscular unless the woman is know to be rhesus positive .
NOTE:
- The use of medical management in case of incomplete miscarriage may show no great benefit over conservative management .
Septic miscarriages :
Infection may occur during spontaneous miscarriage but it more often occurs after one that has been induced .
- The blood clots and necrotic debris in the uterus form an excellent culture medium .
Clinical features :
Fever , chills , abdominal pain and tenderness , prolonged vaginal bleeding , foul smell vaginal discharge , low blood pressure , in sever cases low body temperature , decrease urine output or absent , breathing problem , septic shock , sign of peritonitis , cervical motion tenderness ( + ve ) .
Complications :
Septic shock , renal failure , disseminated intravascular coagulopathy ( DIC ) , adult respiratory distress syndrome ( ARDS ) , permanent blockage of the fallopian tubes , pelvic or generalized peritonitis , even death .Microbiology :
- The most common septic abortion infecting organisms are staphylococcus aureus , coliform bacteria , Bacteriodes organisms and clostridium welchii .- Of these the most dangerous are the Gram negative and anaerobic organisms which produce endotoxic shock .
- The potentially lethal cases of infection with the β-haemolytic streptococcus group A are , fortunately , seldom seen .
Management :
The woman must be admitted to hospital and isolated from other obstetric and surgical woman .
High vaginal swabs and blood specimens are sent for bacteriological culture , while treatment is started with a wide-spectrum antibiotic .
There is much debate about the best choice ; one that has been recommended is cephalosporin , 250 – 500 mg every 6 hours together with metronidazole 500 mg . Both of these can be given intravenously if the woman is vomiting when the bacteriological report is received that antibiotic treatment is modified according to the sensitivities of the organisms discovered .
Also blood specimens are sent for complete blood count , clotting study , renal function test , urine analysis , chest X-ray , abdominal X-ray to rule out uterine perforation ( see gas under diaphragm ) , and pelvic ultrasound examination to rule out retained product of conception .
Supportive measures like blood transfusion and corticosteroid and fresh frozen plasma for shock and paracetamol for fever .
The uterus must be emptied , but if the bleeding is not too serious ; evacuation is best postponed until 24 hours after the antibiotic treatment has taken hold but if there is serious bleeding , it cannot be deferred . In most cases evacuation is performed under anaesthesia with a suction curette or ring forceps . In cases of more than 14 weeks gestation in which a dead fetus is retained its expulsion may be achieved by oxytocin infusion and vaginal use of prostaglandins .
Some women are gravely ill , especially if anaerobic infection has occurred with high swinging fever , anaemia and sometimes haemolytic jaundice. Endotoxic shock may be superimposed on hypo-volaemic shock , with circulatory failure due to peripheral vasodilation caused by endotoxins released from coliform organisms which have invaded the bloodstream . Before surgical intervention massive doses of intravenous pencillin and metronidazole are used . Both are usually given by mouth , but in severely ill women the intravenous route may be preferable . Intravenous hydrocortisone is sometimes helpful if restoration of the blood volume does not quickly restore the blood pressure . The urinary output must be watched carefully , since oliguria may indicate renal cortical or tubular necrosis .
Missed Miscarriage :
This occurs when the embryo dies or fails to develop , and the gestation sac is retained in the uterus for weeks or months . Haemorrhage occurs into the choriodecidual space and extends around the gestation sac . The amnion remains intact and becomes surrounded by hillocks of blood clot with a fleshy appearance , hence the term carneous mole . Mild symptoms like those of threatened abortion are followed by absence of the usual signs of progress of the pregnancy . The uterine size remains stationary and the cervix of often tightly closed . Serum placental hormone and protein measurements are low and if repeated are shown to be falling . The diagnosis , if ever in doubt on initial ultrasound scan , on repeat scan will show no growth of the fetal crown-rump measurement and absence of fetal heart activity .
- By ultrasound examination
a. If gestational age ≤ 6 weeks , mean sac diameter ( MSD ) > 20 mm here we should see embryonic pole , if not Missed miscarriage .b. Fetal heart activity should be detected when embryo is 6 mm length , if not missed miscarriage .
c. IF MSD < 20 mm and no embryonic pole repeat ultrasound ( u/s ) after 10 days .
Note : Blighted ovum : early embryo death and absorption of embryo with persistence of the placental tissue so the appearance by u/s will be as an empty gestational sac without fetal pole .
Treatment :
- All missed abortions would probably be expelled spontaneously in the long term , but there may be a delay of weeks or months and many women become distressed once the diagnosis is made , so that active treatment is often chosen .- In a few late cases there is a risk of hypofibrinogenaemia after retention of a dead fetus for some weeks , probably caused by thromboplastins from the chorionic tissue entering the maternal circulation DIC ( disseminated intravascular coagulopathy .
The management options are :
Expectant management .Surgical management .
Medical management .
1. Expectant management :
- It often results in absorption of retained tissue with little associated bleeding .
- It is likely that at least 74% of non-viable pregnancies would miscarry successfully without intervention .
- The clinical dilemma is which patients are suitable for expectant management ( many factors affecting the success rate , were the type of miscarriage , duration of follow-up , and whether clinical or ultrasound features were used for review ex. - Completed miscarriage rates are higher in these patients who have bleeding at the time of diagnosis and those who have detectable intervillous pulsatile blood flow on scan .
- Expectant management allows for the avoidance of surgery and general anaesthesia , women undergoing expectant care may start to bleed heavily .
Objective
The students should be know :
How can diagnose the incomplete miscarriage .
The management options.
septic miscarriage ,its complications ,and how can manage this serious condition .
Septic miscarriage &its management options .