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 .