Miscarriages

By Sajid Sultan

08-162

Final Year MB,BS.

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In the Name Of ALLAH,the most merciful and the beneficient.

Surely we have created the human in the best template….

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Fetal chromosomal abnormalities

Mainly associated with recurrent abortions.Theseabnormalities are three times more common in females.Most common chromosomal abnormalities are:1.Robertsonian translocation.2.Reciprocal translocation.3.Inversion. 4.Chromosomal mosaicismFetal structural anomalies Neural tube defects and Potter’s syndrome

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Endocrinal abnormalities

a) Polycystic ovarian disease.b) Corpus luteum insufficiency.c) Diabetes mellitus.d) Thyroid dysfunction.

Maternal factors:

a) Congenital anomalies of uterus are present in 10-15% of cases.These include bicornuate , subseptate,unicornuate uteri.b) Intra uterine adhesions are also responsible presumably due to inadequate placentation.c) Fibroid uterus.d) Incompetent cervix.

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Ascending genital tract infections

Intrauterine bleeding

Cervical weakness(congenital and acquired)

Mid trimester amniocentesis

Smoking and alcohol

Immunological factors.

a) Alloimmune factors e.g production of suppressor cells within decidua,blocking antibodies, trophoblastic leucocytecross reacting antigens.b) Auto immune diseases e.g in SLE , lupus anticoagulants, cardiolipins antibodies appear before clinical onset of disease which increases incidence of recurrent abortion.

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Complete

Incomplete

Inevitable

Missed

Induced

Septic

Threatened

Recurrent

Tum apne RAB ki kon kon see NAIMATON kojhutlaoge…….

(Al Quran)

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All the products of conception are expelled in complete miscarriage while in incomplete one not all of the products of conception are expelled.2. Inevitable miscarriages:

When the process of abortion has become irreversible because the dilation of the cervix has occured3. Missed miscarriages:

When inutero death of the fetus has occurred and the mother remained unaware of it.4. Induced miscarriages:

Intentional medical and surgical termination of the pregnancy before 24th week of gestation

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5.Recurrent miscarriages:3 or more consecutive miscarriages e.g. in chronic liver

diseases, incompetent cervix etc.6. Septic miscarriages:

When aseptic techniques are not used during the process, mostly practiced illegally, leading to endotoxic shock.

7. Threatened miscarriages:When there is a threat to abort( in trauma etc) but

abortion has not occurred yet.

Every Living thing has to taste the death…………

(Al Quran)

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Management

History: generally unwell with fever previous miscarriages ,preterm birth invasive prenatal diagnoses. lower abdominal discomfort with backaches discomfort or pain from uterine contractions vaginal discharge of mucus, blood or amniotic fluid

Always enquire about:

o any urinary or bowel symptoms

o fetal movements

o dating of the pregnancy

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Management

Examination:1.GPE

pulse BP temperature state of hydration

2.Per AbdominalEvidence of UTI, palpation of uterus, hand held

doppler device to auscult ate the fetal heart

3.Inspection of sanitary towel and undergarments(to know about discharge)

4.per vaginal examinationspeculum, vaginal swab.

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SYMPTOMS SIGNS

Complete Bleeding Passage of clotsExpulsion of some products of conceptionNow normal

P\A: no uterus.P\v: cervix is closedU\S: no fetus

incomplete Patient still bleeding or in shock

P\A: uterus palpableP\v: products of conception being expulled.U\S: fetal parts

Continued…..next page

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SYMPTOMS SIGNS

Threatened Bleeding ContractionsAbnormal vaginal discharge

Minimal cervical dilationIntact membranes

Inevitable Any of the above or may be minimal

Cervical dilation>3cmMembranes ruptured

missed Usually none Fetal death onultrasound

septic Above + malaise FeverTachycardiaHypotensionUterine tenderness

Continued …….From last page

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DIFFERENTIAL DIAGNOSIS:

1. BOWEL DISORDERS: constipation, colitis, gastroenteritis

2. URINARY DISORDERS: infection, renal stones.

3. CERVICAL DISORDERS: ectropion, leucorrhea, neoplasia

4. UTERINE DISORDERS: red degeneration of fibroids, round ligament stretching

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Management

Investigations:1) urine sample: Infections2) cervico-vaginal swabs: Infections3) CBC: anemia 4) blood Group: Anti D may be required5) Transabdominal ultrasound: to confirm

gestation.6) Transvaginal Ultrasound: for cervical

length measurement.

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Management

Treatment:1. Support:

holistic approach to the situation

sympathy, explanations, pain relief, reassurance

a specialist midwife co-ordinator to relieve the process

2. Pre-viable membrane rupture: precise diagnosis by speculum examination and u\s

scan

counseling about self temperature taking and

observation of vaginal discharge and tenderness.

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Management 3. Antibiotics Best choice erythromycin…….possibly with clindamycin or metronidazole……for 7 days

4. Tocolyticso No place for their use in mid trimester miscarriages.o Secure short term prolongation by their use in later pregnancy.

5. Emergency cervical cerclage A difficult and unsure process of stitching the cervix

6. Augment Contractions: Induction by prostaglandins such as Cytotec. If previous C.section or any other uterine surgery, special care should be taken

7. Delivery Adequate pain relief Counseling about the next prgenancy

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WHAT I WANA SAY???? ALLAH is THE only and the best Creator and the cherisher. The days of every one in this world have already been counted. The Real world is the World After death.

The Actual wise is the One who has prepared for the death.

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QUESTIONS please……………………

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