First presentation of my Post graduate training

2. Miscarriages
Dr. Sarah Safdar
PGR - I
Unit – II, LWH

3. Definition
“Miscarriage is defined as the loss of a
intrauterine pregnancy before 24
completed weeks of gestation”
WHO definition
“The expulsion of fetus or an embryo
weighing 500 g or less and also a
gestational age limit of less than 22
completed weeks of pregnancy”

4. Types :
• Sporadic/Spontaneous
• Recurrent

5. Spontaneous Miscarriages
• Expulsion of a fetus before 24 completed weeks of
gestation or an embryo weighing 500 g or less
spontaneously
• Incidence = 15%(1 in 6)
• Actual incidence is difficult to assess because
 Some women abort without knowing that they have been
pregnant
 Some women have vaginal bleeding after variable amenorrhea
but not having confirmed evidence of pregnancy
 Spontaneous origin by deliberate interference

6. Etiology
• Fetal
• Placental
• Maternal
• Unknown in 25% of cases

7. 1) Fetal causes
• Chromosomal abnormalities
i) Aneuploidy ~ 50%
a. Trisomy
b. Monosomy
c. Triploidy/Tetraploidy
ii) Structural chromosomal abnormalities ( common in recurrent
M)
• Developmental defects(NTDs,cleft
palate,cyclopia,amniotic bands,syrinomelia & caudal regression)

8. Causes……
2) Placental
Haemorrhage in decidua basalis or necrotic tissue in tissue
adjacent to bleeding
Hydropic degeneration in plcental villi
3) Maternal
 More common in second trimester
 Mostly associated wd recurrent miscarriages
 These includes
 Uterine Anomalies
 Infections
 other maternal causes

9. Causes……
 Uterine Anomalies
– Bicornuate and subseptate uterus
– Cervical incompetence(most common Cause of 2nd
trimester abortions)
– Uterine myomas
– Asherman syndrome

11. Causes…….
 Infections
– More commonly associated with isolated abortions
– Any acute illness like typhoid fever, malaria,
pyelonphritis & appendicitis can cause miscarriage
Bacteria : L monocytogenes,Compylobacter,Mycoplasma,ureaplasma
Spirochetes : Treponema Pallidum
Parasites : Toxoplasma gondii
Viruses : Cytomegalovirus,Rubella,Herpes,Coxsackie

12. Causes…..
 Other Maternal ailments :
Chronic ailments
 40 yrs
Smoking
Diabetes
Hypertension
Renal disease
Thyroid disease

13.  Fetal Sex,Multiple Pregnancy,Maternal
age and Parity
4) Unproved Causes ~ 25 %
 Progesterone deficiency
 Immunological causes
 Radiations
 Direct or indirect trauma

14. Presentations Of Spontaneous
Miscarriages
o Threatened
o Inevitable
o Incomplete
o Complete
o Missed
o Septic

15. Threatened Miscarriage Inevitable Miscarriage
P/V
bleeding
Fresh Blood,small in amnt Fresh blood ,more in amount wd
sum clots
Pain Painless Typical L pains
Others Cervical Shock syndrome
Abdominal
Ex
Fundal ht = dates Fundal ht = dates
P/S Fresh blood coming thru cervix Bag of membrns bulging thru
cervix
P/V Cervical os closed Cervical os open
Ix FCA present on USG FCA may or may not b present
Rx Bed Rest,Avoid Coitus,Hormonal
Rx, Antibiotics
Evacuation of uterus

16. Outcome

17. Incomplete Complete
P/V bleeding Heavy bleeding wd passage of
clots & tissue
May b asymptomatic WD Hx of
bleeding & RPOC’s passage
earlier
Pain Crampy lower abd pain May gv Hx of pain Earlier
Others Hypovolemic shock
Abdominal Ex Fundal Ht < dates FH < dates
P/S POC’s present in cx or vagina Cervical os may appear close
P/V Cervical os open,POC may be
felt in uterus
Cervical os may appear close
or open
Ix RPOC’s on USG Empty uterus on USG
Rx Evacuation No Rx

18. Missed Miscarriage
P/V bleeding When present,old blood,small in amount
Pain Usually absent at the time of diagnosis
Others Absent fetal movements,& FCA
Regression of pregnancy symptoms
Abdominal Ex Fundal Ht < dates
P/S Old discolored blood if present
P/V Cervical os closed
Ix FCA absent,Spalding & Robert’s sign in advanced preg
Rx <12 wks ~ Suction & evacuation
>12 wks Expulsion F/b Curettage

19. %• Complications of
surgical evacuation :
• Tearing or laceration of cervix
• Perforation of uterus leading to
bowel perforation
• Bladder perforation
• Damage to broad ligament
• Infection
• Asherman syndrome

20. Septic Miscarriages
P/V bleeding Bleeding variable in amount,foul smelling,vaginal discharge in
case of infection
Pain Crampy lower abd pain
Others Pyrexia,Tachycardia,dehydration,electrolyte imbalance,abdominal
distension,paralytic illeus,septic shock
Abdominal Ex Tenderness,guarding.rigidity in lower abd,abdominal
distension,paralytic ileus
P/S Blood/pus coming through cervix
P/V Cervical os may be open or closed,pelvic tenderness,uterine
mobility restricted,adenexal mass
Ix POC’s within the uterus,tubo-ovarian mass
Rx Ab,fluid & electrolyte correction,blood transfusion,evacuation of
uterus.,laparotomy

21. Recurrent Miscarriages
• Three or more consecutive miscarriages
• TYPES OF RMC
• Primary RMC :
where there have been no previous live birth
• Secondary RMC ;
where atleast one successful pregnancy have been
occurred previously
Ectopic, molar, and biochemical pregnancies not
included.

22. RMC Subtypes
• All pregnancy losses, no viable pregnancy
• Viable pregnancy followed by pregnancy losses
• Pregnancy losses interspersed with
viable pregnancies

23. Causes Of Recurrent Miscarriages
Genetic
Anatomical
Infective
Endocrine
Immunological

24. Genetic
• Parental Chromosomal aneuploidy
– balanced reciprocal translocation
– robertsonian translocations
– Pericentric chromosomal inversion
• Recurrent aneuploidy
– Inc tendency to nondisjunction
– Mostly seen in IVF embryos

25. • Other genetic Factors
– euploidy
– single gene defect
– molecularr mutations
• Peripheral blood karyotyping
• Specialized genetic counselling

26. Anatomical Factors : Septate Uetrus
• Most common
• Poorest outcome
• Miscarriage > 60 %
• Fetal survival with untreated cases 6 to 28 %
• The mechanism
– Not clearly understood
– Poor blood supply
– poor implantation

27. Submucosal Fibroids
• The mechanism -
– Their position
– Poor endometrial receptivity
– Degeneration with increasing
cytokine production

28. Investigation and Treatment
• HSG,Laparoscopy,Hysteroscopy,MRI,CT & 3
D USG
Surgery :
• Hysteroscopy
Procedure of choice
Septum excision, polypectomy
• Laparoscopic myomectomy
For fibroids
• Laparotomy
• Likelihood of live births in untreated pts is as high as
66 %
• Open pelvic surgery wth RMC ~ Infertility

29. Cervical Incompetence
• Associated wd MC after 12-14 wks or PM labour
• Silent dilatation of cervix without painful cont
Dx:
Previous Hx of mid-trimester MC
Ix :
TVS
Rx :
Cervical cerclage after 12-14 wks
Mcdonald/Shirodkar

30. Infective factors
• Syphilis : recurrent late 2nd
trimester MC
» Routine screening
» Prophylaxis wd penicillins
• Bacterial Vaginosis
» Recurrent 2nd
trimester loss
» Metronidazole
• Regular sterile speculum EX
• Regular high n low vaginal swabs
• Low dose antibiotic for repeated positive
results

31. Endocrine Factors
• Systemic Endocrine Diseases
• Luteal Phase Defect
• PCO & Hypersecretion of LH

32. Luteal Phase Defect
– Progesterone is essential for
implantation and maintenance of
pregnancy
• A defect in Corpus luteum
impaired progesterone production.
• LPD cannot be diagnosed during
pregnancy; a consistently short luteal
phase duration is the most reliable
diagnostic criterion.

33. PCO & Hypersecretion of LH
• Polycystic ovary morphology itself does not predict an
increased risk of future pregnancy loss among ovulatory
women with a history of recurrent miscarriage who
conceive spontaneously
• Hyperinsulinemia & level of Plasminogen Activator↑
Inhibitor activity – implicated as the proximate cause of
incidence of loss(30-50%)among PCOS women
• METFORMIN treatment can reduce or eliminate risk of
miscarriage in PCOS women

34. Investigations :
• Thyroid Function Tests- T3 ,T4, TSH
• S.Prolactin
• Glucose tolerance test
• HbA1c
• S.FSH
• S.LH
• S.Progesterone

35. Treatment
• Luteal-phase insufficiency
– luteal-phase support with progesterone
– There is insufficient evidence to evaluate the effect
of progesterone supplementation in pregnancy to
prevent a miscarriage
• PCOS, hyperandrogenism, hyperinsullinemia
– insulin-sensitizing agents (METFORMIN)
• overt diabetes mellitus
– prepregnancy glycemic control
• hypothyroidism
– thyroid hormone replacement

36. Autoimmune & Thrombophilic Defects
Autoimmune :
Autoimmune Alloimmune
(directed to self) (directed to foreign
tissues/cells)
-Systemic Lupus Erythmatosus An Abnormal
maternal
-Antiphospholipid Syndrome immune response
to fetal or placental antigen.

37. • Systemic Lupus Erythmatosus (SLE)
-Risk for loss is 20%,mostly in 2nd
and 3rd
trimester of pregnancy and associated with
antiphospholipid antibodies.
• Antiphospholipid syndrome (APA)
– 5 - 15 % of women with RPL may have APA
APA likely induce microthrombi at placentation site.
Altered vascularity affects developing embryo,
induces MISCARRIAGES

38. Diagnosis :
CLINICAL
1) Thrombolic events :
arterial,venous,small vessel
2)Pregnancy loss-
» ≥3 losses at <10wks gestation
» fetal death after 10wks
» premature birth at <34wks associated with severe
preeclampsia or placental insufficiency.

39. LABS
1) Lupus Anticoagulant
2) Anticardiolipin antibodies(IgG or IgM)
Any lab test results must be observed on at least 2
separate occasions 8 wks apart.

40. • Treatment for APA
1. Low Molecular weight Heparin
– 3000 IU S/C twice a day
– Expensive treatment
1. Un-fractionated Heparin is better option
2. Low dose Aspirin
3. Steroids? Mainly for anti nuclear antibodies
– 10 – 20 mg prednisolone / day

41. Investigation

42. Treatment
• 50 % of Miscarriages ~No Cause
• Prognosis is good
• ReAssurance & Psychological Support
• 75 % of live births in unexplained RPL

43. • MiSCARRIAGES DON’T OCCUR IN A
UTERUS BUT IN A WOMAN,AND
MISCARRIAGES DO NOT OCCUR SOLELY
IN A WOMEN BUT IN A FAMILY

44. Support should Includes
• Care in Specialist clinic
• Psychological support
• Easy access to named contact
• Close monitoring including
 USG
 APPropriate reassurance
 helpful & caring staff

45. • Should be offered to all patients wd RPL
• Explanation of possible causes & prognosis
• After 3 consecutive early preg losses ~
60-70% chances of next successful pregnancies
• Even after 6 miscarriages~the chance of successful
preg is still 45 %
Counselling

46. Your Main Title