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( 2 )
Miscarriage
Management of missed miscarriage
Expectant management :- within few weeks may aborted
spontaneously (risk of DIC and septicemia)
Medical management:-
By using uterotonic therapy alone or in conjugation with antihormone
therapy. The advantages of medical therapy is that no surgical
procedures are needed if it is successful. Passage of tissue should
happen within a few days of receiving medical therapy. If it is not
successful, then a surgical approach may follow. The risks for medical
therapy include bleeding, infection, possible incomplete abortion, and
possible failure of the medication to work.
The first tablet, mifepristone (ante progesterone) , will be taken by
mouth. . If the patient start to bleed heavily and pass clots after taking
this first tablet, there is no need for any further medication. If she is
only spotting blood, continue with the second medicine, misoprostol
(uterotonic agent). Insert misoprostol, into the vagina 36-48 hours
after taking the mifepristone.
Surgical management :-evacuation of uterus by D&C under local or
general anesthesia , cervical dilatation can be assumed by cervical
priming agent such as PG agonist ( misoprostol ), at least 2 hr. before
operation ,this reduce the pressure required for dilatation of the cervix
& hence the risk of uterine perforation . The advantage of D&C is that
the procedure is scheduled and occurs at a known time. The risks of a
D&C include bleeding, infection, possible perforation of the uterus, and
possible Asherman syndrome after the procedure
Complications
Risk of GA, Infection, Retained products, Uterine perforation,
Asherman syndrome (intrauterine adhesion result from vigorous
curettage)
Recurrent miscarriage
1.Genetic causes
Most spontaneous miscarriages are caused by an abnormal (aneuploid)
karyotype of the embryo.
Diagnosis
Perform karyotype of parents with family or personal history of genetic
abnormalities
Perform karyotype of the abortus in recurrent cases
Management
For couples who have had an SAB due to a suspected genetic cause, the
standard of care is to offer genetic counseling.
However, couples in whom pregnancy loss can be attributed to a
balanced translocation may benefit from specific genetic testing by
preimplantation genetic diagnosis (PGD).
2.Immunologic causes
Tests for antiphospholipid antibodies (APLAs), signaling the presence of
the autoimmune disease antiphospholipid antibody syndrome (APS),
have reportedly been positive in 10-20% of women with recurrent early
pregnancy losses.
Three classes of clinically significant APL antibodies have been
identified: anticardiolipin (aCL), lupus anticoagulant (LAC), and anti-β2
glycoprotein I antibodies.
Diagnosis
Diagnosis of APS requires the presence of at least 1 of the clinical
criteria and at least 1 of the laboratory criteria .
The clinical criteria include the following:
- Vascular thrombosis
- 3 or more consecutive unexplained miscarriages
- At least 1 unexplained death of a morphologically normal fetus at or
after 10 weeks' gestation
- At least 1 premature birth of a morphologically normal neonate at or
before 34 weeks' gestation, associated with severe preeclampsia or
severe placental insufficiency
The laboratory criteria include the following:
-aCL: Immunoglobulin G (IgG) and/or immunoglobulin M (IgM) isotype
is present in medium or high titer on 2 or more occasions, 6 or more
weeks apart
-Demonstration of a prolonged phospholipid-dependent coagulation on
screening tests (eg, activated partial thromboplastin time, clotting time,
prothrombin time)
-Failure to correct the prolonged screening test result by mixing with
normal platelet-poor plasma
-Shortening or correction of the prolonged screening test result with
the addition of excess phospholipids
-Exclusion of other coagulopathies as clinically indicated (eg, factor VIII
inhibitor) and heparin
Management
Treatment options for APS include the following:
Subcutaneous heparin, Low-dose aspirin, Prednisone,
Immunoglobulins and Combinations of these therapies
Anatomic causes
Anatomic uterine defects can cause obstetric complications, including
recurrent pregnancy loss, preterm labor and delivery, and
malpresentation.
Diagnosis
Imaging studies in the diagnosis of uterine defects include the
following:
Hysteroscopy, Hysterosalpingography (HSG) , Sonohysterograms and
Vaginal ultrasonography
Management
Surgical correction of uterine anomalies .
Infectious causes
Infection is considered a rare cause of recurrent miscarriage. Most
patients with a history of recurrent miscarriage do not benefit from an
extensive infection workup.
Environmental causes
Approximately 10% of human malformations result from environmental
causes. Clinicians should encourage life-style changes and counseling
for preventable exposures to reduce the risk of environmentally related
pregnancy loss.
Endocrine causes
Diabetes
Women with poorly controlled diabetes are at a significantly increased
risk of miscarriage and fetal malformation. However, screening for
occult diabetes in asymptomatic women is not necessary unless the
patient presents with an elevated random glucose level or exhibits
other clinical signs of diabetes mellitus or if there is an unexplained loss
in the second trimester.
Thyroid dysfunction
Although the presence of antithyroid antibodies may represent a
generalized autoimmune abnormality, which could be a contributing
factor in miscarriages, screening for thyroid disease is not useful unless
the patient is symptomatic.
Luteal phase defects
The criterion standard for the diagnosis of a luteal phase defect (LPD) is
the finding that the histologic characteristics of a luteal phase
endometrial biopsy are more than 2 days behind the findings expected
in a normal cycle. However, the physician must be selective in deciding
who should be screened for such defects, since there is no definitive
treatment to make a difference in pregnancy outcomes in patients with
an LPD.
Hematologic causes
Many recurrent miscarriages are characterized by defective
placentation and microthrombi in the placental vasculature . Many
recurrent miscarriages are characterized by defective placentation and
microthrombi in the placental vasculature. In addition, certain inherited
disorders that predispose women to venous and/or arterial thrombus
formation are associated with thrombophilic causes for pregnancy loss.
Various components of the coagulation and fibrinolytic pathways are
important in embryonic implantation, trophoblast invasion, and
placentation.. In addition, certain inherited disorders that predispose
women to venous and/or arterial thrombus formation are associated
with pregnancy loss.
Management
Aspirin and heparin therapy may be administered for proven diagnoses
of thrombophilic disorders.
The gestational age at the time of the SAB can provide clues about the
cause. For instance, nearly 70% of SABs in the first 12 weeks are due to
chromosomal anomalies. However, losses due to antiphospholipid
syndrome (APS) and cervical incompetence tend to occur after the first
trimester.
24 wk
-
pregnancy loss between 12
trimester miscarriage :
nd
2
trimester
t
s
15) predominantly due to same causes of 1
-
Early(12
-
miscarriage especially chromosomal abn. & structural uterine
anomalies .
-Mid (16-18) aminocentesis which has 1 in 200 risk of miscarriage .
-Late (19-24) predominately same causes of preterm labour such as
over distended uterus –multiple pregnancy , polyhydrominos -,
intrauterine bleeding which irritate uterus and lead to uterine
contractions ,Asending infection which stimulate local PG and enhance
uterine contractions , thrombophilia ,cervical weakness which is either
congenital or acquired.
Cervical insufficiency (cervical incompetence)
Cervical insufficiency (cervical incompetence) is defined as the inability
of the uterine cervix to retain a pregnancy in the second trimester, in
the absence of uterine contractions. the following indications for
cervical cerclage:
History of second trimester pregnancy loss with painless cervical
dilatation
Prior cerclage placement for cervical insufficiency
History of spontaneous preterm birth (prior to 34 weeks’ gestation) and
a short cervical length (ie, < 25 mm) prior to 24 weeks’ gestation
Painless cervical dilatation on physical examination in the second
trimester
Signs and symptoms
The diagnosis of cervical insufficiency is primarily based on a history of
a previous midtrimester pregnancy loss, which can present with the
following:
Painless cervical dilatation and bulging fetal membranes upon
presentation in the second trimester of pregnancy
Preterm premature rupture of membranes (PPROM)
Rare or absent uterine contractions
In women without a history of pregnancy loss, the diagnosis of cervical
insufficiency is based on a combination of the following:
Clinical presentation, Physical examination &Ultrasonographic findings
Most patients are asymptomatic, but some may present with any the
following symptoms:Pelvic pressure , Cramping , Back pain , Increased
vaginal discharge
Diagnosis
Although the diagnosis of cervical insufficiency may be based on a
history of midtrimester pregnancy loss, the following measures may
also be useful:
Ultrasonographic transvaginal measurement of cervical length –
Cervical length has a strong inverse correlation with the risk of
spontaneous preterm birth, particularly in women with a history of
preterm delivery
Fetal fibronectin (fFN) testing – Studies have demonstrated the utility
of fFN testing in addition to cervical length assessment, with a
significant improvement in the prediction of preterm delivery in women
with a positive fFN and a cervical length of less than 30 mm
Management
The mainstay of surgical treatment for cervical insufficiency is cervical
cerclage, which is reasonable in the following situations:
History of second trimester pregnancy loss with painless cervical
dilatation
Prior cerclage placement for cervical insufficiency
History of spontaneous preterm birth (prior to 34 weeks’ gestation) and
a short cervical length (ie, < 25 mm) prior to 24 weeks’ gestation
Painless cervical dilatation on physical examination in the second
trimester
Cerclage can be accomplished either transvaginally or
transabdominally. Cerclage is usually done transvaginally as either a
procedure. When these 2 procedures are
or Shiradkor
McDonald
unsuccessful or difficult to perform, the transabdominal cerclage
procedure is done .
RH status
AntiD is required in the following circumferences for non-sensitized Rh
negative women .
Spontaneous miscarriage 12 wk & more .
At any GA with surgical or medical intervention
At any GA with repeated severe bleeding .