Miscarriage (Abortion) : (Adhesions Inside The Uterine Cavity)
Miscarriage (Abortion) : (Adhesions Inside The Uterine Cavity)
Miscarriage (Abortion) : (Adhesions Inside The Uterine Cavity)
Definition
Miscarriage: spontaneous termination of pregnancy.
Abortion: induced termination of pregnancy.
It is expulsion or extraction of products of conception before
fetal viability i.e. before 24 weeks of gestation (during the 1 st 2
trimesters).
Incidence
Is the commonest gynecological & obstetric disorder
Sub-mucous fibroid
Thrombophilia: anti-phospholipids syndrome, congenital
deficiency of protein C, S & anti-thrombin III
Immunological disorders : Anticardiolipin syndrome & SLE
Missed abortion:
Most of missed abortions are diagnosed accidentally during
routine U/S in early pregnancy.
History (in some cases there may be):
Episodes of mild vaginal bleeding
Regression of early symptoms of pregnancy.
Stop of fetal movements after 20 weeks gestation.
Examination
Closed cervix
Small or compatible for date
U/S (essential for diagnosis):
Diagnosed if 2 U/S (T/V or T/A) at least 7 days apart showed
an embryo of >7 weeks gestation (CRL > 6mm in diameter &
gestational sac > 20 mm in diameter) with no evidence of
heart activity.
2 U/S 7 days apart because of the possibility of wrong dating due to
irregular period, lactating or OCPs If there was heart activity in
previous ultrasound in the previous visit and now there is no heart
activity then almost no need for 2nd ultrasound.
Management (the best method is the medical & the worst one is the
conservative)
Complications of abortion:
1. Hemorrhage (abortion is one of the leading cause of maternal
death & mostly due to hemorrhage).
2. D&C or E&C (surgical) complication:
a. Uterine perforation rupture uterus in the subsequent
pregnancy.
b. Cervical tear & excessive cervical dilatation cervical
incompetence.
c. Infection infertility & Asherman's syndrome.
d. Excessive curettage Adenomyosis
3. Rh-iso immunizations (anti-D is not given or the dose is
inadequate).
4. Psychological trauma.
Post-abortion management:
1. Support from the husband, family& obstetric staf
2. Anti-D (Rh ve, nonimmunized patients, whose husbands are
Rh+ve)
3. Counseling & explanation:
Recurrent abortion
Definition:
3 or more consecutive spontaneous abortions.
Types:
1. Primary: All pregnancies have ended in loss (before 24w).
2. Secondary: One or more pregnancies has proceeded to viability
(>24 w) with all others ending in loss.
Incidence: 1% of women of reproductive age.
Causes (50% Idiopathic & 50% known causes):
1. Chromosomal disorders:
Fetal chromosomal & structural abnormalities.
Parental balanced translocation (not afects the parents but
afect their fertility).
2. Anatomical disorders:
Cervical incompetence (congenital and acquired)
Uterine causes
Submucous fibroids
Uterine anomalies
Ashermans syndrome
3. Medical disorders:
Endocrine disorders (DM, thyroid disorders, PCOS & corpus
luteum insufficiency.
Immunological disorders: Anticardiolipin syndrome & SLE.
Thrombophilia:
Acquired: anti-phospholipid syndrome
Congenital deficiency of Protein C&S, anti-thrombin III &
presence of factor V Leiden.
4. Infections:
ToRCH, esp. CMV.
Genital tract infection (Bacterial vaginosis).
5. Rh-isoimmunization
Diagnosis:
1. History:
Previous abortions: GA, place & fetal abnormalities.
Medical history: DM, thyroid disorders, PCOS, autoimmune
diseases & thrombophilia.
2. Examination:
General: weight , thyroid & hair distribution
Pelvic: cervix (length & dilatation) & uterine size.
3. Investigations:
For chromosomal disorders:
Parental karyotyping: Parental balanced translocation.
Fetal karyotyping: Fetal chromosomal anomalies.
For anatomical disorders:
TV/US: fibroids, cervical incompetence & PCOS.
Hysteroscopy or HSG: fibroids, cervical incompetence,
uterine anomalies & Asherman's syndrome.
Management:
1. Idiopathic:
Support & good antenatal care, the chance of successful
spontaneous pregnancy is about 60-70%.
Advice: stop smoking & alcohol intake, decrease physical
activity
Tender loving care
Drug therapy
i. Progesterone & HCG: once she gets pregnant, start
from the luteal phase & up to 12 weeks.
ii. Low dose aspirin (75 mg/day) start from the
diagnosis of pregnancy (4th -5th wk) & up to 37wks.
iii. LMWH (low molecular weight heparin) (20-40
mg/day) subcutaneously start from the diagnosis of
fetal heart activity (7th wk) & up to 37 wks
2. Endocrine disorders
Control DM and thyroid disorders before pregnancy.
PCOS: ovulation induction drugs, ovarian drilling or IVF.
Corpus luteum insufficiency: progesterone or hCG.
3. Anti-cardiolipin syndrome:
Low dose aspirin (75 mg/day) & prednisilone (20-30 mg
/day)
Starting when pregnancy is diagnosed till 37 weeks.
4. Thrombophilia:
Low dose aspirin (75 mg/day) starting when pregnancy is
diagnosed and
LMWH (20-40 mg/day) starting when fetal heart activity
diagnosed & to continue both till 37 weeks.
5. Uterine disorders:
Cervical cerclage in cervical incompetence, best time at
14w GA
Myomectomy in submucus fibroid
Excision of uterine septum in septate & subseptate uterus
Adhesolysis in Asherman's syndrome.
6. Infection: treatment of the genital tract infection.
7. Rh-isoimmunization: Repeated intrauterine transfusion
8. Parental balanced translocation
Explain the risk of fetal chromosomal disorders (30%)
Encourage to try again or adoption.
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