DR. SAMAA NAZER

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MISCARRIAGE

• DR. SAMAA NAZER
• Assistant Professor of Obstetrics Gynecology
• Jeddah, Saudi Arabia

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Definition

• Termination of pregnancy either spontaneouslly or
  intentionally before 20 weeks of gestation
  calculated from the date of onset of last menses
  .
• Alternative definition
• A delivery of fetus with a weight of less than
  500 g.
• Early before 12 weeks
• Late 12 20 weeks
• Incidence 15 - 20
• Pathology Haemorrhage into the decidua basalis,
  followed by necrosis of tissues adjacent to the
  bleeding.

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• Etiology
• Fetal factors
• Maternal factors
• Fetal factors
• More than 80 of abortions occur in the first 12
  weeks of pregnancy and at least half result form
  chromosomal anomalies.

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• Aneuploid abortion approximately 50 60 of
  embryos and early fetuses that are spontaneously
  aborted contain chromosomal abnormalities.
• 95 of chromosomal abnormalities were due to
  maternal gametogenesis errors and 5 percent to
  paternal errors.
• Autosomal trisomy, monosomy x (45 x), triploidy
  associated with hydropic placental degeneration.

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• Maternal factors
• I - Medical disorders and environmental condition
  
• Infection
• Mycoplasma hominis, ureaplasma, urearyticum,
  listeria, or toxoplasma should be specifically
  sought in woman with recurrent abortion
• Chronic debilitating disease celiac disease has
  been reported to cause both male and female
  infertility and recurrent abortions
• Endocrine abnormalities
• Hypothyroidism, thyroid antibodies were
  associated with an increased incidence of
  abortion.
• Diabetes mellitus
• The rate of spontaneous abortion and major
  congenital malformation are both increased in
  women with insulin dependent diabetes. It depend
  also on the control of DM

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• 11- Progesterone deficiency
• Luteal phase defect, due to insufficient
  progesterone secretion by corpus luteum
• I11 Nutrition
• Nutrition do not appear an important cause of
  abortion
• 1V Drug use and environmental factors
• Tobacco Smoking has been linked with an
  increased risk for abortion

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• Alcohol
• Both spontaneous abortion and fetal anomalies
  may result from fregnant alcohol used during the
  first 8 weeks of pregnancy
• Caffeine
• Woman who consumed at least 5 cups of coffee per
  day
• exhibited a slight increased risk of abortion.
• Radiation
• Insufficient doses, radiation is a recognized
  abortifacient
• Contraception
• O.C.P. and spermicidal agent does not increase
  the risk
• IUCD increase the risk

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• Environmental Toxins
• Arsenic, lead, formaldehyde, benzen and ethylene
  oxide are possible abortifacient
• Exposure to 3 or more hours of nitrous oxide per
  day without gas scavenging equipment. Woman
  occupationally exposed to anesthetic gases had
  increased risk of spontaneous abortion

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• V-IMMUNOLGICAL FACTORS
• Immune system is important in recurrent pregnancy
  loss (15 of aborting women)
• Autoimmune factors
• Antiphospholipids antibodies (lupus
  anticoagulant, anticardiolipin antibody)
• The mechanism of pregnancy loss in women with
  these antibodies involve placental thrombosis and
  infarction
• Women with both history of early pregnancy loss
  and high level of those antibodies may suffer a
  70 abortion recurrence
• ALLO immune factors
• Inherited thrombophilia
• Several genetic disorders of blood coagulation
  may increase the risk of thrombosis

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• VI PHYSICAL TRAUMA
• In general contribute minimally to the incidence
  of abortion
• VII - Uterine defects
• Acquired uterine defect
• - leiomyomas, their location is more important
  than their size.
• - Asherman syndrome (uterine synechiae) due to
  insufficient support of pregnancy.
• Developmental uterine defect
• Abnormal mullerian duct formation, fusion
  defect (spontaneously or may follow in
  utero-exposure to diethylstilbestrol)
• Incompetent cervix
• It is characterized by painless cervical dilation
  in the second trimester with prolapse and
  ballooning of membrane into the vagina followed
  by expulsion of an immature fetus.

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• Etiology of incompetant cx
• Previous trauma to the cervix (dilation and
  curettage, conization, cauterization, amputation)
  exposure to
• diethylstibestrol
• VIII - Paternal factors
• Little is known about paternal factor in the
  gensis of spontaneous abortion, certainly
  chromosomal abnormality in the sperm

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• Types of spontaneous abortion
• 5 subgroups
• 1. Threatened
• 2. Inevitable
• 3.Complete or incomplete
• 4.Missed abortion
• 5.Recurrent abortion

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• I Threatened abortion
• Diagnosed clinically when bloody vaginal
  discharge or
• bleeding appears through a closed cervical os
  during the
• first half of pregnancy .
• Prognosis
• 1. Half of the cases abort, the risk decrease if
  fetal cardiac
• activity can be documented
• 2. Increase risk of preterm delivery
• 3 . Increase low birth weight fetuses
• 4. Increase perinatal death
• Note The risk of a malformed infant does not
  appear to be increased
• Treatment
• Bed rest
• Anti D

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• II - Inevitable abortion
• Bleeding, evidence of rupture of membrane and
  the presence of cervical dilation
• Treatment
• Allow abortion
• III - Complete, Incomplete abortion
• Complete abortion spontaneous expulsion of the
  fetus and placenta from the uterine cavity
• Clinically the cervix is closed
• Ultrasound show empty uterus

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• Incomplete abortion
• Passage of some but not all fetal or placental
  tissue through the cervix
• The diagnosis is radiological and clinical
• Treatment is evacuation

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• IV - Missed abortion
• The uterus retains dead products of conception
  behind a closed cervical os for days or even
  weeks
• Diagnosis
• Clinically
• Absence of pregnancy symptoms .
• Size of uterus smaller than date .
• Vaginal bleeding .
• Radiologically.

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• Investigation
• CBC, PT, PTT,fibrinogen level,BhCG,pelvic us.
• Management
• Surgical,immediate evacuation.
• Medical
• Expectant (disadvantage DIC if left 3 5 weeks
  ).
• IV-Recurrent abortion
• The consecutive loss of three or more pregnancies
  before 20 weeks of gestation.
• Causes
• Systemic causes diabetes mellitus ,SLE, thyroid
  disease, lupus anticoagulant
• Paternal and maternal chromosomal abnormality.
• Uterine anomalies

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• Investigation
• GTT
• TFT
• Antiphospholipid antibody,and anticardiolipin ab,
  ANA
• Paternal chromosomal analysis
• Hysterosalpingogram

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• American college of obstetrics and gynecology
  (2001) recognize two test
• 1- Paternal cytogenetic analysis to identify
  couples at risk of unbalanced chromosomal
  translocation.
• 2 - lupus anticoagulant and anticardiolipin
  antibodies assay, thrombophilia antibody assay.

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• INDUCED ABORTION
• medical before fetal viability
• surgical
• Indication
• Maternal
• Persistent heart disease after cardiac
  decompensation
• Advanced hypertensive vascular disease
• Invasive carcinoma of the cervix
• Fetal
• Fetuses incompatible to life
• Legal factors

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• CONSEQUENCES OF ELECTIVE ABORTION
• Maternal mortality
• Impact on future pregnancies
• Increase second trimester spontaneous abortion,
  preterm delivery, ectopic pregnancy increase risk
  of placenta previa.
• Septic abortion
• 1. criminal abortion
• 2. Pregnancy on top of
  intrauterine contraceptive device

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• RESUMPTION OF OVULATION AFTER ABORTION
• Ovulation may resume as early as 2 weeks after an
  abortion
• Differential diagnosis of bleeding in early
  pregnancy
• Abortion
• Ectopic pregnancy
• Vesicular mole
• Endometrial carcinoma
• Cervical polyp
• Cervical lesion and erosion
• Trauma
• Medical disease (coagulation defect)

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• THANK YOU