TBL (Miscarrriage)
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Transcript of TBL (Miscarrriage)
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Miscarriage
Andy Lim Yew Ann
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Definition of Miscarriage
Pregnancy that ends spontaneously before thefetus has reached a viable gestational age.
Legal definition of miscarriage in UK:
Spontaneous loss of pregnancy at or before 24weeks of gestation.
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Clinical Forms of Miscarriage
Types of Miscarriage Definition Clinical Presentation
Threatened MiscarriageVaginal bleeding with a
viable pregnancy
Per vaginal bleeding and
pain
Speculum: Cervical os closed
Inevitable MiscarriageBleeding with cervical
dilation without passage offetal tissue
Per vaginal bleeding and
painSpeculum: Cervical os open
Complete MiscarriageSpontaneous passage of all
products of conception
Pain and bleeding has
resolved
Speculum: Cervical os closed
Incomplete MiscarriageRetained products of
conception
Per vaginal bleeding and
painSpeculum: Cervical os open,
products of conception
located in cervical os
Missed Abortion
Intrauterine fetal demise
without passage of tissue
With or without pain and
bleeding
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Causes of Miscarriage
Chromosomal Abnormalities
(Maternal age>35 years old)
Trisomies ( Downs syndrome),
Triploidies and tetraploidies
Monosomy X (Turners syndrome)
Translocation and inversion
Endocrine Disorders Diabetes, hyperthyroidim, luteal phase
deficiency, polycystic ovarian syndrome
Abnormalities of the Uterus Uterine septa, endometrial adhesions(post-
curettage or Ashermans sundrome)
Infections Salmonella typhi, malaria, cytomegalovirus,
Brucella, toxoplasmosis, Mycoplasma
hominis. Chlamydia trachomatis and
Ureaplasma urealyticum
Chemical Agents Tobacco, anaesthetic gases, arsenic,
benzene, solvents, lead, mercury,
pesticides, cadmium
Immunological Disorders Antiphospholipid syndrome,
thrombophilia (Hereditary)
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Signs and Symptoms of Miscarriage
Symptoms
Vaginal bleeding
Crampingabdominal pain
Fading of pregnancysymptoms
No fetal movement
Signs
Cervix may bedilated
Fetal tissue may befelt at cervical os
Uterine size may besmaller than
menstrual dating
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Ultrasonography Findings of
Miscarriage
No heartbeat in an embryo larger than5mm/ earlier ultrasound revealed fetal
heartbeat, subsequent u/s no heartbeatdetected
Gestational sac larger than 8mmand has no yolk sac
Gestational sac larger than 16mmand has no embryo
Transvaginal Ultrasound
A: Gestational
sacB: Crown
lump length
C: Amniotic
sac
D: Yolk sac
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Definition of Recurrent Miscarriage
Three or more spontaneous consecutive
pregnancy losses before week 20.
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History & Physical examination
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Questions to Ask
Uterine instrumentation ?
Are the menstrual cycles regular ?
Is there galactorrhea ? History of congenital abnormalities or
karyotypic abnormalities ?
Any exposure to environmental toxins ? Any history of venous or arterial thrombosis ?
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Hirsutism ?
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Uterine malformation ?
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Cervical laceration ?
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Investigation
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Karyotyping
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Sonohysterography
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Hysterosalpingogram
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Hysteroscopy
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MRI
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Other investigation
Anticardiolipin antibodies and lupus
anticoagulant
Thyroid function test and thyroid peroxidase
(TPO) antibodies
Culture and serology
Hypercoagulable state
Progesterone level
Endometrial biopsy
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Pathogenesis of Septic Abortion
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Introduction of Foley Catheter
To Vaginal Orifice
Infection of Uterine Lining
Septic Abortion
(Abortion that is complicated by infection)
Circulatory System RenalSystem Gastro-IntestinalSystem Respiratory System ImmuneSystem
Positive
hematoma
(abnormal
hematologicexamination
specifically
hemoglobin and
hematocrit)
Blood in urine
Acidic (ph of 5.8)
Difficulty andpainful urination
Possible renal
failure
Loss of appetite
Difficulty in
swallowing
Loss of weight
hemoglobin
oxygen carrying
capacity
CO2
stimulation for
breathing
Hyperventilation
WBC
Positive infection
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Indications for Therapeutic
Abortion
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Maternal condition
History of dilated cardiomyopathy in previous pregnancies
Myocarditis, Pericarditis, Heart Failure
Hypercoagulability
Marfan syndrome, when ascending aorta is wider than 5 cm
Eisenmenger's Syndrome
Pregnancy induced fatty liver
History of esophageal varicosities hemorrhage
Uncontrollable autoimmune hepatitis Renal failure
Hypertension which is not controllable with permitted drugs during pregnancy
Any of the pulmonary diseases that leads to pulmonary hypertension even to a milddegree (emphysema, fibrosis, diffuse bronchiectasis)
Active uncontrollable SLE which has involved a major organ Vasculitis
Pemphigus vulgaris and severe generalized psoriasis and advanced melanoma Multi-drug resistant epilepsies
Multiple sclerorosis in which the patient is disabled
Myasthenia gravis
Some type of motor neuron diseases like amyotrophic lateral sclerosis (ALS) which isintensified following by pregnancy and will seriously endanger mother life
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Fetal Condition
Osteogenesis imperfecta Osteochondrodysplasia
Osteopetrosis and infantile neuroaxonal dystrophy
Bilateral renal agenesis
Polycystic kidney
Multicystic dysplastic kidney
Potter syndrome
Congenital nephrotic syndrome and hydropsSevere bilateral hydronephrosis Alpha thalassemia and hydrops fetalis
Thrombotic disorders
Trisomy 13, 18, 3, 16, 8
Anencephaly
Cat cry syndrome
Holoprosencephaly
Syringomyelia Cranioschisis
Meningoencephalocele
Meningohydroencephalocele
Thanatophoric dysplasia
Cyclopia with holoprosencephaly
Ichthyosis congenita
Schizencephaly
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Counselling
Objectives of Counselling :
To educate the patient about Recurrent Pregnancy
Loss
What are the causes ?
Who is at risk ?
How to prevent / manage?
To provide care and support for the patient Help the patient to cope with their emotional distress
and prevent them from developing psychiatric disorder
Genetic causes
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Genetic causes
Perform karyotype of parents with family or personal history of genetic abnormalities.
Perform karyotype of the abortus in recurrent cases.
Provide genetic counseling for families with recurrent loss or familial history of genetic disease.
In patients with a high risk for recurrent, chromosomally abnormal conceptus, discuss the optionsof adoption, gamete donation, and PGD.
Immunologic causes
Perform APLA testing if indicated.
If APLA levels are elevated, counseling with a hematologist and a specialist in maternal fetalmedicine is recommended.
Aspirin and heparin therapy may be given to patients who are diagnosed with APS.
Anatomic causes
Imaging may include HSG, hysteroscopy, ultrasonography, and/or MRI.
Surgical correction may be required.
Infectious causes
Cervical cultures should be obtained during the evaluation of infertility.
Empiric antibiotics should be given before invasive testing, such as HSG.
Environmental causes
Encourage life-style changes and counseling for preventable exposures.
Endocrine factors
Perform thyroid-stimulating hormone (TSH) screening in symptomatic patients.
Thrombophilic disorders
Aspirin and heparin therapy may be given for proven diagnoses.
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Thank You =)