Transcript Septic miscarriage

Miscarriage
Dr Mariem Gweder
DHR MSc MRCOG DOGUS
Definition
Miscarriage = Spontaneous abortion
 Spontaneous loss of a fetus before the
24th week of pregnancy.
 WHO definition: loss of an embryo or
fetus weighing 500 grams or less, (20 to
22 weeks or less.
(Pregnancy losses after the 20th week are
called preterm deliveries.)
Incidence
Occurs in about 15% to 20% of all clinical
pregnancies,
 60% to 70% occur during the first
trimester.
 Most miscarriages occur during the first 7
weeks of pregnancy.
 The rate of miscarriage drops after the
detection of fetal heart.

Classifications
Clinical / ultrasonic
 Threatened Miscarriage: bleeding seen, cervix closed, the fetus
is viable.
 Inevitable Miscarriage : the cervix has already dilated, but the
fetus has yet to be expelled. This usually will progress to a
complete miscarriage.
 Complete Miscarriage: is when all products of conception
have been expelled. Endometrium is less than 15mm thick on
US.
 Incomplete Miscarriage: part of conception is passed, cervical
os is open, and the retained part is more than 15mm thick
 Delayed or missed miscarriage: the embryo or fetus has died,
but the os is closed.
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Anembryonic pregnancy (blighted ovum) An empty gestational sac,
the embryo is either absent or stopped growing
Complications
Septic miscarriage: missed or incomplete
miscarrige becomes infected.
 Recurrent pregnancy loss: three consecutive
miscarriages.

Causes & Risk factors
First trimester
 Chromosomal abnormalities: majority of
cases
-Advanced maternal age: more likely to
occur in older women highest after 40
-Woman suffering RPL,
-H/O birth defects.
Causes & Risk factors
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??Progesterone deficiency may be another cause.
No study has shown that first-trimester progesterone
supplements reduce the risk
Polycystic ovary syndrome.: metformin significantly
lowers the rate but insufficient evidence of safety,
Maternal disease: Hypothyroidism, autoimmune
diseases, APL, uncontrolled diabetes
Infections,: TORCH, acute febrile illness, pylonephritis.
Smoking, Recreation drugs, Alcohol, Antidepressants
Physical trauma, exposure to environmental toxins,
Multiple pregnancy
Causes
Second trimester (PTL)
 Uterine malformation: Up to 15%
 Uterine fibroids
 Cervical problems (cervical
incompetence)
Diagnosis
Symptoms
 Examination
 Ultrasound: confirmation
 BHCG
 Microscopically
 Genetic for abnormal chromosomes
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Symptoms
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The most common symptom is vaginal
bleeding with or without abdominal
cramps
Up to 30% of women will have first trimester bleeding or spotting
Low back pain or abdominal pain (dull,
sharp, or cramping)
 Tissue or clot-like material that passes
from the vagina
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Examination
General examination: vital signs
 Abdominal examination : fundal level
 Pelvic exam, cervical dilatation or
effacement, blood clot, POC in the
cervical os
 Abdominal / vaginal ultrasound :
gestational age, fetal heart, retained
products.
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Investigations
Blood type (if Rh-negative, anti-D immune
globulin is needed.
 Complete blood count (CBC): HB to
determine blood loss, WBC and
differential to rule out infection
 HCG to confirm pregnancy
 HCG (quantitative) to rule out ectopic
pregnancy
 HVS and Blood C/S if septic
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Management
If in shock or heavy bleeding act as
emergency:
A
B
C
No treatment
-Threatened : bed rest has no proven
benefit.
-Complete
Only
 Counsel
 Anti-D if needed
 Follow up:(weekly)
Management options
For
- Incomplete abortion,
- Anembryonic (empty sac)
-Missed abortion
“Early Pregnancy Assessment Unit”
Options:
Expectant (Conservative)
 Medical or
 Surgical
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Expectant (conservative)
No treatment
 “wait & see”
 (65–80%) will pass naturally within two to
six weeks.
 avoids the side effects and complications
of medications and surgery
 risk of mild bleeding,
 need for unplanned surgical treatment,
and incomplete miscarriage
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Medical management
Mifepristone (anti-progesterone) oral, followed by (3648h)
- Misoprostol: vaginal or oral tabs: repeat in 4-6 hrs if
required
- Success rate 95% will complete within a few days.
Indications:
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Patient choice
 Second trimester: Surgical evacuation is unsafe
 First trimester : >10 weeks, before D&C & cervix is closed
(Misoprostol 400 mcg to ripen the cervix 3-4 hrs prior to dilatation)
 Contraindication to surgery or anaesthesia ,DIC
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Advantages:
 Fewer risks and complications
 Less cost
 Greater patient satisfaction
Surgical treatment
Vacuum aspiration or Traditional (D&C or E&C)
 Fast
 Less bleeding,
 Less pain
 Convenient for karyotype analysis (cytogenetic or
molecular),
 The patient is febrile (>37.50 C)
◦ After appropriate antimicrobial management
The patient or your health facilities are incapable of
appropriate follow up
Complications:
 injury to the cervix (e.g. cervical incompetence)
 perforation of the uterus,
 Asherman's syndrome: scarring of the endometrium
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Septic miscarriage
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Occurs when the tissue from a missed or incomplete miscarrige
becomes infected.
Unsafe abortion: gram negative, E.Coli Streptococci Staphylococci
Bacteroides Chlostridium Perfringens
STIs: Niesseria Gonorrhea Chlamydia Trochomatis
Presentation:
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Prolonged or heavy vaginal bleedin
offensive vaginal discharge
Fever
hypotension
Hypothermia, oliguria
Septic shock may lead to kidney failure and disseminated
intravascular coagulation(DIC).
chronic pain, PID, and infertility
Risk of septicaemia and maternal death.
Septic miscarriage management
Intravenous fluids
 Broad-spectrum IV antibiotics should be
given until the fever is gone.
 D&C or misoprostol
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Recurrent pregnancy loss(RPL)
Recurrent miscarriage (habitual abortion) three consecutive miscarriages.
 1% of miscarriages
Causes
 Chromosomal: balanced translocation or Robertsonian translocation in one of parents
 Endocrinal
 Thrombophilia, Antiphospholipid syndrome
 Anatomical: cong anomalies, fibroids
 Cervical incompetence
Work up
 Ultrasound: 2D, 3D, Sonohysterography
 Hysterosalpingogram (HSG)
 Hysteroscopy
 Karyotyping
Women with unexplained recurrent miscarriage have an excellent prognosis for
Future pregnancy
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After miscarriage
The tissue passed should be sent to
histopathology to exclude molar
pregnancy.
 Possible to become pregnant immediately.
However, it is recommended that women
wait one normal menstrual cycle before
trying to become pregnant again.
 Anti-D for RH negative.
 Counseling, support, explanation
 Follow up
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Summary
Miscarriage mostly occurs in first
trimester
 Majority of cases are due to
chromosomal abnormalities
 Classification is clinical and ultrasonic
 Proper counseling is needed
 Patient choice should be considered in
management options.
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Questions???