Bleeding in early pregnancy 25%bleeding before 20 weeks gestation -implantation bleed : spot of blood occur 5-7 days after blast cyst implantation . Causes of bleeding in early pregnancy 1-miscarriage 2 ectopic pregnancy 3benign lesion lower genital tract

4 hyditidform mole 5-cervical pregnancy Spontaneous miscarriage

Definition : -termination of pregnancy prior to 24 weeks gestation ,fetal weight less than 500 gm N.B: -survival rate 50% - extremely premature less than 26 weeks infant ) -incidence 15-20 % end by miscarriage -most of miscarriage occur prior to 13 weeks -1-2 %miscarriage occur between 13-24 weeks Etiology :

1-genetic abnormalities 50% - chromosomal abnormalities failure to develop embryo -trisomy 21 down syndrome {Mongol}

-polyploidy monosomy 2-endocrinefactors -early failure of corpus luteum due to progesterone deficiency -PCOS (poly cystic ovarian syndrome) poor un-controlled DM -untreated thyroid disease Lead to miscarriage ,fetal malformation 3-maternal illness : maternal cardio-vascular , hepatic , renal problem 4-maternal infections -syphilis ,listeria,toxoplasmosis,maternal febrile

illness ( influenza,pyelitis ) ,malaria, bacterial vaginosis 5- abnormalities of uterus -uterine anomalies : 1-bicornuate 2- subseptate 15-30% causes of miscarriage 3 sub mucosal fibroid Anatomical defect: 4 asherman syndrome :adhesion between endometrium & inner uterine walls 6-cervical incompetence : painless

dilatation of the cervix ,lead to SORM (spontaneous rupture of membrane), miscarriage ,or PTL(preterm labor) Dx:history of recurrent miscarriage -u\s (TVS) funnel internal cervical os ,shortening of the cervical canal less 2 .5 mm.

Causes of cervical incompetence 1-congenital anomalies of genital tract 2-physical damage after ( D&C,E&C ) 3-birth trauma

7-auto immune disease: -antiphospholipid syndrome{ APS} - lupus anticoagulant {LA} - anticardiolipin antibody {ACL} 8-thrombophilic defect -defect antithromin III -protein C,S deficiency -defect factor V Leiden Action: formation of thrombosis ,uteroplacental blood vessels ,defect trophoblast

function ,lead to 1-miscarriage 2-IUGR 3-preeclampsia 4-DVT 9-alloiummuno factors Immune defect cytotrophoblast reject fetal allograft Types of miscarriage 1-threatened miscarriage -bleeding in early pregnancy -uterine size normal corresponding with gestational age

-cervix closed . -minimal lower abdominal pain . -80%will continue pregnancy . -no specific treatment reassurance & support -bed rest?? 2-inevitable / incomplete :

- more abdominal pain -heavy vaginal bleeding . -cervix open -product of conception ,passed through vagina 3-incomplete ;

-heavy bleeding . -cervix open -sever abdominal pain -part of conception remain in the uterus Treatment: medical management Surgical evacuation E&C under local or general anesthesia to curette the retained tissue

4-complete miscarriage : All of conception expel out of uterus cervix closed ,involution of the uterus treated by blood replacement 5-septic miscarriage : Any type of miscarriage with infection -infection presented in the uterus

Clinical Findings Amenorrhea Bleeding Pain Clinical picture :

Incomplete miscarriage -adenxial pain -tenderness of abdomen. -purulent vaginal discharge -pyrexia -sepsis ,endotoxic shock {septic shock }renal failure, DIC , petechial Hge . - Types of micro-organism ,Ecoli, staphili coccus facalis, staphylucous albus , aures , kllebsella, clostrdium welchi & c. perfringens. 6- Missed or silent miscarriage :

- fetal demise , ultrasound no fetal heart rate. - fetal pole presence of gestational sac by uls. - regress of abdominal Size. -regress signs of pregnancy . - blighted ovum

7- Recurrent miscarriage : - Three or more successive miscarriage, prior to viability Diagnosis:

1-karyotype of both parents { geneticist} 2-fetal product. 3-maternal blood sample for LA, aCA{ during 6 weeks of miscarriage }done twice to be sure of the result . 4-u\s for @ ovarian morphology { PCOS} @ uterine cavity Threatened Abortion Incomplete Inevitable

Missed Laboratory Findings Ultrasonography Gestational sac and viable embryo with heart motion Pregnancy tests HCG

Blood count Anemic Treatment :-aspirin or heparin -cervical cerclage {shourtkhar } done on 14-16 weeks gestation under general anesthesia, & remove at 38 weeks gestation or at the onset of labor .

DX : as general for all types of miscarriage clinical assessment. Haemodynamic stability. Assessment of blood loss. Distension of cervical canal by conception.

Hypotension Brady cardia "cervical shock" Rupture ectopic pregnancy need abd, examination . V. E is open to distinguish the type. TVS to confirm the DX. Gestational sac less than 20 mm, fetal pole less than 6 mm No evidence of cardiac activity. Urine BHCG positive 9-10 days of conception. HCG level double every 48 hrs [4-6 weeks]

Indication for E & C : Persistent excessive bleeding . haemmodynamic instability. infected retained tissue give A/ B(antibiotics) 12- 24 hrs before E&C . suspicion gestational trophablastic disease

preoperative management : treat infection if present by A\B. Give prostaglandin to dilate cx. Consent form.

CBC & blood group ,canula IV fluid . V/E & uls. Emptying bladder. Wearing gowns ,v/S. PCR, endo- cervical swabs for STIS. Complications of E & C :

Cervical / uterine Trauma, Tears. uterine perforation. Intra abd. Trauma . Intra. uterine adhesion. Internal bleeding. death increase Mortality rate. increase a chance to develop of PID who has syphilis ,gonorrhea, & or BV(bacterial vaginosis). DILATATION & EVACUATION (D and E) ABORTION

-Used for 2nd trimester abortions, at which point in fetal development the fetal bones become calcified. Over all management :

history passage of conception. Medical Management : PG " Antiprogesrone ".prostaglandin dose according to size of Gestational sac. type of Miscarriage . gestational weeks.

Anti- D Immune globulin: -Mother RH ve should take Anti D after 12 weeks gestation . -Indication to give Anti- D before 12 weeks gestation heavy bleeding. pain. Dont forget to document Anti D. * psychological aspect of miscarriage : anger ,grief ,guilt feeling continue up to six weeks after miscarriage . loss in the second trimester liable to mood disorder ,like post partum depression .

grief up to 6 months .

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