CASE 1

A 26 yr old nulliparous woman presented

with 8 weeks of amenorrhea. She has not
been using any contraception and normally
has a regular menstrual cycle every 28 days.
A pregnancy test was positive and she is
approximately 6 weeks pregnant.
However, today she noticed vaginal bleeding.

WHAT IS THE LIKELY DIFFERENTIAL

DIAGNOSIS OF PV BLEEDING IN EARLY
PREGNANCY?

Implantation bleeding
Non gestational
Miscarriage
Ectopic pregnancy
Hydatidiform molar pregnancy

MISCARRIAGE

DEFINITION:
THE EXPULSION OF THE PRODUCTS OF
CONCEPTION FROM THE UTERUS
BEFORE THE 28TH WEEK OF GESTATION

MISCARRIAGE

SPONTANEOUS

INDUCED

ETIOLOGY OF MISCARRIAGES
Fetal chromosomal abnormality
Trisomies 13, 18, 21
Triploidies and tetraploidies
Monosomy X (Turners syndrome)
Translocation (hereditary)

Uterine abnormalities
Congenital: Septate uterus, uni/bicornuate
uterus
Acquired: intrauterine adhesion, fibroids,
retroverted uterus

ETIOLOGY OF MISCARRIAGES
Cervical incompetence
Congenital: deficiency of connective tissue
Acquired: previous cervical laceration, previous
overzealous dilation of the cervix

Maternal infections

Hormonal causes: DM, progesterone deficiency

Autoimmune disease: SLE

Antiphospholipid Syndrome

ETIOLOGY OF MISCARRIAGES
OTHER:
Cigarette smoking
Cocaine increased risk of miscarriage
Alcohol - higher in women ended up with
miscarriage
Caffeine high level ass. with miscarriage
Chemicals : lead, ethylene oxide, solvents,
pesticides, vinyl chloride & anesthetic gases
ass. with fetal loss
Radiotherapy & Chemotherapy

CASE 1
A 26 yr old nulliparous woman presented with
8 weeks of amenorrhea. She has not been using
any contraception and normally has a regular
menstrual cycle every 28 days.
A pregnancy test was positive and she is
approximately 6 weeks pregnant.
However, today she noticed vaginal bleeding.

WHAT ADDITIONAL INFO WOULD YOU

ASK FOR IN YOUR HISTORY?
1.

Description of the bleeding.

2.

Is there pain? What kind of pain?

3.

Did you pass out anything?

4.

What were you doing when the bleeding

started?

5.

Do you have a fever or any other symptoms?

WHAT CLINICAL EXAMS WOULD YOU

PERFORM?
1.

General examination, vitals and signs of anemia

2.

Abdominal exam- to assess uterine size and

exclude peritonitis

3.

Speculum exam- visualize the cervical os,

cervical lesions

4.

Vaginal exam and bimanual exam- to asses the

os, elicit cervical excitation and adnexal masses
in ectopic pregnancy

WHAT INVESTIGATIONS WOULD YOU

ORDER?
1.

Urine and serum HCG concentrations

2.

Complete blood Count

3.

Ultrasound- to locate fetus, assess viability and

look for products of conception

4.

High vaginal swab for culture if febrile

MANAGEMENT OF EARLY
PREGNANCY FAILURE
1.

Expectant: Wait and see

2.

Medical evacuation of the uterus

3.

Surgical evacuation of the uterus

EXPECTANT MANAGEMENT

Must come in if there is severe pain and bleeding

or fever occurs
Several weeks of follow up may be required and
repeat of the clinical and USS evaluation must be
performed
Some resorb the trophoblastic tissue with little or
no bleeding
Others bleed for weeks

MEDICAL MANAGEMENT
Drugs that stimulates rhythmic contractions of the
uterus, increases the frequency of existing
contractions, and raises the tone of the uterine
musculature
1. Syntocinon, syntometrine (synthetic form of
oxytocin)
2. Misoprostol (syntheticPGE1) causes uterine
contraction and ripening of the cervix
3. Mifeprostone (synthetic steroid compound) that
antagonizes progesterone

SURGICAL MANAGEMENT
Dilatation and curettage
The woman is usually put undergeneral
anesthesiabefore the procedure begins.
A curette, a metal rod with a handle on one end
and a sharp loop on the other, is inserted into the
uterus through the dilated cervix.
The curette is used to gently scrape the lining of
the uterus and remove the tissue in the uterus.
This tissue is examined for completeness

SURGICAL MANAGEMENT
Evacuation of retained products of
conception
Instead of a curette, a cannula is inserted into
the uterus for the extraction of the fetus. The
cannula has a tube attached to it that leads to a
bottle and a pump that acts as a gentle vacuum.
After the cannula has been removed, a pair of
forceps is inserted to remove any remaining
tissue. A curette is used for this as well to scrape
the lining for any remaining traces of the fetus.
And, then, the womb is vacuumed out again just
to make sure the job was done properly.

SURGICAL MANAGEMENT
Indications for Surgical uterine evacuation :
1.
2.
3.
4.
5.

Patients preference
Persistent excessive bleeding
Haemodynamic instability
Evidence of infected retained tissue
Suspected gestational trophoblastic disease

SURGICAL MANAGEMENT
COMPLICATIONS :
1. Cervical incompetence
2. Perforation of the uterus
3. Ashermans syndrome
4. Anesthetic complication
5. Urinary retention
6. Hemorrhage
7. Pelvic pain/ infection
8. Scarring

THREATENED MISCARRIAGE
Pain: Variable, possibly slight lower abdominal
pain or backache
Bleeding: Scant, during first 3 months
Cervical Os: Closed, no dilation
Uterus: If palpable, soft and not tender

Gentle speculum exam to assess the source of blood

and exclude cervical lesions.
Ultrasound: shows intrauterine gestational sac, fetal
heart activity, intrauterine bleeding, haematoma
Heavy or increased amount of bleeding in an
ominous sign and may precede inevitable abortion

RX OF THREATENED MISCARRIAGE
Bed rest
Avoidance of coitus
Assessment for whether patient is a candidate for
progesterone supplements
Depro- provera to reduce uterine contractions
Reassurance and psychological support
recommended

INEVITABLE MISCARRIAGE
Pain: Severe, rhythmical
Bleeding: Heavy, clots
Cervical Os: Open with dilation
Uterus: If palpable, smaller than expected

VE: dilation of the cervix, POC in cervical canal or

bulging bag of membranes felt.
Ultrasound: important in determining the absence
or persistence of conception products inside uterine
cavity

INEVITABLE MISCARRIAGE
Occasionally severe shock may be due to
massive haemorrhage / vasovagal reaction
cervical shock syndrome due to distension of the
cervix by POC
Oxytocic drug may be given such as syntocinon
infusion
Evacuation of uterus maybe be required if the
miscarriage is incomplete

INCOMPLETE MISCARRIAGE
Pain: Severe
Bleeding: Heavy, profuse
Cervical Os: Open with dilation
Uterus: Tender and painful
Other: Tissue present in cervix

Static or slowly falling HCG levels

Ultrasound: persistence of conception products
inside uterine cavity

INCOMPLETE MISCARRIAGE
Evacuation of retained products of conception
from the uterus carried out
Medical management possible using
prostaglandin analogues such as misoprostol or
mifeprostone and synthetic oxytocinsyntometrine to maintain contractions
If surgical evacuation required, woman should be
screened for chlamydial infection
Transfusion may be given if blood loss excessive

COMPLETE MISCARRIAGE
Pain: Diminishing or absent
Bleeding: Minimal or absent
Cervical Os: Closed
Uterus: If palpable, firm and contracted

History of abdominal pain, bleeding with passing of

clots and tissue
Once miscarriage is complete, pain and bleeding
subside and cervix closes
Ultrasound shows empty uterus coupled with
falling HCG levels

MISSED MISCARRIAGE
Bleeding between uterine wall and gestational sac
occurs and intrauterine fetal death occurs before 28th
week of pregnancy resulting in the formation of a
carneous mole or there is formation of a blighted
ovum
Pain: Absent
Bleeding: Some spotting possible, brown colour
Cervical Os: Closed
Uterus: If palpable, smaller than expected
Ultrasound: no fetal movement, heart sounds, small
for dates

RX OF MISSED MISCARRIAGE

Weekly estimation of fibrinogen concentration

and platelet count should be done (risk of
hypofibrinogenemia with secondary hemorrhagic
phenomena)

Uterine size < 12 weeks: curettage

Uterine size > 12 weeks: misoprostol and prostin

SEPTIC MISCARRIAGE
Pain: Severe or variable
Bleeding: Variable, may be offensive
Cervical Os: Open
Uterus: Bulky, tender and painful on
examination
Other: fever, tachycardia, headache, nausea and
general malaise, purulent vaginal discharge

May occur after spontaneous or induced abortion,

more likely after incomplete miscarriage

SEPTIC MISCARRIAGE
Causitive organisms:
E. coli
Proteus
Klebsiella
Clostridium Welchii
Clostridium perfingens
High vaginal swab and blood cultures should be
taken
Risks include septicaemia, endotoxic shock, DIC,
liver and renal damage, salpingitis and infertility

RX OF SEPTIC MISCARRIAGE
Mild/uncomplicated- no Hx of shock, peritonitis
temp <100F
1.
2.
3.
4.

Speculum: POC removed with ovum forceps

Stat dose of syntometrine and IV oxytocin
infusion
Antibiotics: Augmentin + metronidazole
Evacuation of remaining POC

RX OF SEPTIC MISCARRIAGE
Sever- shock, generalized peritonitis, temp >100F,
hypotension, bladder and bowel injury, oliguria
1.
2.
3.
4.

Cefuroxime sodium (Zinacef)

Metronidazole
Fluids and electrolytes
Early evacuation of the remaining POC is
necessary

POA

PV

POC

BLEED

AB

CERVICAL

UTERINE

PAIN

OS

SIZE

DIAGNOSIS

Nil/+

Closed

= dates

THREATENED

Spotdark
brown

Minim
al

Closed

< dates

MISSED

Open

= dates

INEVITABLE

Open

< dates

INCOMPLETE

+++

Closed

< dates

COMPLETE

Closed

< dates

ECTOPIC

Vesice
ls

Open

> Dates
(50%)
25%= dates
25< dates

MOLE

CASE 2
A 32-year-old patient, Para 0+4 is referred to the
antenatal clinic after presenting with amenorrhea
for the last 10 weeks and positive urine pregnancy
test. Her last 4 pregnancies have ended
spontaneously at 18 to 20 weeks.

RECURRENT OR HABITUAL
MISCARRIAGES
Definition: loss of 3 consecutive pregnancies
Etiology:
Genetic abnormalities
Uterine anomalies
Uterine fibroids
Cervical incompetence
Polycystic Ovarian syndrome, insulin resistance
and hyperprolactinaemia
Anti phospholipid syndrome

RX RECURRENT OR HABITUAL
MISCARRIAGES
Anti phospholipid syndrome:
HEPARIN
low dose ASPIRIN
IVIG and prednisolone
PCOS: metformin
Cervical incompetence: cervical cerclage (14 to 16 th
week) Shirodkar technique
Mc Donald stitch

THANK YOU