2nd trimester Miscarraige Dr. Alia kareem

Lecture headlines Definition Incidence Causes Incompetent cervix

Definition Miscarriage is a spontaneous pregnancy loss before the gestational age of fetal viability

Gestational age of fetal viability Viability implies the ability of fetus to survive extra uterine life this is generally considered to occur at 24 weeks gestation.

second trimester miscarriage Is a spontaneous pregnancy loss occurs between 12and 24 weeks gestation

Incidence 2nd trimester miscarriage constitutes <3% of all pregnancy outcomes.

Etiology aetiology underlying late miscarriage varies with gestational age. Conditions associated with2nd trimester pregnancy loss overlap those of the 1st and third trismeters. The predominant causes of losses at 12– 16 weeks are those of first trimester miscarriage

Etiological factors Idiopathic Fetal maternal

Fetal factor The predominant causes of losses at 12– 16 weeks are fetal chromosomal and 'structural anomalies

Maternal factor Anatomical factors: A- uterine anomaly : -congenital(septate &bicornuate uterus). -acquired: Asherman syndrome B-cervical incompetent

Infection Endocrine disease Acute sever illness Thrombophilia Over distension of uterus Abdominal, pelvic surgery amniocentesis

Cervical incompetent Is an inability of cervix to retain pregnancy in abscence of uterine contraction or labour.

Etiology of cervical incompetent Congenital :Congenital exposure to DES in utero , connective tissue disorders Acquired:(dilatation and curettage, conization, cauterization, or amputation,cx laceration following SVD

Clinical presentation Cx dilatationand effacement in the 2nd trimester with fetal membrane visible at or beyond the ext.osin absence of contraction

Dignosis before pregnancy: -Historical features: Hx of tow or more 2nd trimester pregnancy loss Hx of pregnancy loss at an earlier gestational age HX of painless cx dilatation up to4-6 cm Absence of clinical finding consistent with placenta abruptio Hx of cx trauma

investigation Before pregnancy Easily passing of 8 Hegar dilator through cx with no resistence Funneling of IO on HSG During pregnancy:TVU of cx: Short cx: <25mm before 24 weeks Funneling of membrane through IO

Normal CX(a) shortcx(b)

Treatment approach Cervical cerclage surgically reinforces a weak cervix by some type of purse-string suturing

Types according to indication Prophylactic cx cerclage cerclage should be offered to women with three or more previous preterm births and/or second-trimester losses Women with a history of one or more spontaneous mid-trimester losses or preterm births who are undergoing transvaginal sonographic surveillance of cervical length should be offered an cerclage if the cervix is 25 mm or less and before 24 weeks of gestation.

2-Rescue cx cerclage Insertion of cerclage as a salvage measure in the case of premature cervical dilatation with exposed fetal membranes in the vagina in absence of ut.contraction.

Types according to surgical approach 1-Transvaginal cerclage (McDonald) 2- High transvaginal cerclage (Shirodkar) 3- Transabdominal cerclage

1-Transvaginal cerclage (McDonald) A transvaginal purse-string suture placed at the cervicovaginal junction, without bladder mobilisation.

High transvaginal cerclage (Shirodkar) A transvaginal purse-string suture placed following bladder mobilisation, to allow insertion above the level of the cardinal ligaments.

3- Transabdominal cerclage A suture performed via a laparotomy or laparoscopy, placing the suture at the cervicoisthmic junction.

Time of application Transabdominal cerclage can be performed preconceptually or in early pregnancy. Trans vaginal cerclage at 14-16 weeks

Time of removing A transvaginal cervical cerclage should be removed : between 36+1 and 37+0 weeks Labour PROM IUD

All women with a transabdominal cerclage require delivery by caesarean section, and the abdominalsuture may be left in place following delivery.

Contraindications for cx cerclage active preterm labour ● clinical evidence of chorioamnionitis ● continuing vaginal bleeding ● PPROM ● evidence of fetal compromise ● lethal fetal defect ● fetal death.

Complications of cx cerclage -1-during insertion of cervical cerclage. small risk of: intraoperative bladder damage, cervical trauma, membrane rupture and bleeding 2- Shirodkar cerclage usually requires anaesthesia for removal and therefore carries the risk of anadditional anaesthetic. 3- Cervical cerclage may be associated with a risk of cervical laceration/trauma if there is spontaneouslabour with the suture in place.