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 3–benign 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-pre-eclampsia 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 Inevitable Incomplete Missed

Laboratory Findings Ultrasonography Pregnancy tests Blood count Gestational sac and viable embryo with heart motion Ultrasonography 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. Don’t 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 .