1. Bleeding in early pregnancy

2. -25%bleeding before 20 weeks gestate
-implantation bleed :spot of blood occur 5-7 days after blast cyst implantation .

3. Causes of bleeding in early pregnancy :
-miscarriage –ectopic pregnancy 3–benign lesion lower genital tract –hyditidform mole 1
-cervical pregnancy 5

4. Spontaneous miscarriage
Definition :termination of pregnancy prior to 24 weeks gestation ,fetal weight less than 500 gm
-survival rate 50% 23weeks (extremely premature less 26 weeks infant )

5. -incidence 15-20 % end by miscarriage
-most of miscarriage occur prior to 13 weeks
-1-2 %miscarriage occur between weeks
Etiology :
1-genetic abnormalities 50%
- chromosomal abnormalities failure to develop embryo
-trisomy 21 down syndrome Mongol
-polyploidy monosomy

6. 2-endocrinefactors
-early failure of corpus luteum due to progesterone deficiency
-PCOS
–poor un-controlled DM
-untreated thyroid disease
Lead to miscarriage ,fetal malformation
3-maternal illness : maternal cardio-vascular , hepatic , renal problem

7. 4-maternal infections
-syphilis ,listeria,toxoplasmosis,maternal febrile illness ( influenza,pyelitis ) ,malaria, bacterial vaginosis ( second trimester )
5- abnormalities of uterus
-uterine anomalies :-bicornuate –subseptate % causes of miscarriage –sub mucosal fibroid –asherman syndrome adhesion between endometrium & inner uterine walls

8. 6-cervical incompetence : painless dilatation of the cervix ,lead to SORM, miscarriage ,or PTL
Dx:history of recurrent abortion
-u\s TVs –funnel internal cervical os ,shortening of the cervical canal less25 mm.

9. Causes of cervical incompetence
1-congenital anomalies of genital tract
2-physical damage D&C,E&C
3-birth trauma
7-auto immunes
-antiphospholipid syndrome{ aps}
-LA lupus anticoagulant
-aCL anticardiolipin antibody

10. 8-thrombophilic defect
-defect antithromin III
-protein C,S deficiency
-defect factor V Leiden
-formation of thrombosis ,uteroplacental blood vessels ,defect trophoblast function ,lead to
1-miscarriage IUGR 3-pre-eclampsia 4-DVT

11. 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%willcontinue pregnancy .
-no specific treatment reassurance & support
-bed rest??

12. 2-inevitable / incomplete :
- more abdominal pain
-heavy vaginal bleeding .
-cervix open
-product of conception ,passed through vagina

13. -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.

14. complete miscarriage :
All of conception expel out of uterus cervix closed ,involution of the uterus
treated by blood replacement

15. 5-septic miscarriage :
Any type of miscarriage with infection
-infection presented in the uterus
Clinical picture :
Incomplete abortion
-adenexial pain -

16. 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 all albus aures , kllebsella, clostrium welchi: & c. perfringens

17. 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 ovarian morphology { PCOS}
@ uterine cavity

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

19. 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.

20. Gestational sac less than 20 mm, fetal pole less than 6 mm
No evidence of cardiac activity.
Urine BHCG, +ve 9-10 days of conception.
HCG level double every 48 hrs [4-6 weeks]

21. Indication for E & C :
Persistent excessive bleeding .
haemmodynamic instability.
infected retained tissue give A/ B hrs before E&C .
suspicion gestational trophablastic disease

22. 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.

23. 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.

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

25. 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.

26. * 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

27. induced abortion :
-named pregnancy termination .
-two doctor at least should decide induced abortion when these are greater risk physically & mentally on mother & child , also there is risk of abnormality .
-termination prior to 24 weeks or before 20 weeks gestation .
-counseling includes social ,medical , & psychological aspect .

28. Methods of termination of pregnancy :

29. -screening for STIs & give antibiotic .
-anti-D for RH –ve ,after termination .
-after termination check physical &contraceptive measures.
-12 % who need termination if does not given antibiotic can develop PID & c.trachomatis

30. Surgical termination of pregnancy ;
Most common used in the 1st trimester
-use of dilator to open the cervix this called suction curette
-E&C in the second trimester under GA if 10 weeks or less under local anesthesia to decrease the incidence of hospitalization .

31. Medical termination of pregnancy :
-used after 14 weeks gestation instead of E&C
-progesterone antagonist { mifepristone} given orally then hours orally or vaginal pessary ,success rate more than 35 %.
-in the second trimester : vaginal prostaglandin every 3 hours

32. -extra amniotic infusion –{use of mifepristone through folly catheter fitted in the cervix, then do E&C to remove placenta, remember this procedure need to be client in single room ,with maintenance privacy ,& analgesia .this referred to legal abortion .

33. Complications of termination :
** early complication:
Bleeding –uterine perforation –damage pelvic viscera –cervical laceration –retained product & sepsis-small failure rate
**late complications:
-infertility –cervical incompetence –isoimmunization –psychiatric disease
NB; unsafe abortion one cause of maternal death which lead to septic abortion ( commonly illegal & used in non sterile technique

34. psychological sequelae of termination :
?-fatal abnormality
-?pregnancy wanted or not .
-?previous diagnosis of the problem
-feeling of distress & traumatic experience
-need support from Dr,midwife husband –family support

35. ** role of midwife ;
-primary caring of mother
-provide well care to mother
-prevent harm
-assist in blood test ,& amniocentesis
-give advice & necessary information .
-ready to care with her in case of emergency

36. Thank you