1. Bleeding in early pregnancy
25%bleeding before 20 weeks gestation
-implantation bleed :
spot of blood occur 5-7 days after blast cyst implantation .

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

3. 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 % end by miscarriage
-most of miscarriage occur prior to 13 weeks
-1-2 %miscarriage occur between weeks

4. 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

5. 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 % causes of miscarriage
3 –sub mucosal fibroid

6. Anatomical defect:

7. 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.

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

9. 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

10. Action:-
formation of thrombosis ,uteroplacental blood vessels ,defect trophoblast function ,lead to
1-miscarriage IUGR pre-eclampsia 4-DVT
9-alloiummuno factors
Immune defect cytotrophoblast reject fetal allograft

11. 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??

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

13. 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

14. 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

15. Clinical Findings
Amenorrhea
Bleeding
Pain

16. 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.

17. 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

18. 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

20. Threatened Abortion
Inevitable
Incomplete
Missed

21. Laboratory Findings Ultrasonography Pregnancy tests Blood count
Gestational sac and viable embryo with heart motion
Ultrasonography
Pregnancy tests
HCG
Blood count
Anemic

22. 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 .

23. 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.

24. 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]

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

26. 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.

27. 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).

28. DILATATION & EVACUATION (D and E) ABORTION -Used for 2nd trimester abortions, at which point in fetal development the fetal bones become calcified.

29. 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.

30. * 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 .