2. Objectives:  At the end of this lecture, the student should:  Know the main categories of bleeding in early pregnancy.  Can clinically assess a woman with bleeding in early pregnancy.  Differentiate between the causes of bleeding in early pregnancy depending on the history, clinical signs and certain investigation when required.

3.  Differentiate between the different types of abortion depending on clinical assessment.  Know the available options of management for each individual case.

4.  The three main causes of bleeding in early pregnancies are: Miscarriage Ectopic pregnancy Gestational trophoblastic disease

5. miscarriage

6. Definition:  is the spontaneous termination of the pregnancy before the fetus is sufficiently developed to survive (less than 24 weeks gestation based on the date of LNMP or fetal weight less than 500g).

7. Terminology:  In medical contexts, the word "abortion" refers to the termination of pregnancy, either spontaneously or intentionally, before the fetus develops sufficiently to survive.  Many women who have had miscarriages, however, object to the term "abortion" in connection with their experience, as it is generally associated with induced abortions.  In other word, the term abortion most commonly refers to the induced abortion of a human pregnancy, while spontaneous abortions are usually termed miscarriages.

8. Incidence  50% of all conceptions fail (most unrecognized)  25% of recognized pregnancies are lost, 90 % of these before 12-14 weeks  10-20% of pregnant women have 1 sporadic spontaneous abortion  2% have 2 consecutive spontaneous abortion  0.4-1% have 3 consecutive spontaneous abortion

9. Causes:  Miscarriages can occur for many reasons, not all of which can be identified. Some of these causes include:  Chromosomal abnormalities  Endocrine disorders  Abnormalities of the uterus  Infections  Chemical agents  Psychological disorders  Immunological disorders

10. First trimester  Most clinically apparent miscarriages occur during the first trimester.  Chromosomal abnormalities are found in more than half of embryos miscarried in the first 13 weeks.  A pregnancy with a genetic problem has a 95% probability of ending in miscarriage.  Most chromosomal problems happen by chance, have nothing to do with the parents, and are unlikely to recur.  Chromosomal problems due to a parent's genes is, however, a possibility. This is more likely to have been the cause in the case of repeated miscarriages, or if one of the parents has a child or other relatives with birth defects. Genetic problems are more likely to occur with older parents; this may account for the higher miscarriage rates observed in older women.

11.  Autosomal trisomies are the most common, with an incidence of 30-35%, followed by triploidies and monosomies X (45,X)  Autosomal trisomy is the most frequently identified chromosomal anomaly associated with first-trimester abortions.. Trisomies for all autosomes except chromosome number 1 have been identified in abortuses, but autosomes 13, 16, 18, 21, and 22 have been found most commonly.  Structural chromosomal rearrangement such as translocations or inversions are present in only 1.5% of abortuses in the general population but are a significan t cause of recurrent miscarriages.

12.  Another cause of early miscarriage may be progesterone deficiency. Termed luteal phase defect, insufficient progesterone secretion by the corpus luteum or placenta has been suggested as a cause of abortion. Currently, the diagnostic criteria and efficacy of therapy for this supposed disorder require validation. If the corpus luteum is removed surgically, such as for an ovarian tumor, progesterone replacement is indicated in pregnancies less than 8 to 10 weeks

13. Second trimester  Up to 15% of pregnancy losses in the second trimester may be due to:  uterine malformation,  growths in the uterus (fibroids),  or cervical problems. (These conditions may also contribute to premature birth).  Problems with the placenta may also account for a significant number of later- term miscarriages

15. General risk factors  Multiple pregnancies: Pregnancies involving more than one fetus are at increased risk of miscarriage.  Uncontrolled diabetes greatly increases the risk of miscarriage. Women with controlled diabetes are not at higher risk of miscarriage.  Polycystic ovary syndrome is a risk factor for miscarriage, with 30-50% of pregnancies in women with PCOS being miscarried in the first trimester.

16.  High blood pressure during pregnancy.  Severe cases of hypothyroidism increase the risk of miscarriage. The effect of milder cases of hypothyroidism on miscarriage rates has not been established.  The presence of certain immune conditions such as autoimmune diseases is associated with a greatly increased risk of miscarriage.  Certain illnesses (such as rubella, chlamydia and syphilis ) increase the risk of miscarriage.  Tobacco (cigarette) smokers have an increased risk of miscarriage. An increase in miscarriage is also associated with the father being a cigarette smoker.The husband study observed a 4% increased risk for husbands who smoke less than 20 cigarettes/day, and an 81% increased risk for husbands who smoke 20 or more cigarettes/day.

17.  Cocaine use increases miscarriage rates.  Physical trauma, and exposure to environmental toxins, have also been linked to increased risk of miscarriage.  Advanced maternal age  The age of the mother is a major risk factor. Miscarriage rates grow at an ever-increasing rate after age 20.

18. Pathology 1.Haemorrhage occurs in the decidua basalis leading to local necrosis and inflammation.

19. 2. The ovum, partly or wholly detached, acts as a foreign body and initates uterine contractions. The cervix begins to dilate.

20. 3. Expulsion complete, The decidua is shed during the next few days in the lochial flow.

21. Types:  Threatened miscarriage.  Inevitable miscarriage.  Incomplete miscarriage.  Complete miscarriage.  Missed miscarriage.  Recurrent miscarriage.

22. Blighted ovum: when the gestational sac is more than 25mm in diameter and no embryonic or fetal part can be seen, the term blighted ovum and anembryonic pregnancy are often used suggesting wrongly that the sac may have developed without embryo. The explanation for this feature is the early death and resorption of the embryo with persistence of the placental tissue rather than a pregnancy originally without embryo.

23. Threatened miscarriage Is the earliest stage of most spontaneous miscarriage. The clinical features of a threatened miscarriage are:  uterus is normal size for dates  vaginal bleeding - the bleeding may be slight as faint brown discharge or a profuse red discharge with clotting  no products have been passed - do not confuse clots with products  cervix is closed  there is generally no pain although there may be a dull ache or discomfort due to congestion of the pelvic organs  pregnancy test is positive  fetal heart sounds and movements are observed

24. Threatened miscarriage Low abdominal pain acompany vaginal bleeding Cervix is closed unrupture of membrane Embryo is viable Pregnancy symptoms are present

25.  Management:  There are no effective therapies for threatened abortion.  Bed rest, although often prescribed, does not alter the course of threatened abortion. Acetaminophen-based analgesia may be given to help relieve the pain.  there is no evidence that progestogens or human chorionic gonadotrophins are of any help in the treatment of threatened abortion  Rhesus prophylaxis if appropriate

26. Prognosis:  Occurring commonly, vaginal spotting or heavier bleeding during early gestation may persist for days or weeks and may affect one out of four or five pregnant women.  Overall, approximately half of these pregnancies will abort, although the risk is substantially lower if fetal cardiac activity can be documented.  Even without abortion, these fetuses are at increased risk for preterm delivery, low birthweight, and perinatal death.  Importantly, the risk of a malformed infant does not appear to be increased.

27. Inevitable miscarriage:  occurs in about 25% of women with a threatened abortion.  It is characterised by:  considerable bleeding  lower abdominal pain  a dilated cervix  products may have been passed - do not confuse with clots

28. Inevitable miscarriage Bleeding increased Pain development Rupture of membrane Cevix dilation Embryo tissue incarcerated in the cervix

29. Incomplete miscarriage:  where the products of conception have not been completely lost from the uterus.  most likely to occur between 8 to 14 weeks gestation when the placenta is not expelled completely and an ERPC is necessary.  In the acute presentation the cervix is dilated, there is continuing haemorrhage and uterine contractions. Blood loss may be severe and require immediate transfusion  In the non-acute presentation a few days after an abortion, continued blood loss and a bulky, tender uterus may suggest that an abortion was incomplete and may necessitate an ERPC

30. Incomplete miscarriage In spite of uterine contractions and cervical dilatation, only the fetus and some membranes are expelled. The placenta remains partly attached and bleeding continues. This abortion must be completed by surgical methods.

32. The fetus and placenta are expelled completely, the uterus contracts and bleeding stops. No further treatment is needed. Complete miscarriage

33. Missed Abortion  In this case, the uterus retains dead products of conception behind a closed cervical os for days or even weeks.  After fetal death, there may or may not be vaginal bleeding or other symptoms of threatened abortion.  For days or weeks, the uterus remains stationary in size, but then gradually becomes smaller.  Mammary changes usually regress.  If the missed abortion terminates spontaneously, and most do, the process of expulsion is the same as in any abortion.

34.  After death of the conceptus, management can be individualized, depending on individual circumstances. Expectant, medical, and surgical approaches can all be reasonable options, each with its own merits and disadvantages.

35. Varieties of spontaneous abortion