The lecture has been given on Nov. 29th & Dec. 1st, 2010 by Dr. Muhabat Salih Saeid.

1. Early pregnancy bleeding Dr. Muhabat Salih Saeid MRCOG-London-UK

4. History Examination Investigations Diagnosis Management Assessment

7. Subserosal Fibroid

11. threatened inevitable incomplete missed

13. 2-Inevitable Abortion: O/H :lower abdominal pain similar to dysmenorrhoea which persist/worse O/E:Cervix is open Abortion will take its course Management: as incomplete abortion

14. 3. Incomplete abortion: * OH: as inevitable i,.e. abdominal pain and passage of clots and tissues * O.E: Cervical os open - If bleeding is severe, the patient may be shocked - Suprapubic tenderness, the uterine size is corresponding to expected gestational age - Bimanual examination: products of conception may be left in the os or in vagina * Ultrasound : remnant of conception in the uterus * Management: - Treatment of shock (plasma expanders and blood transfusion) - Evacuation of retained products under general anaesthesia

15. 4. Complete abortion: * History of abdominal pain and vaginal bleeding as well as passage of clots and tissues * On examination: The uterine size is smaller than expected for gestational; the cervical os is closed (the uterus expelled its contents) * Ultrasound shows empty uterus * Management : Patient usually well and fit to go home Threatened - ※Inevitable ※Incomplete ※ Complete Preg. Continues (majority)

16. Complete miscarriage Bleeding and cramps which are usually settling

17. 5. Septic abortion: * If abortion is associated with infection, it is called septic abortion * It is usually associated with incomplete induced abortion * History of abdominal pain, vaginal bleeding and may have foul vaginal discharge * On examination: the patient usually looks unwell; pyrexia with tachycardia If severe; the patient might have septic (endotoxic) shock Lower abdominal tenderness and enlarged tender uterus on bimanual examination

20. Missed miscarriage Spotting only usually. Expected to be 6-12 weeks by LMP. Fetal pole seen

21. Missed Miscarriage

22. 6. Missed abortion - Embryo dies and the uterus does not expel its contents - Loss of pregnancy symptoms - Uterine size is smaller than expected - Ultrasound showed: *no fetal heart * Embryo / Fetus size is smaller than expected for gestational age Management: If uterus size <12 weeks - evacuation under general anaethesia (suction currtage) bec. Risk of perforation if use sharp one as the uterus in this condition is soft. If uterine size >12 weeks - Extra-amniotic prostaglandins

24. RECURRENT MISCARRIAGE Definition: Three or more consecutive pregnancy loss before viability Incidence 1% Etiology: * Genetic * Anatomical * Infective * Systemic * Immunological * Endocrine

25. 1. Genetic: - Rare (5% of recurrent abortion will have paternal abnormal chromosomes) - usually cause early trimester abortion - Parental karyotyping: * Balanced reciprocal translocation * Invertions & mosaisms Management: Genetic counseling Karyotyping the product of conception Prenatal diagnosis Preimplantation diagnosis

26. 2. Anatomical Causes: - Abnormal mullerian development (Bicorneate uterus, septate uterus, unicorneate uterus) - Uterine Fibroid (submuscous fibroid) - Uterine Synechae (intrauterine adhesion due to previous curettage - Cervical incompetence These causes usually lead to midtrimester miscarriages/preterm deliveries

28. 3. Infective causes: - Rare - TORCH screen unhelpful (reinfection rare in these cases) - Bacterial Vaginosis may lead to recurrent late losses and preterm labour

29. *Normal uterus at laparoscopy *Normal HSG

32. 4. Immunological causes: Antiphospholipid syndrome (API) Definition: Presence of antibodies to patient`s own phospholipids and associated with thrombosis, thrombocytopenia and recurrent abortions. Incidence upto 40%of recurrent abortion. Theory: Disordered platelet function: release of thromboxane. Disordered endothelial function: reduce prostacyclin release  Altered ratio of thromboxane /prostacycline ratio

33. Complications: Obstetrics complications : Fetal losses (early and late); Abruptio placentae; intrauterine growth restriction Vascular complications: arterial and venous thrombosis. Neurological: TIA Diagnosis Lupus Anticoagulant (LA) Positive prolonged APTT Positive anticardiolipin antibodies (ACA) Treatment: Baby Aspirin Heparin Immunoglobulins (under investigations)

35. In Conclusion: Patients with recurrent abortion needs to be investigated by the following tests For all: * Chromosomal analysis of both partners * Serum LH (day 5) for PCO * Antiphospholipid Antibodies (LA, ACA) * Pelvic ultrasound * Rubella antibodies (if negative, vaccinate) For selected patients: * Hysteroscopy/hysterosalpingography

36. Thank you Questions?