TBL (Miscarrriage)
TBL (Miscarrriage)
TBL (Miscarrriage)
Definition of Miscarriage
Pregnancy that ends spontaneously before the fetus has reached a viable gestational age. Legal definition of miscarriage in UK: Spontaneous loss of pregnancy at or before 24 weeks of gestation.
Inevitable Miscarriage
Complete Miscarriage
Incomplete Miscarriage
Missed Abortion
Causes of Miscarriage
Chromosomal Abnormalities (Maternal age>35 years old) Endocrine Disorders Abnormalities of the Uterus Infections Trisomies ( Downs syndrome), Triploidies and tetraploidies Monosomy X (Turners syndrome) Translocation and inversion Diabetes, hyperthyroidim, luteal phase deficiency, polycystic ovarian syndrome Uterine septa, endometrial adhesions(postcurettage or Ashermans sundrome) Salmonella typhi, malaria, cytomegalovirus, Brucella, toxoplasmosis, Mycoplasma hominis. Chlamydia trachomatis and Ureaplasma urealyticum
Chemical Agents
Tobacco, anaesthetic gases, arsenic, benzene, solvents, lead, mercury, pesticides, cadmium Antiphospholipid syndrome, thrombophilia (Hereditary)
Immunological Disorders
Signs
Cervix may be dilated
No fetal movement
Questions to Ask
Uterine instrumentation ? Are the menstrual cycles regular ? Is there galactorrhea ? History of congenital abnormalities or karyotypic abnormalities ? Any exposure to environmental toxins ? Any history of venous or arterial thrombosis ?
Hirsutism ?
Uterine malformation ?
Cervical laceration ?
Investigation
Karyotyping
Sonohysterography
Hysterosalpingogram
Hysteroscopy
MRI
Other investigation
Anticardiolipin antibodies and lupus anticoagulant Thyroid function test and thyroid peroxidase (TPO) antibodies Culture and serology Hypercoagulable state Progesterone level Endometrial biopsy
Circulatory System
Renal System
Gastro-Intestinal System
Respiratory System
Immune System
Blood in urine Acidic (ph of 5.8) Difficulty and painful urination Possible renal failure
WBC
Loss of weight
Positive infection
Maternal condition
History of dilated cardiomyopathy in previous pregnancies Myocarditis, Pericarditis, Heart Failure Hypercoagulability Marfan syndrome, when ascending aorta is wider than 5 cm Eisenmenger's Syndrome Pregnancy induced fatty liver History of esophageal varicosities hemorrhage Uncontrollable autoimmune hepatitis Renal failure Hypertension which is not controllable with permitted drugs during pregnancy Any of the pulmonary diseases that leads to pulmonary hypertension even to a mild degree (emphysema, fibrosis, diffuse bronchiectasis) Active uncontrollable SLE which has involved a major organ Vasculitis Pemphigus vulgaris and severe generalized psoriasis and advanced melanoma Multi-drug resistant epilepsies Multiple sclerorosis in which the patient is disabled Myasthenia gravis Some type of motor neuron diseases like amyotrophic lateral sclerosis (ALS) which is intensified following by pregnancy and will seriously endanger mother life
Fetal Condition
Osteogenesis imperfecta Osteochondrodysplasia Osteopetrosis and infantile neuroaxonal dystrophy Bilateral renal agenesis Polycystic kidney Multicystic dysplastic kidney Potter syndrome Congenital nephrotic syndrome and hydropsSevere bilateral hydronephrosis Alpha thalassemia and hydrops fetalis Thrombotic disorders Trisomy 13, 18, 3, 16, 8 Anencephaly Cat cry syndrome Holoprosencephaly Syringomyelia Cranioschisis Meningoencephalocele Meningohydroencephalocele Thanatophoric dysplasia Cyclopia with holoprosencephaly Ichthyosis congenita Schizencephaly
Counselling
Objectives of Counselling : To educate the patient about Recurrent Pregnancy Loss
What are the causes ? Who is at risk ? How to prevent / manage?
Genetic causes Perform karyotype of parents with family or personal history of genetic abnormalities. Perform karyotype of the abortus in recurrent cases. Provide genetic counseling for families with recurrent loss or familial history of genetic disease. In patients with a high risk for recurrent, chromosomally abnormal conceptus, discuss the options of adoption, gamete donation, and PGD. Immunologic causes Perform APLA testing if indicated. If APLA levels are elevated, counseling with a hematologist and a specialist in maternal fetal medicine is recommended. Aspirin and heparin therapy may be given to patients who are diagnosed with APS. Anatomic causes Imaging may include HSG, hysteroscopy, ultrasonography, and/or MRI. Surgical correction may be required.
Infectious causes Cervical cultures should be obtained during the evaluation of infertility. Empiric antibiotics should be given before invasive testing, such as HSG.
Environmental causes Encourage life-style changes and counseling for preventable exposures. Endocrine factors Perform thyroid-stimulating hormone (TSH) screening in symptomatic patients. Thrombophilic disorders Aspirin and heparin therapy may be given for proven diagnoses.
Thank You =)