Obstetrics and Gynecology PDF

# Obstetrics and Gynecology ## Diagnosis of Pregnancy - In the 1st trimester "FIRST 12 WEEKS" ### Symptoms : - Highly suggestive but Not a sure sign. #### 1- Amenorrhea - Cessation of menses due to high E and P - The cardinal sign of early pregnancy - May have amenorrhea due to other causes, for e...

# Obstetrics and Gynecology ## Diagnosis of Pregnancy - In the 1st trimester "FIRST 12 WEEKS" ### Symptoms : - Highly suggestive but Not a sure sign. #### 1- Amenorrhea - Cessation of menses due to high E and P - The cardinal sign of early pregnancy - May have amenorrhea due to other causes, for example, lactation, ovarian tumor, - May have bleeding in early pregnancy (abortion, Hartman's bleeding). - Pregnancy should be suspected whenever a woman in her childbearing years misses a menstrual period: "pregnant until proved otherwise" #### 2- Breast Symptoms: - As heaviness, pain, enlargement, tingling, colostrum and color changes. - Start from the 2nd month and increase by days (more in PG). #### 3- Morning Sickness - Nausea, sometimes vomiting especially in early morning. - Appears at 6 weeks and disappears 6-12 weeks later, rarely persist all through. - Severe nausea and vomiting is indication of multiple or molar pregnancy. - Appetite changes. Food cravings and aversions (longing) #### 4- Urinary Symptoms: - Frequency of micturition day and night and increased liability to infection - Start at approximately 2 months until the 3rd month, then decrease (but does not disappear and increase again in the last weeks due to engagement). ... This is explained by: 1. Urinary bladder congestion (all through pregnancy). 2. Pressure of uterus on urinary bladder → bladder irritability. 3. Change in maternal osmoregulation → increased thirst and polyuria. - As the uterus straightens up after the 12th week, the symptom disappears. #### 5- Mode Changes: - Fatigability, sleepiness, depression, irritability and insomnia. #### 6- Other Symptoms: - Mild uterine cramping / discomfort without bleeding - Abdominal bloating, Constipation and Heartburn. - Nasal congestion and Shortness of breath - Top four symptoms: urinary frequency, feeling tired, poor sleep, and back pain - Pregnancy-related lightheadedness occurs with standing. It should resolve when she lies on her left side. it is of concern when it is associated with an abnormal heart rate / rhythm or signs suggestive of a seizure, or when it does not resolve in the lateral or head-down position. ### Signs: #### 1- Cutaneous Signs: - Persistence of basal body temperature elevation. (due to progesterone). - Spider telangectasia and palmar erythema. (due to increased Estrogen and Vitamin D). - Cutaneous vasodilatation: dissipate excess heat generated by increased metabolism during pregnancy. it leads to: 1. Mask paller due to anemia 2. Increased glandular activity (sweat and sebaceous glands). 3. Sensation of heat and nasal congestion. #### 2- Breast Signs: - Evident in PG and start at 6-8 weeks. - Diagnostic in PG and may persist after delivery. - In MG, it may be due to previous pregnancy, any hyperestrogenemia. - 1st month: increased size and vascularity (dilated visible veins). - 2nd month: increased pigmentation of nipple and 1ry areola and prominent Montogomry tubercles. They were though to be enlarged sebaceous glands, but recently they are found to be the lips of orifices of active peripheral lacteal ducts. - 3rd month: expression of colostrum from the nipple. - 4th month: 2ry areola appears around the 1ry one. #### 3- Genital Signs: - Vulva (soft and violet) ..... Jaque-Mier sign. - Vagina (soft, warm and violet)... Chadwick sign. - ↑ pulsation, felt through the lateral fornices at the 8th week → Osiander's sign. - Cervix (enlarged, soft by the 6th week and violet) → Goodell sign. - Uterus: Enlarged and soft. ↑ in size by about 1 cm / week after the 4th week. - Change in shape: globular. - Palmer sign (elicited by bimanual examination as early as 4-8 w): painless contraction followed by relaxation not accompanied by cervical dilatation (not reliable after 10 weeks). - Hegar sign due to softening of isthmus : By bimanual examination for 2-3 minutes. You can feel contraction and relaxation phase. Two fingers between the ant. vaginal fornix and abdomen behind the uterus can be approximated (between 6-12wk). - Not <6 w uterus is not soft enough. - Not > 12 w baby occupies whole uterine cavity. - Ladin's sign: softening of the uterus anteriorly in the midline along the uterocervical junction, occur at 6 weeks. - Mc Donald's sign: the uterus become flexible at the uterocervical junction at 7-8 weeks. - Von Ferwald's sign: an irregular softening of the fundus over the implantation site at the 4th-5th week. - Klug's sign: appearance of varicose veins in the vulva and vagina at about the 8th week. - Piskacek's sign: There may be asymmetrical enlargement of the uterus if there is lateral implantation. one half is more firm than the other half. ### Investigations: #### 1. Pregnancy tests: - Principle: depend on detection of the antigen (hCG) in the maternal urine or serum with antibody either polyclonal or monoclonal. #### Tests used: - Immunoassays without radioisotopes: - Aglutination inhibition test: The pregnancy test is negative if there is agglutination - The pregnancy test is positive if there is no agglutination - Direct agglutination test (hCG direct test): urine without hCG) indicates a negative one. The sensitivity is 0.2 IU hCG/mL. - enzyme-linked immunosorbent assay (EL-ISA): based on one monoclonal antibody that binds the hCG in urine and serum. A second antibody that is linked with enzyme alkaline phosphatase is used to 'sandwich' the bound hCG. It is detected by color change after binding. This is more sensitive and specific. ELISA can detect hCG in serum up to 1-2 mIU/mL and as early as 5 days before the first missed period. - Fluoroimmunoassay (FIA) is a highly precise sandwich assay. It uses a second antibody tagged with a fluorescent label. The fluorescence emitted is proportional to the amount of hCG and can detect hCG as low as 1 mIU/mL. FIA takes 2-3 hours. It is used to detect hCG and for follow up hCG concentrations. - Immunoassays with radioisotopes: - Radioimmunoassay (RIA): Using 1125 ido hCG antibodies. This is more sensitive and can detect β subunit of hCG upto 0.002 IU/mL in the serum. It can detect pregnancy as early as 8-9 days after ovulation (day of blastocyst implantation). RIAs are quantitative, so can be used for determining the doubling time of hCG (ectopic pregnancy monitoring). RIAs require 3-4 hours to perform. - Immunoradiometric assay (IRMA) - Uses sandwich principle to detect whole hCG molecule. IRMAs use 125I labeled hCG and require only 30 minutes. It can detect hCG as low as 0.05 mIU/mL. - Selection of time can be made by 8-11 days after conception. The test is not reliable after 12 weeks. - Sample of the test: - Urine tests (conventional pregnancy tests) - Latex (agglutination tests and agglutination inhibition test) and ELISA (20miu/ml). - Collection of urine: The patient is advised to collect the first voided urine in the morning in a clean container (not to wash with soap). - Serum test-subunit (most sensitive - PELISA: can be done ± 7 days postconception (may cross react with LH). - Monoclonal antibodies are the most specific but very expensive - NB: - The hCG concentration doubles every 29 to 53 hours during the first 30 days after implantation of a viable, intrauterine pregnancy; a slower rise is suggestive of an abnormal pregnancy. - Due to wide range of values hCG levels are not useful for estimating gestational age. . - Ovulation can occur as early as eight days after the first day of the last menstrual period (in such patients, hCG has been detected in urine on day 16 of the cycle. HCG has been detected in serum 6 to 8 days after the presumed day of conception. - Other pregnancy tests: - Allergic test: SC injection of liquor or pregnant urine no reaction. - Cervical mucus examinations: +ve fern. - Histidine in urine is diagnostic (decreased renal threshold). ## In the 2nd trimester (13-28 w) ### Symptoms: - Are presumptive until perception of fetal movement. - Amenorrhea (cessation of menstruation) ... - Breast symptoms increase and urinary symptoms (decrease) and morning thickness (decrease). - The new symptoms are: 1. Quickening "feeling of life" (1st perception of fetal movement). In PG 18-20 weeks. In MG 16-18 weeks. 2. Progressive abdominal enlargement. ### Signs: - Breast signs: more evident. - Skin signs: The same as the 1st trimester in addition to increased pigmentation due to increased E or MSH or ACTH. - In face: chloasma gravidarum = mask of pregnancy: a butterfly pigmentations on the cheeks and nose. It usually disappears few monthes after labour. Appear by 24th week. - In the abdomen: - Linea nigra: pigmentation in the midline below the umbilicus. - Stria gravidarum: pigmentation in the lower abdomen, flank, inner thigh, buttocks and breats. They are detected in the 2nd 12 of pregnancyand increase as pregnancy advanced. They start bluish (stira rubra) then become pale to become white (stria albicans) after delivery and persist. - PG have stria rubra only and MG had both SR and SA. - Uterine signs.: become abdominally felt. - Braxton Hick's contractions.: intermittent painless contractions detected by abdominal palpation. - Uterine soufflé may be heard → soft blowing murmur Synchronous to maternal pulse (due to blood flow through the dilated uterine arteries) also with fibroid. - Fetal signs. - Ballottement (due to movement of fetus within amniotic fluid). - Internal ballottement between 16-28 weeks. - External ballottement > 24 weeks. - Palpation of fetal parts (after 24 weeks). - Inspection or palpation of fetal movement. - Auscultation of - fetal heart sounds by Pinard stethoscope (18 wk"). - Umbilical soufflé (funic soufflé) Soft whistling sound Synchronous with the fetal heart sounds. It is due to flow of loop of cord is in a close proximity to the anterior uterine wall. ### Investigations: - Same as the 1st trimester, however, less needed as diagnosis is usually easy. X-ray may be used if no U/S : show parts of fetal skeleton at 16 w and whole skeleton at 24 w (hazardous). ## Sure signs of pregnancy - Inspection of fetal movement. - Palpation of fetal movement/parts. - Auscultation of fetal heart sounds or umbilical soufflé. - Ultrasonography or X-ray to visualize the fetus. ### Cause of false +ve urinary pregnancy test: 1. Protienuria (prevent agglutination) 2. Hematuria. 3. Tumors producing HCG 4. Hypothalamic and pituitary lesions which release LH from pituitary. 5. Drugs as penicilline and phenothiazine 6. Immunologic disease as SLE. 7. Premature menopause. 8. Excessive alkaline urine. 9. HCG injection for TTT of infertility 10. At time of ovulation. ### Causes of false negative urinary pregnancy test 1. Done early. 2. Diluted urine. 3. hCG isoforme measured is different from the hCG isoform in the sample 4. urine stored too long in room temp. 5. hook effect due to exteremly high hCG concentration (> 500, 000iu/L) ### Uses of the fetal heart sounds 1. Sure sign of pregnancy. 2. Diagnosis of presentation and position. 3. Diagnosis of twins. 4. A sign that the fetus is living. 5. Detection of fetal distress. 6. Follow up of progress of labour. ## Differential diagnosis of pregnancy: ### - Early pregnancy: 1. Causes of 2ry amenorrhea. 2. Causes of symmetrically enlarged uterus: myoma, adenomyosis, pyometra, hematometra, metropathia hemorrhagica. 3. Pelvi-abdominal swelling: ovarian swelling, tubal swelling, pelvic hematocele, full bladder. Encysted tubercular peritonitis ### - Late pregnancy: o Causes of huge abdominal swelling: fat (obesity), flatulence, full bladder, fluid (scites), myoma, ovarian cyst, huge hydronephrosis pseudopancreatic cyst. - Pseudocyesis: psychological amenorrhea (hypothalamic) in females near menopausal or fear of pregnancy. - Symptoms: amenorrhea and morning thickness (hypothalamic psychosis), abdominal enlargement (fat or gases), FK (intestinal movements) and labour pain (false spurious at expected date). - Signs: although the uterus is small, yet not or difficult to be felt due to distension but easly felt under general anesthesia. - All investigations of pregnancy are negative, however, pregnancy test may be falsely +ve due to high level of LH. ## SIGNS OF PREVIOUS CHILD BIRTH 1. Breasts become more flabby; nipples are prominent whoever breast-fed their infant; primary areolar pigmentation still remains and so also the white striae. 2. Abdominal wall is more lax and loose. There may be presence of silvery white striae and linea alba. 3. Uterine wall is less rigid and the contour of the uterus is broad and round, rather than ovoid. 4. Perineum is lax and evidence of old scarring from previous perineal laceration or episiotomy may be found. 5. Introitus is gaping and there is presence of carunculae myrtiformes. 6. Vagina is more roomy. 7. Cervix: Nulliparous cervix is conical with a round external os. In parous women, it becomes cylindrical and the external os is a transverse patulous slit and may admit the tip of the finger (Fig. 7.8). However, as a result of operative manipulation even a nulliparous cervix may be torn and resembles a multiparous cervix. ## Antenatal care ### Definition: - It is a program of preventive obstetrics that includes "Medical and psychological supervision of pregnant women so that she will be able to pass through pregnancy, labour and purperium with out complication to her or her baby". - Antenatal care is the strategy, the intranatal care is the tactics in obstetrics. One is indispensible from the other to achieve a good result. - Care should be thorough and based on individual woman's need. - The net effect is marked reduction in maternal mortality (about 1/7th) and morbidity. And reduction in perinatal mortality (about 1/5th) and morbidity. ### Objectives: 1. To try to get a healthy mother and newborn. 2. Estimation of gestational age and expected delivery date. 3. To screen the high risk cases 4. Early prevention, detection and treatment of any diseases during pregnancy. 5. Early detection of congenital fetal malformations. 6. To educate the mother about the physiology of pregnancy and labor by demonstrations, charts and diagrams (mother craft classes), so that fear is removed and psychology is improved. 7. To discuss with the couple about the place, time and mode of delivery, provisionally and care of the newborn. 8. To motivate the couple about the need of family planning and also appropriate advice to couple seeking medical termination of pregnancy. ### DRAWBACKS: (1) Trifling abnormality may be exaggerated for which unnecessary medications or The criteria of a normal pregnancy are-risky operative interference is prescribed. (2) Quality is not always maintained, specially in the developing countries with increasing population. (3) Faulty dietary advice and prescription of harmful drugs produce injurious effects on the mother and/or the baby. ### The criteria of a normal pregnancy are - delivery of a single baby in good condition at term (between 38–42), with fetal weight of 2.5 kg or more and with no maternal complication.. - As such, a normal pregnancy is a retrospective term. ### Consists of : - 1st antenatal visit (should not be deferred beyond the 2nd missed period) 1. History taking (personal, menstrual, obstetric, medical, surgical, family and current pregnancy). and Physical examination (general, abdominal and vaginal). 2. Estimation of gestational age and estimated date of delivery (by Naegele's rule, gestational calculator and sonography( if menses is irregular or not sure) 3. Investigations ◊ Routine and screening tests. ◊Other investigations according to findings. 4. Plan for a schedule for return visits. 5. Instruction and advice. 6. Reassurance. 7. Plan for delivery. ## High risk pregnancy ### Aim of ANC - Is to detect or suspect any conditions that may lead to maternal or fetal hazards i.e. to detect high-risk pregnancy. ### Definition: - Pregnancy associated with increased risk. Whether maternal or fetal. Due to certain risk factors: 1. Socioeconomic: - Socioeconomic status. - Parental occupation. - Psychological e.g. excess anxiety → preterm labor. 2. Demographic factors : - Maternal age (optimal age is between 20 - 30 yrs). - Maternal education. 3. Medical factors (disease) : - PET - Anemia - DVT - DM - Heart disease - Renal disorders - Thyroid disorders - Hepatic disorders - Respiratory disorders - Hyperemesis gravidarum ### (1) History #### 1. Personal history : - Age ..... lowest rate of MMR and PNMR is 20-26 yrs - Adolescent pregnancy - Nutritional deficiency (immaturity) - Hypertensive disorders - Dystocia (small pelvis ??) - Social and economic - Pregn. In old age (>35 yrs) - Nutritional def (1 consumption) - HIN + DM - Dystocia (osteomalacic pelvis ??) - Chromosomal → Down syndrome - ++ Abortion, IUGR, PIL - Marital status and duration of marriage (female who conceives sooner after marriage is called high fecundity and who conceives late are called low fecundity. A women with low fecundity is unlikely to conceive frequently) - Parity higher MMR and PNMR in 1) Grandmultipara (25 deliveries) → liable toφφφ - Malpresentation (lax abd. Wall) - Pregnancy - Abortion, PTL, anemia - Placenta previa (accreta) - Chronic hypertension, DM - Labor - Uterine atony (more fibrous tissue) - Obstructed labor rupture uterus - PPHge 2) Elderly PG (235 yrs) → liable to - Pregnancy - Abortion, PTL - Chromosomal anomalies (Down) - Hyperemesis gravidarum - Labor - Prolonged labor (maternal anxiety and abnormal ut. Action) - Rigid perineum → episiotomy - Higher rate of CS - Address social conditions and environment. - Occupation → certain occupations have certain risk e.g. Medical personnel infectious diseases, anesthetic gases. Others → radiation (factories). Occupation of husband may be considered in evaluation of socioeconomic status. - Special habits: - Smoking abortion, IUFD, IUGR, perinatal death, APHge. oligoamnios. - Alcohol abortion, IUFD, IUGR, perinatal death, CFMF, mental handicap. - Narcotics fetal depression and addiction. - Pets → risk of toxoplasmosis. #### 2. Menstrual history : - LMP → important for dating of pregnancy and calculation of EDD. Must know if it is average, regular, if sure of dates or not, if pregnant on period of amenorrhea, or after COC. In IVF LMP is 14 days prior to date of embrun transfers (266 days - Number - Year of birth - Place of birth - Antepartum period - Duration of preg. - Onset of delivery - Mode of delivery - Postpartum comp. - Baby - Puerperium - Prolonged period of 2" infertility - Rapid succession → liability to malnutrition - Previous uncomplicated home deliveries → reassuring - Repeated hypertension → expect recurrence - Previous DM → screen for DM - Previous APHge or PROM→ may recur - Previous PTL → suspect maternal or uterine disease - Spontaneous..... induced - Easy vaginal delivery → expect another - If previous complicated → plan for possible CS - Forceps or ventouse → suspect CPD - Cesarean section → why? - PPHge - Alive, incubated, malformed, dead - Male/female - Weight - Breast/bottle fed - Puerperal sepsis, DVT #### 4. Past history : - Medical → DM: screen, Hypertension: investigate, DVT: prophylaxis. - Surgical → previous operations. - Drugs → May affect pregnancy or fetus e.g. oral anticoag. - Previous blood transfusion - Presence of allergy to drugs. #### 5. Family history : - DM → screen.... - Hypertension → investigate - CFMF→ screen. - Twins → suspect. - Consanguinity. ### (2) Examination #### 1. General: - Decubitus: dyspnea. - Build: Overweight Average/Thin. Nutrition; Good/Average/Poor. - Height: if less than 150 cm → be aware of CPD. - Weight: if obese → be aware of D.M., HTN, macrosomia and dystocia. Normal weight gain = 12.5-13 kg Underweight women = BMI < 20 kg/m² Overweight women = BMI > 26 kg/m² Obese if BMI > 29 kg/m². - Fetus: 3500 - Maternal fat: 3500 - Blood: 1500 - Extravascular fluid: 1500 - Uterus: 1000 - Amniotic fluid: 1000 - Placenta: 500 - Breasts: 500 - Total: 12.5-13 kg - B.P: for hypertensive > 140/90 ... how ?? Disappearance of sounds (Korotkoff 5) rather than muffling of sounds (Korotkoff 4) is the best representation of diastolic pressure during pregnancy. - Pulse ...... abnormal pulse, esp. in heart disease. - Temperature - 3 colors: - Jaundice esp. in infection or PROM. pregnancy associated or induced. The sites to be noted are bulbar conjunctiva, under surface of the tongue, hard palate and skin. - Cyanosis - Pallor central or prepheral. anemia, bleeding with pregnancy. The sites to be noted are lower palpebral conjunctiva, dorsum of the tongue and nail beds. - Tongue, teeth, gums and tonsils: - Evidences of malnutriton are evident from glossitis and stomatitis. - Evidence of any source of infection in the mouth is to be eradicated. - 3 neck: - Thyroid..... Slight physiological enlargement in 50% of cases. - Vessels engorged normally († blood volume). - LNs. - 3 chest: - Lung. chest infection, PVC - Heart what are sure signs of pregnancy? - Breast normal changes in pregnancy, galactorrhea. - others: Gait (look for limping → CPD). Back. Lower limb varicosities, DVT and edema. (The sites for evidence of edema are over the medial malleolus and anterior surface of the lower 1/3rd of the tibia. The area is to be pressed with the thumb for at least 5 seconds) - 2. Abdominal: - Preliminaries: Verbal consent for examination is taken. The patient is asked to evacuate the bladder. She is then made to lie in dorsal position with the thighs slightly flexed. Abdomen is fully exposed. The examiner stands on the right side of the patient. - Inspection : - Size → huge (twins or polyhydramnios) - Shape → if pendulous in PG → contracted pelvis and whether the uterine ovoid is longitudinal or transverse or oblique - Striae, veins, scars - Supra-pubic hair → feminine / masculine - Movement with respiration - Pigmentation → linea nigra - Hernial orifices - Umbilicus - Palpation (4 Leopold's maneuver): The uterus is to be centralized if it is deviated. - Fundal level by ulnar border of the hand or in cm above S. pubis (SFH with a tape). - Fundal grip (1" Leopold's). - Cephalic or breech. How to differentiate? . Empty transverse lie. - Umbilical grip((2nd Leopold's): Hands on either side of the umbilicus to palpate one after the other. - For lie. - For back and limbs. - For amount of liquor. - Expected fetal weight. - For any local uterine swelling. - 1* pelvic grip (3rd Leopold's =Pawlick's grip). The overstretched thumb and four fingers of the right hand are placed over the lower pole of the uterus keeping the ulnar border of the palm on the upper border of the symphysis pubis. When the fingers and the thumb are approximated, the presenting part is grasped distinctly (if not engaged) and also the mobility from side to side is tested. In transverse lie, Pawlik's grip is empty. - To determine presenting part (head, breech, transverse Lie). - To determine head engagement. - 2nd pelvic grip (4th Leopold's): The examination is done facing the patient's feet. Four fingers of both the hands are placed on either side of the midline in the lower pole of the uterus and parallel to the inguinal ligament. The fingers are pressed downwards and backwards in a manner of approximation of finger tips to palpate the part occupying the lower pole of the uterus (presentation). If it is head, the characteristics to note are: (1) precise presenting arva (2) attitude and (3) engagement. To determine degree of flexion of the head e.g. extended in face. - Auscultation: point varies according to fetal position....tic-tac rhythm ( what is the FDD) - FHS can be used for - Sure sign of pregnancy - Fetal life/distress - Twins ... Arnoux sign - Progress in labor - Position and presentation - Different sites for FHS - Normal (OA) → between umbilicus and ASIS - O.P. at ASIS - Face MA at < umbilicus, MP at flanks - Breech complete > umb, frank < umb - Transverse lie at one side - 3. Local: Done only at: - In early pregnancy for - Diagnosis (Hegar's sign, Ballottement) - In some complications e.g. ectopic preg. - Any associated pathology e.g. prolapse. - To take cervico-vaginal smear - In late pregnancy for: - To diagnosis labor - To assess pelvis for CPD - Any associated Pathology. - Steps of vaginal examination: * The patient must empty her bladder prior to examination and placed in the dorsal position with the thighs flexed along with the buttocks placed on the footend of the table. Hands are washed with soap and a sterile glove is put on the examining hand (usually right). * Inspection: By separating the labia-using the left two fingers (thumb and Index), the character of the vaginal discharge, if any, is noted. Presence of cystocele or uterine prolapse or rectocele is to be elicited. * Speculum examination: done prior to bimanual examination for exfoliative cytology or vaginal swab is to be taken. A bivalve speculum is used. The cervix and the vault of the vagina are inspected with the help of good light source placed behind. * Bimanual: Two fingers (index and middle) of the right hand are introduced deep into the vagina while separating the labia by left hand. The left hand is now placed suprapubically. Gentle and systematic examination are to be done to note: 1. Cervix: Consistency, direction and any pathology. 2. Uterus: Size, shape, position and consistency. 3. Adnexae: `Any mass felt through the fornix. ## Abortion _(Miscarriage = early preg. Loss = early preg. failure)_ ### Definition: - Termination / interruption of pregnancy or the attempt of uterus to expel the product of conception before period of fetal viability (gestational age at which fetus is capable of extra-uterine existence). i.e. (20-24 weeks = 500 gm) in developed countries. or (28 weeks = 1.000 gm) in developing countries. - Miscarriage is a non-professional term used in pregnancy loss. - It is appropriate that miscarriage and abortion are terms used interchangeably in a medical context. But because popular use of abortion by lay persons implies a deliberate intact pregnancy termination, many prefer miscarriage for spontaneous fetal loss. ### Clinical types: #### Spontaneous - Threatened - Missed - Septic - Inevitable - Complete - Incomplete - Cervical - If recurrent > 3 times → Habitual #### Induced - Medical indication - Therapeutic - Non-medical indication - Elective (voluntary) - Criminal - NB: - Biochemical preg. Loss : failed pregnancy not located on scan. - Empty sac: sac with absent or minimal structure. - Early preg. Loss: empty sac or sac with dead fetus < 12 weeks. - Late pregnancy loss: loss of FHA > 12 weeks. - Delayed miscarriage = silent or missed miscarriage = as early pregnancy loss. - Pregnancy of unknown location: no identifiable pregnancy (intra or extra uterine) on scan with +ve HCG. - IU pregnancy of uncertain viability: TV US shows IU GS with no embryonic heart beats and no findings of definite pregnancy failure. ### Complications of miscarriage: - Risk from abortion itself: - Hemorrhage, shock due to hemorrhage. pain. - Severe cramping (due to blood clots), - Traumatic injury of bladder or intestine. - Infection. - Rh isoimmunization. - Infertility. - DIC. - Increased risk of breast cancer (late in pregnancy breast epithelial cells differentiate and cease to proliferate which have protective effect of the 1" term pregnancy). - Psychological impact. - Risk from anaethesia. - Risk from surgical interference: bleeding tear, perforation, infection. ### (A) Spontaneous abortion ### Definition: - a abortion that occur accidentally either once or twice. - It is the most common complication of pregnancy. ### Incidence: - 10-20%... More than 80% in the 1st trimester esp. in the 3rd month (due to same and in "P" from C.L.., while placenta still not fully developed yet, the window gap). - The incidence decreases after the 8th week to about 10% &, and drop to 3% if a viable fetus has been recognized on US. - True incidence may be much more (50-80%) due to : 1. Subclinical abortion (very early before patient recognition). 2. Notification is not done in all cases (especially illegal). ### Incidence increases with ": 1. Increase in maternal and paternal age. 2. Balanced translocation carrier 3. Previous abortions or stillbirth or CFMF. 4. Extreme of weight. 5. Increased gravidity and parity. 6. Low SE status. 7. Prolonged time to conception. 8. Heavy smoking.alcohol and cocaine. - Folate ### Etiology: #### A) Fetal - malformed fetus - - The commonest cause (50-60%) of 1st trimesteric abortion. - Chromosomal abnormalities → - Aneuploidy: trisomy (50%), polyploidy (25%), monosomy X (15%). - Structural abnormalities e.g. translocation, deletion, inversion, ring formation, mosaic, double trisomy, etc. - IUFD, multiple pregnancy, acute hydraminos, hydatidiform mole - Blighted ovum (anembryonic sac): - Is a type of CFMF in which fetal tissue is replaced by homogenous structure less sac. Due to severe chromosomal abnormalities non development of the inner cell mass. - There may be a yolk sac but fetal pole note seen. - Suspected if: No yolk sac when GS > 10 mm, or when no fetal pole when the GS 18-20 mm. - Evidence supporting the diagnosis: - Clinical history of more advanced GA than what is seen - Abnormalities of GS. Bleeding and Cramps #### B) Maternal #### 1) Local - fresh fetus - 1) Cervix → Patulous internal os (midtrimesteric abortion) - 2) Uterus → - Congenital malformation: septum, hypoplasia or bicornuate. → mid-trimesteric abortion. Causes of fetal loss are: - Reduced intrauterine volume and expansile property of the uterus - Reduced placental vascularity when implanted on the septum - Increased uterine irritability and contractility. - Sub-mucous fibroid as above. - Asherman's $. interfere with implantation, placentation and growth. - Limited distension: fixed RVF (14-16 w fixed time of abortion). - Overdistension: acute polyhdramnios and twins. #### 2) General: - macerated fetus(6-24 h) - 1. Maternal disease as HTN, chr. Renal disease severe anemia, starvation - 2. Endocrinal (25%). - C Luteum or placental insufficiency → progesterone. - PCO → ↑ androgens (premature luteolysis by high LH). - Other hormonal dist. → DM, hypo or hyper-thyroidism. - 3.Infections (STORCH EB): (5%): Any organism causing high fever e.g. typhoid fever - Bacteria → Syphilis, mycoplasma, Chlamydia, listeria. - Viruses → acute viral infection, rubella, CMV. - Protozoa → toxoplasma ?!, malaria - Mechanism of abortion in infections: - Organism crosses the placenta and affects the fetus. - Fever releases PG and stimulation of contraction. - Malaria can obstruct the placental blood vessels. - 4.Immunological: (5-10%) - i. Autoimmune → SLE, APS. - These antibodies cause rejection of early pregnancy. - Antibodies responsible are: Antinuclear antibodies (ANAs): Anti-DNA antibodies: Antiphospholipid antibodies. - Pathology: Spiral artery and placental intervillous thrombosis, placental infarction and fetal hypoxia. - ii. Alloimmune → Rh isoimmunization. Rh incompatibility is a rare cause of death of the fetus before the 28th week - iii. HLA sharing (due to lack of blocking Abies)→fetal rejection. - iv. Blood group incompatibility: Incompatible ABO group may be responsible for early pregnancy wastage and often recurrent. Couple with group 'A' husband and group "O' wife have got higher incidence of abortion. - 5.Drugs: cytotoxic or chemicals (heavy metals) or Radiation. - The main complications of prenatal exposure to irradiation are:...X-ray exposure up to 10 rad is of little risk. - Radiation during preimplantation period → death of rapidly developing blastomere. - Radiation during period of organogenesis (10-42 day) → congenital anomalies e.g. CNS (microcephaly), eyes and CVS will be affected more than other