Welcome to weekly

clinical
presentation of
Department of
Gynaecology and
Obstetrics.

Presented by :
Dr. Akash
Dr. Galib
 TOPIC :

Missed Abortion
 PARTICULARS OF THE PATIENT

• NAME – Mst Mallika Khatun

• AGE – 32 years
• SEX - Female
• RELIGION – Islam
• OCCUPATION – Homemaker
• MARITAL STATUS – Married for 10 years
• ADDRESS – Khukni,Sirajganj.
• DATE OF ADMISSION – 15.11.24 AT 09.30 AM
• DATE EXAMINATION – 15.11.24 AT 10.30 AM
 CHIEF COMPLAINTS

1. amenorrhea for 13+ weeks .

2. Per vaginal bleeding for 12 days.

 HISTORY OF PRESENT ILLNESS

According to the statement of the patient, she is

ammenorrhic for 13+ weeks.Which was uneventful
untill 12 days back when she noticed discharge coming
from vagina. Discharge was continuous ,bloody in nature
. She did not experience any fever, chill or burning
sensation of micturition. She did not give any history of
cough or respiratory distress. Her bowel and bladder
habits are normal. With all these complaints she got
admitted in this hospital for better management.
MENSTRUAL HISTORY –

She had menarche at the age of 13 years, her menstrual cycle

was regular , menstrual periods lasted for 4-5 days and the
menstrual flow was regular in amount. LMP-8.8.24 ; EDD-
15.05.25

OBSTETRIC HISTORY -
She has been married for 10 years with 3 children all of them born via
normal vaginal delivery.
 HISTORY OF PAST ILLNESS

HISTORY OF PAST ILLNESS:

Patient is non diabetic,
normotensive, non-asthmatic and
has no history of any other disease.
• FAMILY HISTORY – All her family members are in good
health

• History of allergy – Nothing contributory

• Drug history- She took iron and calcium
supplementation irregularly.
• Immunization history –
She has been fully immunized according to the EPI
schedule
GENERAL
EXAMINATION
• Appearance : Ill looking
• Intelligence: Average
• Co-operation: Co-operative
• Body Built: Average
• Decubitus: On choice
• Nutritional Status: Below
average
• Anemia: Present
• Cyanosis: Absent
• Jaundice: Absent
• Koilonychia: Absent
• Leukonychia: Absent
• Edema: Absent
• Dehydration: Present
• Pulse: 78 bpm
• Blood Pressure:110/80 mm
• Respiration:18 breaths/min
• Temperature:98o F
• Lymph Nodes: Not
Palpable
• Thyroid gland: Not
enlarged
• Breast: Normal.
• Hair Distribution: Normal
• Skin Condition: Normal
 SYSTEMIC EXAMINATION

Per Abdominal Examination:

On Inspection- Abdomen is symmetrically
enlarged. Umbilicus is centrally placed.
On Palpation- Abdomen is soft & non-tender.
SFH is 12 cm which corresponds with gestational
age . No Palpable contraction or fetal movement.
On Percussion- Not done.
On Auscultation- Bowel Sound Present
P/V Examination –
VAGINAL EXAMINATION :
Inspection – Vulva is healthy

Per speculum examination :

Cervix closed.
 SALIENT FEATURES

My Patient, Mst. Mallika Khatun, 32 years old, non-diabetic,

normotensive and non asthmatic, hailing from
Khukni,Sirajganj got admitted in this hospital with the
complaints of amenorrhea for 13+ weeks with per vaginal
discharge for last 12 days .Discharge was
continuous ,bloody in nature & profuse in amount. She did
not experience any fever, chill or burning sensation of
micturition. She did not give any history of cough or
respiratory distress. Her bowel and bladder habits are
normal.
On general examination, her appearance is ill-looking, body
built is average. She is anaemic, anicteric,non-
odematous,non-dehydrated and there is no lymph node
On Per Abdominal Examination: Abdomen is soft, non-tender &
symmetrically enlarged,
On per vaginal examination we found: cervix was closed.

Other systemic examinations reveal no abnormalities.

Provisional Diagnosis
Missed Abortion

Plan
Expulsion of products of
conception
INVESTIGATIONS FOR CONFIRMING DIAGNOSIS:

-CBC with ESR

-USG of pregnancy
profile
MANAGEMENT OF OUR PATIENT

Our patient was admitted on 15 th

November 2024
Diet : Normal
Inj Cipro 200 mg
1 bottle I/V ….stat and BD
Inj Biozyl 400 mg
1 bottle I/V ….stat and TDS
Inj Pronex 40 mg
1 vial I/V ….stat and bd
M-M kit
Mefepristone 1 tab per oral stat…
Then, after 24 hours
Misoprostol 200 mcg
e Gave Mefepristone….1 tab at 1.50 pm on 15.11.24

hen
tab Misoprostol 200 mcg was given buccally
ext day at 1.50 PM

ithin next 6 hours, Spontaneous expulsion of product

conseption occurred .
 Discharge

Patient was discharged on

17.11.24

On discharge Medications:
1Ciprozid Ds
2. Biozyl 400
3.Pronex 20mg
4.Cytomis 200 mcg
5.Foly 5 mg
CASE DISCUSSION

Missed Abortion
DEFINITION: Abortion is the expulsion or
extraction from its mother of an embryo or fetus
weighing 500 g or less when it is not capable of
independent survival.

The word abortion is the recommended

terminology for spontaneous miscarriage.
 INCIDENCE:

10–20% of all clinical pregnancies end in

miscarriage

About 75% miscarriages occur before the 16th

week and of these about 80% occur before the
12th week of pregnancy.
ETIOLOGY

- Genetic : Autosomal trisomy is

the most common (50%)
- Endocrine and metabolic: 10-
15% cases
Ex-Luteal phase defect
(LPD),DM
- Anatomic
- Infection
-Immunological
- Thrombophilias
-Environmental
- Others
COMMON CAUSES OF MISCARRIAGE

First trimester:
(1) Genetic factors (50%),
(2) Endocrine disorders (LPD, thyroid
abnormalities, diabetes),
(3) Immunological disorders (autoimmune and
alloimmune),
(4) Infection, and
(5) Unexplained.
 COMMON CAUSES OF MISCARRIAGE

Second trimester:
(1)Anatomic abnormalities—
(a) Cervical incompetence (congenital or acquired),
(b) Müllerian fusion defects (bicornuate uterus,
septate uterus),
(c) Uterine synechiae, and
(d) Uterine fibroid.

(2) Maternal medical illness.

(3) Unexplained.
MECHANISM OF MISCARRIAGE:
In the early weeks, death of the ovum occurs
first, followed by its expulsion. In the later
weeks, maternal environmental factors are
involved leading to expulsion of the fetus which
may have signs of life but is too small to
survive.

- Before 8 weeks: The ovum, surrounded by the

villi with the decidual coverings, is expelled out
intact. Sometimes, the external os fails to dilate
so that the entire mass is accommodated in the
dilated cervical canal and is called cervical
Between 8 and 14 weeks: Expulsion
of the fetus commonly occurs
leaving behind the placenta and the
membranes. A part of it may be
partially separated with brisk
hemorrhage or remains totally
attached to the uterine wall
Beyond 14th week: The process
of expulsion is similar to that
of a ‘mini labor’. The fetus is
expelled first followed by
expulsion of the placenta after
a varying interval.
Classification
MISSED MISCARRIAGE

DEFINITION: When the fetus is dead and

retained inside the uterus for a variable
period, it is called missed miscarriage or
early fetal demise.
PATHOLOGY: The causes of prolonged retention of the
dead fetus in the uterus are not clear. Beyond 12
weeks, the retained fetus becomes macerated or
mummified. The liquor amni gets absorbed and the
placenta becomes pale, thin and may be adherent.
Before 12weeks, the pathological process differs when
the ovum is more or less completely surrounded by the
chorionic villi
CLINICAL FEATURES: The patient usually presents
with features of threatened miscarriage followed by:
(1) Persistence of brownish vaginal discharge.
(2) Subsidence of pregnancy symptoms.
(3) Retrogression of breast changes.
(4) Cessation of uterine growth which in fact becomes
smaller in size.
(5) Non-audibility of the fetal heart
sound even with Doppler ultrasound.
(6) Cervix feels firm.
(7) Immunological test for pregnancy
becomes negative.
(8) Real-time ultrasonography reveals an
empty sac early in the pregnancy or the
absence of fetal cardiac motion and fetal
movements.
MANAGEMENT

- Expectant
- Medical
- Surgical
 Uterus is less than 12 weeks:
(i) Expectant management—Many women expel the
conceptus spontaneously
(ii) Medical management: Prostaglandin E1
(misoprostol) 800 µg vaginally in the posterior fornix is
given and repeated after 24 hours if needed. Expulsion
usually occurs within 48 hours.
(iii) Suction evacuation or dilatation and evacuation is
done either as a definitive treatment or it can be done
when the medical method fails. The risk of damage to
the uterine walls and brisk hemorrhage during the
operation should be kept in mind.
Uterus more than 12 weeks:
Induction is done by the following methods: Prostaglandins are
more effective than oxytocin in such cases. The methods used
are:
 Prostaglandin E1 analog (misoprostol) 200 µg tablet is
inserted into the posterior vaginal fornix every 4 hours for a
maximum of 5 such.

 Oxytocin—10–20 units of oxytocin in 500 mL of normal saline

at 30 drops/min is started. If fails, escalating dose of oxytocin to
the maximum of 200 mlU/min may be used with monitoring
Many patients need surgical evacuation following
medical treatment. Following medical treatment,
ultrasonography should be done to document empty
uterine cavity. Otherwise evacuation of the retained
products of conception (ERPC) should be done.

-Dilatation and evacuation is done once the cervix

becomes soft with use of PGE1. Otherwise cervical
canal is dilated using the mechanical dilators or by
laminaria tent. Evacuation of the uterine cavity is done
thereafter slowly.
COMPLICATIONS: Blood coagulation disorders
are less likely to occur in missed miscarriage
1. Psychological upset
2. Infection
3. During labour- Uterine inertia, retained
placenta and postpartum hemorrhage.
ventive Measures-

ure proper antenatal care

ly recognition and management of high risk pregnancie

per surgical technique to prevent trauma.

of prophylactic antibiotics for septic abortions.

Key Learning Points-

Accurate diagnosis
Misoprostol
Support
Although the world is full of
suffering, it’s also full of
overcoming