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MISCARRIAGE - SPONTANEOUS

Spontaneous miscarriage is the loss of fetus before 20 weeks of gestation or delivery of a fetus weighing <500 g, in the absence of elective medical or surgical measures to terminate pregnancy.
Early loss is considered if it occurred before menstrual week 12 while late loss refers to those that occurred from menstrual week 12-20.
It is also known as spontaneous abortion, spontaneous pregnancy loss or early pregnancy failure.

Surgical Intervention

  • Surgical management following treatment for early pregnancy loss is not required in asymptomatic patients with thickened endometrial stripe 
Surgical Uterine Evacuation
  • Offered to women who have heavy bleeding and or severe pain, unstable vital signs, when gestational trophoblastic disease or retained early pregnancy tissue is suspected, if with infected intrauterine tissue, or depending on patient’s preference
    • Retained tissue increases the risk of infection and hemorrhage
  • Dilatation and curettage is the traditional treatment for spontaneous miscarriage
  • May also be performed using suction evacuation which is associated with less blood loss, less pain and shorter duration of the procedure
    • Manual vacuum aspiration technique may be performed in the clinic for uterine evacuation in patients with missed and incomplete miscarriage
  • Delay surgery for 12 hours to allow antibiotic administration if infection is suspected
    • Patients with incomplete miscarriage may be given preoperative antibiotics at least 1 hour prior to uterine evacuation  
  • Patients undergoing surgical evacuation may be given an oxytocic to bring about uterine evacuation and to prevent bleeding from the procedure 
  • Possible complications: Uterine perforation, cervical tears, intra-abdominal trauma, hemorrhage, possible blood transfusion, or infection
    • Blood product replacement must be available in cases of bleeding due to coagulation disorders

Cervical Cerclage

  • An ultrasound-indicated cerclage should be offered to women with singleton pregnancy and a history of one second trimester miscarriage due to cervical factors if a cervical length of ≤25 mm is detected by transvaginal scan before 24 weeks of gestation
  • May also be performed in patients with second trimester recurrent miscarriages due to insufficient, incompetent or weak cervix
  • Associated with hazards secondary to surgery and risk of stimulating uterine contractions
Hysteroscopic Surgery
  • May be done in patients with septate uterus
    • Repair of bicornuate or unicornuate uteri, which have good obstetrical outcomes, is not recommended due to invasiveness of the procedure and higher complication risk
  • There is lack of conclusive evidence that surgical treatment in patients with Asherman syndrome/intrauterine synechiae, uterine fibroids, or uterine polyps will reduce the risk of pregnancy loss but should still be considered in patients with significant uterine cavity defects
    • IVF with transfer of embryos may be considered in patients with irreparable anatomic uterine abnormalities and recurrent pregnancy loss
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Endometriosis is a common gynaecological condition affecting about 6–10% of women of reproductive age and can be a debilitating disease. It is the second most common reason for surgery in premenopausal patients. It is defined as the presence of endometrial-like tissue outside the uterine cavity, leading to a chronic inflammatory reaction. The exact aetiology is unknown, but the retrograde menstruation model is the most widely accepted theory explaining the development of pelvic endometriosis. According to this model, menstrual blood containing endometrial fragments passes through the fallopian tubes into the pelvic cavity, resulting in the formation of peritoneal endometrial deposits. There are three distinctive pathological types of pelvic endometriosis: superficial peritoneal implants, ovarian endometriomas, and deep infiltrating nodular lesions. The extent of the disease is very variable and often does not correlate with the severity of symptoms. Although it can sometimes be asymptomatic (in about 20% of cases), endometriosis is frequently associated with severe pain and infertility. Several management options exist for endometriosis and the choice depends on several factors such as age, fertility, severity of the symptoms, and extent of the disease. This review presents three different cases of endometriosis with different complexities and presentations. The diagnosis and various medical and surgical treatment options available to the clinician will be discussed.