Miscarriage

This refers to a pregnancy that fails to grow, either because no embryo is formed (blighted ovum) or there is no cardiac activity (no heartbeat). Loss of a pregnancy prior to the 23rd completed week is generally considered a miscarriage. However, some guidelines use the cut-off of 20 to 22 weeks to define it.

How common is it?

It happens in about 20% of pregnancies. Majority occurs in the first trimester. It can occur so early in some pregnancies that the woman may be unaware that she is pregnant.

Causes

During the first trimester (first 12 weeks of pregnancy), the possible causes are:

  • Genetic (chromosome abnormalities such as Down’s syndrome) or structural abnormalities of the fetus.
  • Uterine abnormalities that prevent the fertilized egg from growing normally.
    Smoking.
  • Severe stress (nutritional; psychological).
  • Use of substances that can harm the fetus (cocaine, smoking, anti-cancer drugs).
  • Infections, especially viral infections (rubella or influenza).
  • Trauma
  • Severe medical conditions (uncontrolled or complicated diabetes mellitus or hypertension, autoimmune disease).

Older women (above age of 35) will have a slightly higher rate of miscarriage.

Symptoms and signs

Some women may not have any symptoms at all and only found out during the early routine ultrasound scan of the pregnancy. Women with miscarriage may have the following presentation:

  • Lower abdominal pain, due to uterine cramps, with increasing intensity over time
  • Vaginal bleeding, from slight to heavy
  • Passing out products of the pregnancy through the vagina
  • Feeling weak, faint, slowed heart rate or low blood pressure may be present due to excessive bleeding or the presence of the product of the pregnancy at the cervix

Possible complications

  • Uterine infection – with fever, chills, abnormal vaginal discharge, and body ache
  • Excessive bleeding from the vagina
  • Incomplete‖ miscarriage, in which some placenta or fetal tissue remains in the uterus and may requires

Diagnosis

This is made by clinical history, positive pregnancy test and confirmed by ultrasound scan of the pregnancy.

 

 

 

Investigations

Ultrasound scan of the uterus is necessary to look for the viable pregnancy. Laboratory blood studies may be needed for:

  • Blood group and Rhesus status
  • Pregnancy hormone level measurement – this is performed only if the diagnosis is uncertain and more than one measurement is usually done to evaluate whether the pregnancy is progressing normally

Treatment

  • If a fetal heartbeat can be seen, this means that there is a 95 % chance that the pregnancy will proceed normally. This is labelled as a threatened miscarriage (vaginal bleeding, without any pain). You should follow your doctor advice. Rest at home is often enough to stabilize the pregnancy
  • Avoid sexual intercourse, exercise, strenuous activity or traveling until the bleeding has stopped or the outcome is known
  • Once a diagnosis is made, women can opt to wait and see if the pregnancy tissue will be expelled spontaneously or go straight for suction evacuation. If the spontaneous expulsion is complete, then no further action is required. If there is still residual pregnancy tissue seen in the uterus via the ultrasound scan, then suction evacuation is advisable
  • Following a miscarriage, expect a small amount of vaginal bleeding or spotting for 8 to10 days. Use sanitary napkins—not tampons to absorb blood or drainage
  • Wait through 2 or 3 normal menstrual cycles before attempting to become pregnant
  • After a miscarriage, antibiotics is not routinely given. It is only given if there is a risk of infection
  • If the woman is Rhesus negative and her husband is Rhesus positive, an injection consisting of an anti-D (immune globulin) is given
  • After a miscarriage, reduce activity and rest often during the next 48 to 72 hours. There is no special dietary restriction. Eat a normal and balanced diet. Feelings of loss and grief are common. Feelings of guilt may also be present. Discuss this with your health care provider. Be open about it. If these persist, seek professional psychological help
  • Avoid sexual intercourse until bleeding has stopped. Please discuss contraception with your doctor prior to resuming intercourse

Prevention

Most miscarriages cannot be totally prevented because the developing fetus is not normal. However, you should:

  • Aim for a healthy body weight before and during pregnancy
  • Ensure you are fully vaccinated for certain infectious disease prior to pregnancy
  • Obtain regular medical check-ups during pregnancy
  • Ensure that any medical illness that is currently present should be under good control or in remission. Women with medical disorders and currently on medications should discuss with their doctor regarding pregnancy, so that the doctor can adjust and chose the appropriate medications that are safe to be taken before and during pregnancy
  • Eat a normal, well balanced diet
  • Do not drink alcohol, smoke cigarettes, or use recreational drugs prior to and during pregnancy
  • Do not use any medications, including non-prescription drugs, without proper medical advice

See your doctor immediately if there is:

  • Bleeding and cramps which worsen during a threatened miscarriage or you pass tissue
  • Presence of infection, including fever, headache, muscle aches, dizziness or a general ill feeling during a threatened miscarriage or following a miscarriage
  • Increasing nausea and vomiting, short of breath or feel faint
  • Bleeding (other than vaginal) or unexplained bruising
  • Prolonged (more than 2 weeks) or very heavy vaginal bleeding (presence of clots or need to change pads frequently) following a miscarriage
  • Persistent and abnormal vaginal discharge.

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Combined oral contraceptives (COC) pills

The reason for practicing contraception (or birth control) is to prevent an unplanned pregnancy. Most methods of contraception enable sexually active couples to temporarily avoid pregnancy. Permanent birth control is accomplished through sterilization. There are many types of birth control methods that are currently available. There is no perfect method at the moment. Each has its own advantages and disadvantages. Be sure you know and understand the different types of birth control available to you, the risks and benefits of each, and any side effects, so that you can make an informed choice.

Combined oral contraceptives (COCs) pills prevent ovulation (release of a ripened egg from the ovary) and therefore make pregnancy unlikely. It also thickens the mucus in the cervix, making it difficult for sperm to reach an egg. The inner lining of the womb thins out during pills taking, so it is less likely to accept a fertilized egg.

Effectiveness

The effectiveness is dependent on whether the pills are taken correctly, without missing a significant number of pills. If the pills are taken according to instructions (excellent compliance), then it is almost 99 % effective. This means that less than one woman in 100 using this method for a year will get pregnant. However, in a general population, the effectiveness is slightly lower at about 91%.

Advantages

  • Highly effective, with lowest failure rate of any non-permanent method if all pills are taken as prescribed.
  • Periods become more regular.
  • Less painful menstrual periods (reduction in period pain)
  • Decrease in the amount of menstrual bleeding in most women.
  • May help with premenstrual symptoms
  • Less likelihood of anaemia.
  • COCs use is associated with a significant reduction in risk of endometrial and ovarian cancer that increases with duration of use and persists for many years after stopping the pills.
  • Decrease in incidence of pelvic inflammatory disease.
  • Use of COCs is associated with a reduced risk of colorectal cancer
  • can be used for management of acne, hirsutism and menstrual irregularities associated with polycystic ovary syndrome (PCOS).
  • May reduce the risk of fibroids, ovarian cysts and (non-cancerous) breast disease

Disadvantages

  • Not suitable for women who are smokers and above age of 35.
  • Will not protect against sexually transmitted infections (STIs). A form of barrier protection will need to be used in those at risk.
  • Not suitable for those who are forgetful to take the pills on a regular basis.
  • May not be suitable for some women due to side effects.

Side effects and risks

  • There may be side effects from the pill. Many of these are not common and even when there are, the frequency will decrease in severity after 1 to 2 months. Most patients experience no side effects at all.
  • Common mild or minor side effect may include headache, nausea, fluid retention, breast fullness or tenderness and mood changes. If these do not stop within a few months, changing the type of pill formulation or brand may help.
  • Breakthrough bleeding (unexpected bleeding on pill taking days) and spotting is common in the first few months of pill use and will usually subside after a few cycles.
  • Serious side effects are stroke, heart attack and blood clots in the calf veins. Fortunately, these are exceedingly rare in healthy and non-smoking women.
  • Long term risks – current use of COCs for more than 5 years is associated with a small increased risk of cervical cancer; risk reduces over time after stopping COCs and is no longer increased by about 10 years after stopping. Therefore, regular cervical cancer screening via Thin Prep is important. Recently, there is data to suggest that there is slight increase in breast cancer risk in long term users. However, the net increase is still exceedingly small and not a concern if you have gone through a thorough clinical examination and no contra-indication to start the pills. It is also reassuring to note that there is a large epidemiological data to suggest an overall net reduction of all types of cancer in long term pill users as well.

Instructions – When and How to start?

There are many conditions that might make the pill unsuitable for you. Your doctor will take a thorough medical history and perform a physical examination prior to prescribing combined oral contraceptives. If any of the conditions are present that makes the pills unsuitable, another form of birth control will be recommended.

When?

  • During menses – starts from day 1 onwards but not later than day 5. You will be protected from pregnancy immediately.
  • Starts immediately upon switching from other methods such as injectables type, implants or intrauterine device. You will be protected from pregnancy immediately.
  • Can start from 6 weeks onwards following delivery if you are not breastfeeding. If you are still breast feeding, please discuss with your doctor and you may want to consider other options
  • Immediately after miscarriage or ectopic pregnancy

Pills Formulation

COC pills contain low doses of 2 hormones—a synthetic progestogen and oestrogen. These are similar to the natural hormones (progesterone and oestrogen) released from the ovaries in a woman’s body. Different brands contain different combinations and dosages of oestrogen and progestogen. The older progestogens COC pills (containing either levonorgestrel or norethisterone) are the safest and it is recommended as the first line choice for contraception. The newer progestogens are more suited to those women with gynaecological or dermatological disorders.

Some brands come in a 21 tablets strip while others may contain 28 days tablets. In those with 28 tablets, there will be either 4 or 7 days of dummy or placebo pills (comes in different colors from the hormone pills) that does not contain any hormone at all. For the 28 pills pack, you need to start a new pack immediately after completing the current pack, with no omission of the pills.

Since there are so any different formulations and brands, your doctor will assess and recommend a formulation of COC pills that best suits your reproductive and gynaecological needs.

How?

To start the first pack:

  • Count the first sign of your menstrual bleeding as day 1. On either day 1, 2 or 3, begin taking 1 pill each day. Pick a time that suits you and stick to it as your routine. The effect of pregnancy prevention by the pills is immediate. However, if you start the pill only after the 5th day, additional contraceptive protection (e.g using condoms) is required for 7 days before the pills is able to offer the pregnancy prevention effect.
  • For those who start following delivery, miscarriage, ectopic pregnancy or changing from another method, first day of pill taking will be Day 1
  • You can start anytime in your menstrual cycle, provided you are sure you are not pregnant or there was no prior unprotected sex.
  • Continue taking the pills for 21 days. Use a method to remind you daily to take the pill. Set up an alarm daily in your mobile device and swallow the pill immediately when the alarm goes off. Fluid is not necessary, and you can swallow it with saliva to ensure that you do not forget.
  • Stop taking the pills for 7 days once you finish the 21 days pack (this is called the pill free interval). You will have withdrawal bleeding (similar to menses) a few days after stopping the pills. Begin taking pills again for the next cycle after these 7 days of rest, no matter when menstrual bleeding begins or ends. You should still start even though you are still menstruating on the day you are supposed to start a new pack.
  • If for whatever reasons you want to delay your period, you can continue to the next pack without stopping (no pill free interval). There will not be any withdrawal bleeding as long as the pills are taken. You can take 2 or 3 packs continuously without a break. There are no additional risks.
  • If you do not have menses during the pill free interval, do not start the next pack. See your doctor first for further evaluation. This can occur in a small minority of women and can be normal. However, pregnancy needs to be excluded first.
  • For those brands that comes in a 28 pills pack, you should start a new pack once you completed the current pack. There is no need to break for 7 days, unlike the 21 days pills pack.
  • If you forget to take the pill/pills, please refer to the patient information leaflet on missed COCs pills.

Factors that affect effectiveness of COC

  • Effectiveness may be reduced in women who have had bariatric surgery
  • Women using enzyme-inducing drugs

Most broad-spectrum antibiotics do not affect COC and no additional contraceptive precaution is required unless the antibiotics (and/or illness) cause vomiting or severe diarrhoea. If vomiting occurs within 3 hours of taking COC, take another pill. If severe diarrhoea occurs for >24 hours, you should consider this as missed pills. Refer to pamphlet on missed pills for advice.

See your doctor immediately if there is:

  • Increased frequency, amount, or duration of menstrual bleeding.
  • Painful during intercourse or bleeding afterward.
  • Pain and swelling in the calf of your leg, or any unusual leg pains.
  • Severe chest pain or shortness of breath.
  • Blood pressure goes up.
  • Symptoms of gallbladder disease: upper abdominal pain, fever, jaundice,
  • Any signs or symptoms that make you suspect pregnancy.
  • See flashing lights or blurred images, or your ability to see decreases.
  • Severe, throbbing headache.

Follow-up
You should continue follow up as per recommendation to review any side effects related to COC pills, monitor your blood pressure, continue the routine cervical cancer screening, and to discuss any change in your reproductive needs.

 

 

 

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Cervical Intraepithelial Neoplasia (CIN)

Cervical intraepithelial neoplasia (or CIN) refers to the presence of abnormal cells seen on the cervical cytology smear. These abnormal cells are obtained from the lining of the outer cervix and can range from mild to severe changes. A diagnosis of CIN changes is not cancer. However, the severe form of dysplasia can be considered a precancerous condition and may eventually progress to cancer in several years if not treated.

The cervical cytology smear was previously referred to as Pap smear. Currently, the newer cervical cancer screening uses a liquid based cytology and the commonest one used are: Thin Prep or Sure-Path. These are better and more accurate compared to the conventional Pap smear test.

Classification of CIN 

CIN is divided into 3 groups, which is CIN I, II and III. This is based on the severity of the cell changes (dysplasia). CIN III refers to abnormal cells that involve the whole thickness of the surface lining of the outer cervix and has the highest chance of further progression to cancer.

Read moreCervical Intraepithelial Neoplasia (CIN)

Endometriosis

Endometriosis is a condition whereby tissues from the lining (endometrium) of the uterus becomes implanted in areas outside the uterus such as the outer surface of the uterus, the fallopian tubes or the ovaries. Rarely, the endometrial tissue may spread beyond the reproductive organs and pelvic region.

In a normal menstrual cycle, the endometrial tissues respond to cyclical female hormones and becomes progressively thicker and will eventually shed each month if the woman is not pregnant. It is discharged as menstrual flow at the end of each cycle. In endometriosis, this shedding and bleeding will occur outside the uterus as well, causing significant pain. Recurrent bleeding and healing cycle will eventually cause scar tissue formation and destruction of pelvic structures. The excessive blood will accumulate over a period of time and eventually forms a cyst in the ovary (called endometriotic cyst or endometrioma).  The 4 stages (classification) of endometriosis (minimal, mild, moderate or severe) are used to describe the location and the severity of the disorder.

Read moreEndometriosis

Vaccination and Pregnancy

It is important to ensure that you are adequately protected against certain infectious diseases during your pregnancy. In the community, people are protected against infectious disease because they have had the infections before and developed immunity to it. Some are protected against chickenpox, for example, because they had it when they were kids, causing their immune systems to make antibodies to the chickenpox virus. However, over time the antibody level may decline to a very low levels and the person may lose the protection against that particular infectious agent.

Alternatively, many in the community have been vaccinated and developed antibodies to that specific infectious agent contained in the vaccine. Many countries now have an immunization schedule that tries to cover as many infectious disease as possible, hoping to reduce the disease burden to the community and the health care system.

Read moreVaccination and Pregnancy

Laparoscopy in Gynaecology

Laparoscopy is a procedure that allows visual examination and surgical treatments of the pelvic and abdominal organs pathology. The procedure is performed with a laparoscope, which is a small lighted telescope.

INDICATIONS – When is it necessary

  • Evaluation and treatment of women who has difficulty in conceiving.
  • Evaluation and treatment of known or suspected endometriosis.
  • Pelvic infections
  • Removal of diseased fallopian tubes, ovaries, cysts or uterus
  • Undiagnosed pelvic pain
  • Uterine fibroids
  • Voluntary sterilization (tubal ligation or occlusion for permanent family planning)
  • For diagnosis and treatment of a variety of other pelvic or abdominal disorders

Read moreLaparoscopy in Gynaecology