The National Ribat University
Faculty of Graduate Studies and Scientific Research
Study of Early Pregnancy Failure among in North Kurdofan
State Using Ultrasonography
A Thesis Submitted for Partial Fulfillment of M.Sc. Degree in
Medical Diagnostic Ultrasound
By:Gaber Mohamed Gaber Mohamed
Supervisor:Dr. Elsir Ali Saeed
1439- 2018
I
االيه
ٹ ٹ
ک ک گ گ گ گ ڳ ڳ ڳ ڳ ڱ ڱ ڑ ڑ ک ک چ
ہ ہ ہ ھ ھ ھ ہڱ ڱ ں ں ڻ ڻ ڻ ڻ ۀ ۀ
﮶ ﮷ ﮸ ﮵ھ ے ے ۓ ۓ ﮲ ﮳ ﮴
﮹ ﮺ ﮻ ﮼ ﮽ ﮾ ﮿ ﯀ ﯁
چ ڭ ڭ
صدق هللا العظيم
﴾5اآلية﴿ الحجسورة
II
DEDICATION
I dedicate my research work to my family
;my father and mother , my brother and
my sisters
I dedicate my teacher
I dedicate my friends
Special thank to my love
To all people in my life who touch my
heart.
III
Acknowledgment
I would like to thank God for enabling me to complete this thesis. Especially
I wish to thank my supervisor who encouraged me throughout this study. I
sincerely thank Dr. Elsir Ali Saeed the supervisor of my thesis for his
continues help, supervision and guidance.
I greatly thank all those who supported and helped me to complete this
thesis. I am very grateful to all teachers in all educational levels,
IV
Abstract
This study carried out to determine the incidence of pregnancy failure in
north kurdufan state; 100 pregnant women in their 1st trimester with or
without symptoms of early pregnancy failure were enrolled in the study
which was conducted in U/S departments in different hospitals and
diagnostic centers in Kurdufan state-Sudan, during the period from February
2017 to December 2017.All patients were investigated and evaluated
descriptively by ultrasonography, following the international scanning
guideline and protocols. In this study the early pregnancy failure among
Kurdufan women found 45% complete miscarriage were 32% incomplete
miscarriage were 16%, missed miscarriage and threaten miscarriage was 7%.
The study found that the incidence is high among the pregnant women with
age less than 28 years (55%), PID, multigravidity and those with
hypertension and uncontrolled diabetes mellitus. The study show that
ultrasonography is the method of choice for diagnosis of the early pregnancy
failure; it is the most sensitive, specific, very practical and useful imaging
test for the detection of different categories of early pregnancy failure it play
a crucial and vital role in decreasing morbidity and mortality rates caused by
pregnancy complication in the first trimester.
V
ملخص الدراسه
011نفذت ىذه الدراسة لتقرير ندبة فذل الحسل السبكر في والية شسال كردفان ومن خالل دراسة
او ال تعاني من اعراض فذل الحسل السبكر اجريت ىذه الدراسة امراة حبمى في ثمثيم االول تعاني
باقدام السهجات فهق الرهتية بسختمف السدتذفيات ومراكز التذخيص بالسهجات فهق الرهتية بهالية
، اخزع جسيع السرضى بهاسطة 7102حتى ديدسبر 7102شسال كردفان في الفتره من فبراير
كهالت العالسية . السهجات فهق الرهتية وفقا لمبروته
% 27، اجياض كامل % من فذل الحسل السبكر54شسال كردفان تبمغ اشارت الدراسة في نداء
% من حاالت 2% وفاة الجشين في الذيهر االولى من الحسل ، وندبة 01اجياض غير مكتسل ،
الحسل السيدد باالجياض .
سشو والالئى ندبة لمزواج 73قل من سن وقد وجدت الدراسة أن الشدبة ترتفع عشد الشداء الحبمى ا
عشد الشداء السرابات بمتيابات الحهض، كذالك لديين عدد والدات اكبر و السبكر في ىذه الهالية
ىه الدبب الرئدي لفذل الحسل . كسا وجد ان مرض الدكري الذي اليسكن الديطره عميو وامراض
ر.ضغط الدم ايزا تتدبب في ارتفاع حاالت اإلجياض السبك
كسا اشارت الدراسة الى اىسية السهجات فهق الرهتية في تذخيص فذل الحسل السبكر إذ تمعب
الدور الحاسم والحيهي في اكتذاف اسبابو مسا يهدي الى نقص االصابات ومعدالت الهفيات التي
تشتج عن مزاعفات الحسل الحسل السبكر .
VI
List of Contents
Contents Page No
االيهإ I
Dedication II
Acknowledgment III
Abstract IV
V ملخص الدراسه
List of contents VI
List of Tables VIII
List of Figures X
Chapter one
1.1 Introduction 1
1.2 Problem of the study 2
1.3 Objectives of the study 2
1.3.1 General objective 2
1.3.2 Specific objective 2
1.4 Thesis outline 2
Chapter two
Theoretical Background and literature review
2.1 Pregnancy in the first trimester 4
2.2 Pathology of the Female reproductive System 5
2.2.1 Failure of pregnancy in first trimester 5
2.2.2 Causes of Miscarriage 7
2.2.3 Types of miscarriage 7
2.2.3.1 Threatened Miscarriage 7
2.2.3.2 Missed Miscarriage 8
2.2.3.3IncompleteorInevitableMiscarriage 8
2.2.3.4 Complete Miscarriage 9
2.2.3.5 Recurrent Miscarriage 9
VII
2.2.3.6 Blighted Ovum 9
2.2.3.7 Ectopic Pregnancy 10
2-2-3-8 Molar Pregnancy 11
2.2.4. Signs and symptoms of Early Miscarriage 12
2.2.5 Others Diseases affect early pregnant failure 13
2.2.5.1 Renal Disease in pregnancy 13
2.2.5.2 Pregnancy and Thyroid Disease 14
2.3 Role of Ultrasound in diagnosis early pregnant loss 14
2.3.1 Ultrasound evaluation in the failure of first trimester 16
2.3.2 Doppler Ultrasound Predicts Risk of Miscarriage 17
2.3.3 Side Effects and Safety Risks of Ultrasounds 17
Chapter Three
Material and Method
3.1 Material 40
3.2 Method and scanning technique 40
3.2.1 Patient preparation 41
3.2.2 Patient position 41
3.2.3 Coupling agent 41
3.2.4 Study design 41
3.2..5 Study area 41
3.2.6 Study duration 41
3.2.7 Study population 41
3.2.8 Sampling and sample size 41
3.2.8 Study variables 42
3.2.8 Method of Data collection 42
32..9 Data analysis 42
3.2.10 Data presentation 42
3.2.11 Ethical consideration 42
VIII
Chapter Four
The results
Results 43-64
Chapter Five
Discussion, Conclusion & Recommendations
5.1 Discussion 67
5.2 Conclusion 69
5.3 Recommendation 70
References 71
Appendixes 68-78
IX
List of Tables
Tables Page No
Table (4-1) show Descriptive Statistics 43
Table (4-2) showed the frequency distribution of duration of
VB
44
Table (4-3) showed the frequency distribution of severity of
pain
45
Table (4-4) showed the frequency distribution of clinical
history
46
Table (4-5) showed the frequency distribution of cause of
failure
47
Table (4-6) showed the frequency distribution of type of
miscarriage
48
Table (4-7) showed the frequency distribution of the parity 49
Table (4-8) show cross tabulation between duration of VB
and severity of the pain
50
Table (4-9) show cross tabulation between duration of VB
and type of miscarriage.
51
Table (4-10) show cross tabulation between duration of VB
and parity
52
Table (4-11) show cross tabulation between clinical history
and severity of the pain
53
Table (4-12) show cross tabulation between clinical history
and type of miscarriage
54
Table (4-13) show cross tabulation between the clinical
history and the parity
55
Table (4-14) show cross tabulation between cause of failure
and severity of the pain
56
Table (4-15) show cross tabulation between cause of the
failure and type of miscarriage
57
Table (4-16) show cross tabulation between cause of failure
and parity
58
Table (4-17) show cross tabulation between age and
duration of VB.
59
Table (4-18) show cross tabulation between age and severity
of pain.
60
X
Table (4-19) show cross tabulation between age and clinical
history .
61
Table (4-20) show cross tabulation between age and cause
of failure .
62
Table (4-21) show cross tabulation between age and type of
miscarriage.
63
Table (4-22) show cross tabulation between age and parity. 64
XI
List of Figures
Figures Tables
Figure 2.1: pregnancy and conception. 5
Figure 2.2:Transvaginal ultrasound for normal gestation sac 6
Figure 2.3: miscarriage embryonal demise 6
Figure 2.4: Threatened Miscarriage 7
Figure 2.5: A missed abortion 8
Figure 2.6: Complete Miscarriage 9
Figure 2.7: ultrasound image showed blighted ovum 10
Figure 2.8: Location of the ectopic pregnancy 11
Figure 2.9 Tubual ectopic pregnancy 11
Figure 2.10 Molar pregnancy 12
Figure (4-1) bar graph showed the frequency distribution of
duration of VB
43
Figure (4-2) bar graph showed the frequency distribution of
duration of VB
44
Figure (4-3) showed the frequency distribution of 45
Figure (4-4) bar graph showed the frequency distribution of
clinical history
46
Figure (4-5) bar graph showed the frequency distribution of
cause of failure
47
Figure (4-6) bar graph showed the frequency distribution of
type of miscarriage
48
Figure (4-7) bar graph showed the frequency distribution of
the parity
49
Figure (4-8) bar graph showed cross tabulation between duration
of VB and severity of the pain
50
Figure (4-9) bar graph showed cross tabulation between
duration of VB and type of miscarriage
51
XII
Figure (4-10) bar graph showed cross tabulation between
duration of VB and parity
52
Figure (4-11) bar graph showed cross tabulation between
clinical history and severity of the pain
53
Figure (4-12) bar graph showed cross tabulation between
clinical history and type of miscarriage
54
Figure (4-13) bar graph showed cross tabulation between the
clinical history and the parity
55
Figure (4-14) bar graph showed cross tabulation between
cause of failure and severity of the pain
56
Figure (4-15) bar graph showed cross tabulation between
cause of the failure and type of miscarriage
57
Figure (4-16) bar graph showed cross tabulation between
cause of failure and parity
58
Figure (4-17)bar graph showed cross tabulation between age
and duration of VB.
59
Figure (4-18) bar graph showed cross tabulation between
age and severity of pain.
60
Figure (4-19) bar graph showed cross tabulation between
age and clinical history.
61
Figure (4-20) bar graph showed cross tabulation between
age and cause of failure.
62
Figure (4-21) bar graph showed cross tabulation between
age and type of miscarriage.
63
Figure (4-22) bar graph showed cross tabulation between
age and parity.
64
I
Chapter One
Introduction
1
Chapter One
1.1 Introduction
Early pregnancy refers to different duration of pregnancy depending on thepurpose
of an author's discussion. In most cases, early pregnancy from an ultrasound
perspective indicates the first trimester of pregnancy. Some authorsmay refer to the
first trimester as l2weeks or l4 weeks. Early pregnancy failure is a general term
that indicates failure of a clinically recognized pregnancy to progress to fetal
viability. Fetal viability refers to the capability of a fetus to survive outside the
uterus at birth.[1]
Miscarriage is the loss of fetus before the 20th week of pregnancy. The medical
term for a miscarriage is spontaneous abortion, but the condition is not an abortion
in the common definition of that term. Miscarriage is one of the most common yet
under-studied adverse pregnancy outcomes. In the majority of cases the effects of a
miscarriage on women's health are not serious and may be unreported. However in
the most serious cases symptoms can include pain, bleeding and a risk of
hemorrhage. Feelings of loss and grief are also common and the psychology and
mental health of those affected can suffer. Recurrent miscarriage is generally
defined as spontaneous abortions repeated consecutively over three or more times.
At present, there exist a small number of accepted aetiologies for RPL these
include parental chromosomal abnormalities, untreated hypothyroidism,
uncontrolled diabetes mellitus, certain uterine anatomic abnormalities, and
antiphospholipid antibody syndrome. Other probable or possible aetiologies
include additional endocrine disorders, hereditary and/or acquired thrombophilias,
immunologic abnormalities, infections, and environmental factors [2].
The most common causes of early pregnancy failure include chromosome
aberrations, uterine abnormalities, and an exposure to teratogens, hormonal
dysfunction and pregnancy with an IUCD. The most common uterine
abnormalities associated with early pregnancy failure include mullerian anomalies,
myomatous disease of the uterus and incompetence of cervix [3]
2
Ultrasound evaluation of an early pregnancy failure include detection of the
pregnancy location; intrauterine or extra uterine, the type of pregnancy; one- fetus
pregnancy, multiple pregnancy, molar pregnancy, the viability of the pregnancy
and establishment of the gestational age. Ultrasonographer also recognizes the
complications that occur in first trimester. [4]
1.2 Problem of the study:
Late diagnosis of early pregnancy failure is a dangerous, it may expose the
pregnant lady to the risk of infection; i.e. incomplete abortion of the products of
conception in the uterus are good media for bacteria, and continuous of vaginal
bleeding associated with spontaneous abortion lead to anemia. Therefore, early
diagnosis of the patients by ultrasound aided in management &preventing this
entire problem.
1.3 Objectives of the study:
1.3.1 General objective:
The general objective of this study was to study early pregnancy failure in north
Kurdufan using ultrasonography.
1.3.2 Specific objective
To study the cause of early pregnancy failure.
To correlate the early pregnancy failure with PID, parity, duration of vaginal
bleeding and severity of pain.
1.4 Thesis outline:
This thesis was aimed to evaluate the causes of early pregnancy failure using trans-
abdominal Ultrasound. Accordingly, it was divided into the following chapters.
Chapter one includes Introduction, Chapter two: provides background information
on previous study, normal anatomy of the female pelvic, pathology, role of
ultrasound in first trimester and normal &abnormal ultrasound appearance of early
pregnancy failure. Chapter three provides an outline of equipment and methods
used in this thesis. While the results were presented in chapter four, Chapter five,
discusses the results, concludes the thesis and recommends for further studies.
1
Chapter Two
Literature Review
3
Chapter Two
Literature Review
2.1 Pregnancy in the first trimester:
Pregnancy is associated with normal physiological changes that assist fetal
survival as well as preparation for labour. It is important to know what
'normal' parameters of change are in order to diagnose and manage common
medical problems of pregnancy. Most of the time, women won't know the
exact day got pregnant. Doctor will count the start of pregnancy from the
first day of last menstrual period. That's about 2 weeks ahead of when
conception happens. Here's a primer on conception: Each month inside
ovaries, a group of eggs starts to grow in small, fluid-filled sacs called
follicles. Eventually, one of the eggs erupts from the follicle (ovulation). It
usually happens about 2 weeks before your next period. After the egg leaves
the follicle, the follicle develops into something called the corpus luteum.
The corpus luteum releases a hormone that helps thicken the lining of uterus,
getting it ready for the egg. If one sperm does make its way into the fallopian
tube and burrows into the egg, it fertilizes the egg. The egg changes so that
no other sperm can get in. At the instant of fertilization, Baby's genes and sex
are set. If the sperm has a Y chromosome, Baby will be a boy. If it has an X
chromosome, the baby will be a girl. Implantation: (Moving to the
Uterus)The egg stays in the fallopian tube for about 3 to 4 days. But within
24 hours of being fertilized, it starts dividing fast into many cells. It keeps
dividing as it moves slowly through the fallopian tube to the uterus. Its next
job is to attach to the lining of uterus. This is called implantation. Some
women notice spot-ting (or slight bleeding) for 1 or 2 days around the time
of implantation. The lining of the uterus gets thicker and the cervix is sealed
by a plug of mucus. It will stay in place until the baby is ready to be born. A
fertilized ovum up to 14 days old, before it becomes implanted in the uterus.
4
The first week of embryonic development will be described in the following:
Fertilization, Capacitation, Acrosome Reaction, Zygote, Cleavage, Morula,
Inner cell mass or embryo blast and Outer cell mass or Trophoblast. The
embryonic development first begins with the fusion of female and male
gametes (with haploid, n number of chromosome). The process of fusion of
male and female pronuclei is known as fertilization. Fertilization occurs in
the ampullary region of the uterine or fallopian tube.[5]
Figure 2.1: pregnancy and conception.
(www.pregnancyandconceptionimages.com)
2.2 Pathology of the Female reproductive System:
The pathological evaluation of the first trimester miscarriage includes
assessment of the morphological features of the gestational sac, embryo or
fetus, whereas the initial pathologic assessment should be used to confirm
the presence or absence of pregnancy tissue as shown in the follow:
2.2.1 Failure of pregnancy in first trimester:
Early pregnancy failure is a common cause of miscarriage. It happens when a
fertilized egg implants in the uterus but the resulting embryo either stops
5
developing very early or doesn't form at all. A miscarriage is a pregnancy
that ends by itself within the first 20 weeks. "Stillbirth" refers to the loss of a
pregnancy with fetal death that occurs after the first 20 weeks. Experts
estimate that about half of all fertilized eggs die and are miscarried, usually
even before the woman knows she is pregnant. Most miscarriages occur
between the 7th and 12th weeks of pregnancy. [6]
Figure 2.2:Transvaginal ultrasound for normal gestation sac
(www.ultrasoundimages.com)
Figure 2.3: miscarriage embryonal demise
(www.Ultrasoundimages.com)
6
2.2.2 Causes of Miscarriage:
Most miscarriages occur when the unborn baby has fetal genetic problems.
Usually, these problems are unrelated to the mother. Other possible causes of
miscarriage include: infection, medical condition in the mother, such as
diabetes or thyroid disease, hormonal factors, immune responses, physical
problems in the mother, and uterine abnormalities. A woman has a higher
risk of miscarriage if she is over age 35or if she has a history of more
previous miscarriages.[7]
2.2.3 Types of miscarriage:
A pregnant woman can undergo different miscarriages that are categorized
by different names. It is used as an umbrella term to explain different types
of loss of pregnancies. These different types of spontaneous loss of
pregnancies are discussed below:
2.2.3.1 Threatened Miscarriage:
This is a type that sends shivers down an expecting mother's spine. In this
condition, a woman suffer from vaginal bleeding along with some light
spotting. It is ,1 in 4 pregnant women suffer from this type of bleeding
during their first trimester. In this type, the cervix remains tightly closed. The
mother and the fetus need to be closely monitored and in majority of the
cases, the pregnancy continues without any major issues. An ultrasound is an
important diagnostic tool to monitor it.[8]
Figure 2.4: Threatened Miscarriage
(www.threatenedabortionultrasoundimages.com)
7
2.2.3.2 Missed Miscarriage:
Many pregnant women experience this type without any symptoms. They are
unaware of the fact that they have just undergone an abortion and suffered
from embryonic death. The embryo is not expelled from the womb for
unknown reasons and thus the mother does not experience any symptoms.
Fetal death is only determined when fetal heart tones checked during an
ultrasound examination. [9]
Figure 2.5: A missed abortion
(www.Ultrasoundimages.com)
2.2.3.3IncompleteorInevitableMiscarriage:
This occurs when the body starts the process of spontaneous abortion, but
fails to expel all the tissues of failed pregnancy from the womb. The cervix
dilates indicating it is a sure sign of expelling the fetus from the uterus. The
mother experiences abdominal or back pain along with bleeding and cramps.
This type of failed pregnancy is inevitable as there is no way from stopping
the loss from occurring. An inevitable miscarriage refers to the presence of
an open internal os in the presence of bleeding in the first trimester of
pregnancy. [10]
8
2.2.3.4 Complete Miscarriage:
When all the products of conception, that is, the embryo have been expelled
from the womb, it is termed as a complete failure. The bleeding will stop
quickly and one can confirm it with the help of an ultrasound.
Essentially, a threatened miscarriage progresses to an inevitable miscarriage
if cervical dilatation occurs. Once tissue has passed through the cervical os,
this will then be termed an incomplete miscarriage and ultimately a complete
miscarriage. [11]
Figure 2.6: Complete Miscarriage
(www.ultrasoundimages.com)
2.2.3.5 Recurrent Miscarriage:
There are about 1% couples who suffer from this form. It occurs when there
is loss of three or more consecutive first trimester miscarriages. absence of
any kind of fetal growth.[12]
2.2.3.6 Blighted Ovum:
When a fertilized egg is implanted in the uterine wall, it will undergo fetal
development. However, in case of a blighted ovum, also called an embryonic
pregnancy, this never occurs. The presence of a gestational sac with or
9
without the presence of a yolk sac. However, there is total absence of any
kind of fetal growth. [13]
Figure 2.7: ultrasound image showed blighted ovum
(www.ultrasoundimages.com)
2.2.3.7 Ectopic Pregnancy:
When a fertilized egg implants itself inside the fallopian tube instead of the
uterus, it is termed as an ectopic or tubal pregnancy. These pregnancies
require immediate termination as the developing egg will lead to rupture of
the fallopian tube. If left untreated, it could lead to serious complications
including maternal death.[14]
10
Figure 2.8: Location of the ectopic pregnancy
(www.locationoftheectopicpregnancyimages.com)
Figure 2.9 Tubual ectopic pregnancy
(www.ectopicpregnancyultrasoundimages.com)
2-2-3-8 Molar Pregnancy:
During fertilization, an error in the genetic coding can lead to growth of an
abnormal tissue. These pregnancies rarely involve the embryo, but cause in
development of cells that make up the placenta. However, there is no fetus
just presence of an incomplete mole. It is actually a form of tumor that will
11
not survive. This is a very rare kind of pregnancy, thus, not seen in majority
of the cases.[15]
Figure 2.10 Molar pregnancy
(www.ultrasoundimages.com)
2.2.4. Signs and symptoms of Early Miscarriage:
Most miscarriage symptoms are not definitive indicators of pregnancy loss,
but possible signs include vaginal bleeding in pregnancy, cramping, and loss
of pregnancy symptoms. Patients with spontaneous complete abortion
usually present with a history of vaginal bleeding, abdominal pain, and
passage of tissue. After the tissue passes, the vaginal bleeding and abdominal
pain subsides. Other symptoms, such as fever or chills, are more
characteristic of infection, such as in a septic abortion. Septic abortions need
to be treated immediately; otherwise they may be life threatening. Patients
who are pregnant and bleeding vaginally need immediate evaluation. [16]
12
2.2.5 Others Diseases affect early pregnant failure:
There are many types of diseases affect the first trimester:
2.2.5.1 Renal Disease in pregnancy:
Renal disease can affect the outcome of pregnancy, pregnancy can affect the
progression of pre-existing renal disease, and pregnancy can itself cause
renal impairment. The renal system undergoes significant physiological and
anatomical changes during a normal pregnancy:
Renal plasma flow increases by 50-70% in pregnancy (the change is most
pronounced in the first two trimesters). There is an increased glomerular
filtration rate (GFR), which peaks at about the 13th week of pregnancy and
can reach levels up to 150% of normal. Therefore, both urea and creatinine
levels are decreased.[17]
Increased levels of progesterone at the beginning of pregnancy increase
relaxation of arterial smooth muscles and so decrease peripheral vascular
resistance, causing a blood pressure fall of approximately 10 mm Hg in the
first 24 weeks of pregnancy. The anatomical changes are mainly in the
collecting system. A dilatation of the ureters and pelvis occurs, which can
lead to urinary stasis and an increased risk of developing urinary tract
infections (UTIs).[18]
There is also an increase in overall kidney size by about 1-1.5 cm. In general,
the physiological changes peak by the end of the second trimester and then
start to return to pre-pregnancy levels; anatomical changes generally take up
to 3 months postpartum to subside. Asymptomatic bacteriuria is found in 2%
of sexually active women, and is more common (up to 7%) during
pregnancy.[19]
Because of the dilatation of the calyces and ureters that occurs in pregnancy,
25% will go on to develop pyelonephritis, which can cause fetal growth
restriction, fetal death, and premature labour. Pyelonephritis is common at
around 20 weeks and in the puerperium. Asymptomatic bacteriuria and
13
urinary tract infections (UTIs) in pregnancy should be treated with
antibiotics. Antibiotic prophylaxis should be given to women with recurrent
bacteriuria or UTIs and kidney disease.[20]
20% of women having pyelonephritis in pregnancy have underlying renal
tract abnormalities and an intravenous urogram (IVU) or ultrasound at 12
weeks postpartum should be considered. [21]
The Problems related to specific kidney diseases in pregnancy:
Reflux nephropathy ,Diabetic nephropathy, and Kidney transplant recipient,
they are Increased risk of miscarriage in the first trimester , hypertension,
and Premature delivery.[22]
2.2.5.2 Pregnancy and Thyroid Disease:
Thyroid disease is a disorder that affects the thyroid gland. Sometimes the
body produces too much or too little thyroid hormone. Thyroid hormones
regulate metabolism, the way the body uses energy-and affect nearly every
organ in the body. Too much thyroid hormone is called hyperthyroidism
and can cause many of the body’s functions to speed up. Too little thyroid
hormone is called hypothyroidism and can cause many of the body’s
functions to slow down. [23]
Thyroid hormone plays a critical role during pregnancy both in the
development of a healthy baby and in maintaining the health of the mother.
Women with thyroid problems can have a healthy pregnancy and protect
their fetuses’ health by learning about pregnancy’s effect on the thyroid,
keeping current on their thyroid function testing, and taking the required
medications.[24]
2.3 Role of Ultrasound in diagnosis early pregnant loss:
Confirming the presence of baby’s heartbeat. The ultrasound can routinely
detect a heartbeat of baby as early as 6-7 weeks. Confirming the correct dates
of pregnancy. Some women are uncertain of their last menstrual period
(LMP) or have irregular menstrual cycles, making it difficult for their doctor
14
to correctly estimate when the baby is due. Establishing accurate dates can be
important, especially if there are concerns about baby later in the pregnancy
(for example, if the baby is not growing well). An ultrasound in the first
trimester can give an accurate estimated date of confinement (EDC) to within
3-5 days. Generally speaking, the earlier in pregnancy the ultrasound is
performed, the more accurate it will be at estimating baby due date (technical
factors such as the quality of the ultrasound image and the expertise of the
sonographer will affect this accuracy.) Confirming the location of pregnancy.
The ultrasound will check if pregnancy is developing normally within the
uterus.[24]
Determining the number of babies present. Ultrasound can concerned about
having more than one baby (for example, twins or triplets) if pregnancy
conceived with the help of clomiphene or a family history of twins or uterus
seems larger than expected. This ultrasound can determine the number of
babies, as well as the type of twins. Identifying pregnancies at increased risk
of miscarriage or pregnancy loss. The first trimester ultrasound detect
changes in the early pregnancy that are concerning and associated with an
increased risk of pregnancy loss (for example, the pregnancy sac is small or
irregular, or the baby’s heart beat is much slower than expected) Such
appearances not always be significant for baby, that pregnancies with these
changes continue without problems over subsequent weeks.[25]
Checking other pelvic organs. Ultrasound checks other things in pelvis apart
from pregnancy, such as the uterus (for example, if there is a history of
fibroids) and the ovaries (for example, pelvic pain and there is concern about
an ovarian cyst).To concerned about abdominal pain or vaginal bleeding.
This early ultrasound can provide reassurance that everything is progressing
normally. It detects a serious problem with either mother or pregnancy, some
of which require further investigations or treatment. Sometimes the results of
a first trimester scan inconclusive or uncertain, and need to be combined with
15
clinical history and blood tests (serum BhCG) .Some women need to return
for another ultrasound scan a few weeks later to assess the progress of the
pregnancy, or they require another blood test (serial serum BhCG). [25]
2.3.1 Ultrasound evaluation in the failure of first trimester:
With the increased availability of ultrasound, patients are receiving earlier
sonographic diagnoses, and it is more precise to describe unsuccessful or
failed pregnancies based on their sonographic appearance with "embryonic
demise" referring to cases where the ultrasound clearly shows an "embryonic
fetal pole" without cardiac activity. An embryonic miscarriage is defined by
sonography as an empty gestational sac at a gestational age where one would
expect to see a yolk sac or embryo with cardiac activity. Ultrasound is the
primary tool for diagnosing miscarriage. In early pregnancy, a vaginal
ultrasound – which is completely safe – is more accurate than an abdominal
ultrasound because the vaginal probe can get very close to the uterus to see
the pregnancy more clearly.[25]
If a woman has a 28-day cycle, by five weeks after her last period, a small
gestational sac can often be seen inside the uterus, and by six weeks, a small
embryo with a heartbeat will usually be present. However, because women
sometimes ovulate later than they think, the absence of these changes doesn't
always mean miscarriage is occurring. Another ultrasound a week later may
be needed. Nevertheless, if the gestational sac is quite big, but there is no
embryo or if the embryo is quite big but there is no heartbeat, or if there has
been no growth over a week, miscarriage is very likely.[26]
An embryonic pregnancy diagnosed when there is no fetal pole identified on
trans-vaginal scanning, and: the size of the gestational sac is such that a fetal
pole should be seen : MSD≥ 25 mm (by RCOG criteria). There is little or no
growth of the gestational sac between interval scans. Normally the MSD
should increase by 1 mm per day if MSD is too small to ascertain viability on
16
the initial ultrasound, a follow up scan in 10-14 days should differentiate
early pregnancy from a failed pregnancy. Other ancillary features include
8 mm
2 mm
An ultrasound scan can be able to detect a pregnancy and a heartbeat in a
normal pregnancy at around 6 weeks, but this varies a great deal and isn’t
usually advised. The best time to have a scan is from about 7 weeks’
gestation when it should be possible to see the baby’s heartbeat in a normal
pregnancy
2.3.2 Doppler Ultrasound Predicts Risk of Miscarriage:
Doppler ultrasound performed in early pregnancy can accurately identify
embryonic congestive heart failure and subsequent risk of miscarriage. 3-
D ultrasound was performed to evaluate vasculature (Uterine artery Doppler
and 3-D power Doppler) and placental volume. [26]
2.3.3 Side Effects and Safety Risks of Ultrasounds:
Most of the time, ultrasounds do not have any side effects other than possible
discomfort from having a full bladder. The procedure is not painful, although
a transvaginal ultrasound is more invasive . Ultrasounds are generally
considered safe. One study suggested that very frequent ultrasound use cause
developmental problems but other studies have found no such risks.[26]
4
Chapter Three
Material and Method
17
Chapter three
Material and method
3.1 Material
The data of this study was collected using Weighing scales to measure
weight. Tape Measure to measure height. Ultrasound gel applying over the
symphasis pubic . A grey scale real-time mindary portable ultrasound
diagnostic system, model( DP50 ), manufactured on china, with
Transabdominal probe convex array transducer and transvaginal, with
different frequency range from 3.5 - 10 MHz, and Sonoace, koren machine,
Model(X4) manufactured in 2006, convex array transducer, with a central
frequency of 3.5 MHz, and a fundamental frequency of 3.5 -5.0 MHz.
Honda, made in Japan, Model (HS 2000), manufactured on 2005,convex
array transducer, with a central frequency of 3.5 MHz, and a fundamental
frequency of 3.5 -5.0 MHz. Mindary, Chinese machine, Model (C6),
manufactured on 2009, convex array transducer, with a central frequency of
3.5 MHz, and a fundamental frequency of 2.5 -5.0 MHz.
3.2 Method and scanning technique
In pelvic ultrasound the uterus should be scanned clearly to check intra
uterine gestational sac, Care should be taken to confirm the fetal heart beat.
Most pelvic ultrasounds are performed using both the transabdominal and
transvaginal approaches; Transabdominal ultrasound involves scanning
through your lower abdomen. Transabdominal ultrasound usually provides
an overview of the pelvis rather than detailed images. The transabdominal
assessment is particularly helpful for the examination of large pelvic masses
extending into the abdomen, which are not always well viewed with
transvaginal ultrasound.
18
A suitable amount of ultrasound gel is put on the skin of the lower abdomen,
with the ultrasound probe then scanning through this gel. The gel helps
improve contact between the probe and your skin.
3.2.1 Patient preparation
Study includes prepared (full urinary bladder for transabdominal scan) and
empty bladder for transvaginal scan.
3.2.2 Patient position
Patients were scan in supine position for transabdominal scan and frog
position for transvaginal scan. The quality control protocol wasn't verified by
a senior ultrasound radiologist to crosschecking the data.
3.2.3 Coupling agent
A coupling agent is necessary to ensure good acoustic contact between
transducer and patient skin to allow total transmission of sound beam.
3.2.4 Study design
This was Descriptive cross-sectional study.
3.2..5 Study area
This study conducted in different hospitals of north Kurdufan state.
3.2.6 Study duration
The duration of study from February 2017 to December 2017
3.2.7 Study population
Pregnant women from north Kurdufan with early pregnant failure.
3.2.8 Sampling and sample size
Sample frame was compromised of 100 patients confirmed early pregnant
failure by ultrasound. Selection of participants was done through random
probability sampling technique on patient with early pregnant loss.
19
3.2.8 Study variables
Age, Duration of vaginal bleeding., Severity of pain, History (previous
failure – diabetic – hypertensive – CS ), Cause of failure ( PID – myoma
trauma – SCH – IUCD – unknown), Parity.
3.2.8 Method of Data collection
Data was collected by data collection sheet which designed to include all
variables that satisfy the study.
ultrasound scanning reports of the female pelvic following international
scanning guidance and protocol for ultrasound scan.
The researcher performed some ultrasound scanning for the patients of the
sample and the other scans done by working radiologist and technologist on
hospitals and centers.
32..9 Data analysis
The data was analyzed by SPSS protocol by using various statistics.
3.2.10 Data presentation
The data was presented in tables and figures.
3.2.11 Ethical consideration:
All ethical consideration and patient privacy was kept. The patients were free
to decide whether to participate or not.
40
Chapter Four
The results
20
Chapter four
Results
Table (4-1) show Descriptive Statistics
N Minimu
m
Maximu
m Mean
Std.
Deviation
age 100 13 49 28.12 10.409
Figure (4-1) bar graph showed the frequency distribution of duration of VB
21
Table (4-2) showed the frequency distribution of duration of VB
Duration of VB Frequency Percent
sever 49 49.0
moderate 26 26.0
mild 25 25.0
Total 100 100.0
Figure (4-2) bar graph showed the frequency distribution of duration of VB
22
Table (4-3) showed the frequency distribution of
severity of pain
Severity of pain Frequency Percent
sever 24 24.0
no pain 24 24.0
mild 27 27.0
moderate 25 25.0
Total 100 100.0
Figure (4-3) showed the frequency distribution of
severity of pain
23
Table (4-4) showed the frequency distribution of
clinical history
Clinical history Frequency Percent
previous 37 37.0
healthy 42 42.0
hypertension 11 11.0
diabetic 5 5.0
CS 5 5.0
Total 100 100.0
Figure (4-4) bar graph showed the frequency distribution of
clinical history
24
Table (4-5) showed the frequency distribution of cause of failure
Causes of failure Frequency Percent
PID 44 44.0
myoma 5 5.0
unknown 38 38.0
trauma 4 4.0
SCH 8 8.0
IUCD 1 1.0
Total 100 100.0
Figure (4-5) bar graph showed the frequency distribution of
cause of failure
25
Table (4-6) showed the frequency distribution of type of miscarriage
Type of miscarriage Frequency Percent
complete 45 45.0
incomplete 32 32.0
missed 16 16.0
threaten 7 7.0
Total 100 100.0
Figure (4-6) bar graph showed the frequency distribution of
type of miscarriage
26
Table (4-7) showed the frequency distribution of the parity
parity Frequency Percent
multiparty 57 57.0
primary 38 38.0
para2 5 5.0
Total 100 100.0
Figure (4-7) bar graph showed the frequency distribution of
the parity
27
Table (4-8) show cross tabulation between duration of VB and severity of the pain
Duration VB * severity
of pain
Severity of pain Total
sever no pain mild moderate
Duration
VB
sever 15 8 13 13 49
moderate 8 3 9 6 26
mild 1 13 5 6 25
Total 24 24 27 25 100
Figure (4-8) bar graph showed cross tabulation between duration of VB and
severity of the pain
28
Table (4-9) show cross tabulation between duration of VB and type of
miscarriage.
Duration VB * type of miscarriage
Type of miscarriage
Total complete incomplete missed threaten
Duration VB
sever 39 7 0 3 49
moderate 6 14 3 3 26
mild 0 11 13 1 25
Total 45 32 16 7 100
Figure (4-9) bar graph showed cross tabulation between duration of VB and
type of miscarriage
29
Table (4-10) show cross tabulation between duration of VB and parity
Duration VB * parity
parity Total
multiparty primary para2
Duration
VB
sever 31 15 3 49
moderate 14 10 2 26
mild 12 13 0 25
Total 57 38 5 100
Figure (4-10) bar graph showed cross tabulation between duration of VB
and parity
30
Table (4-11) show cross tabulation between clinical history and severity of the pain
Clinical history * severity of pain
Severity of pain
Total sever
no
pain mild
moder
ate
Clinical
history
previous 10 9 9 9 37
healthy 7 11 15 9 42
hypertens
ion 5 3 1 2 11
diabetic 1 0 2 2 5
CS 1 1 0 3 5
Total 24 24 27 25 100
Figure (4-11) bar graph showed cross tabulation between clinical history and
severity of the pain
31
Table (4-12) show cross tabulation between clinical history and type of
miscarriage
Clinical history * type of miscarriage
Count
Type of miscarriage
Total complete incomplete missed
threate
n
Clinical
history
previous 21 11 4 1 37
healthy 16 14 8 4 42
hypertensi
on 5 4 2 0 11
diabetic 2 1 1 1 5
CS 1 2 1 1 5
Total 45 32 16 7 100
Figure (4-12) bar graph showed cross tabulation between clinical history and
type of miscarriage
32
Table (4-13) show cross tabulation between the clinical history and the parity
Clinical history * parity
Count
parity Total
multipa
rty
primar
y
para2
clinical
history
previous 37 0 0 37
healthy 3 36 3 42
hypertensi
on
8 2 1 11
diabetic 4 0 1 5
CS 5 0 0 5
Total 57 38 5 100
Figure (4-13) bar graph showed cross tabulation between the clinical history and the
parity
33
Table (4-14) show cross tabulation between cause of failure and severity of
the pain
Causes of failure * severity of pain
Severity of pain
Total sever
no
pain mild
modera
te
Causes of
failure
PID 12 9 13 10 44
myoma 1 2 1 1 5
unkno
wn 8 10 9 11 38
trauma 1 0 1 2 4
SCH 2 3 3 0 8
LUCD 0 0 0 1 1
Total 24 24 27 25 100
Figure (4-14) bar graph showed cross tabulation between cause of failure and
severity of the pain
34
Table (4-15) show cross tabulation between cause of the failure and type of
miscarriage
Causes of failure * type of miscarriage
Count
Type of miscarriage
Total compl
ete
incompl
ete
misse
d
threat
en
Causes of
failure
PID 26 10 6 2 44
myoma 2 3 0 0 5
unkno
wn 15 13 7 3 38
trauma 2 2 0 0 4
SCH 0 3 3 2 8
LUCD 0 1 0 0 1
Total 45 32 16 7 100
Figure (4-15) bar graph showed cross tabulation between cause of the failure
and type of miscarriage
35
Table (4-16) show cross tabulation between cause of failure and parity
Causes of failure * parity Cross tabulation
Count
parity
Total multiparty primary para2
Causes of
failure
PID 37 5 2 44
myoma 4 1 0 5
unknow
n 11 25 2 38
Trauma 1 3 0 4
SCH 3 4 1 8
LUCD 1 0 0 1
Total 57 38 5 100
Figure (4-16) bar graph showed cross tabulation between cause of failure and
parity
36
Table (4-17) show cross tabulation between age and duration of VB.
Duration VB Total
sever moderate mild
age 13-18 12 4 7 23
18.5-23 8 7 5 20
23.5-28 9 3 0 12
28.5-33 4 2 5 11
33.5-38 4 4 3 11
38.5-43 7 5 4 16
43.5-49 5 1 1 7
Total 49 26 25 100
Figure (4-17) bar graph showed cross tabulation between age and duration of
VB.
37
Table (4-18) show cross tabulation between age and severity of pain.
Severity of pain Total
sever no pain mild moderate
age 13-18 6 4 8 5 23
18.5-23 6 4 7 3 20
23.5-28 5 1 2 4 12
28.5-33 1 6 3 1 11
33.5-38 2 3 2 4 11
38.5-43 4 3 3 6 16
43.5-49 0 3 2 2 7
Total 24 24 27 25 100
Figure (4-18) bar graph showed cross tabulation between age and severity of
pain .
38
Table (4-19) show cross tabulation between age and clinical history .
Clinical history Total
previous healthy hypertension diabetic CS
age
13-18 2 21 0 0 0 23
18.5-23 3 16 0 0 1 20
23.5-28 5 3 2 2 0 12
28.5-33 6 0 3 0 2 11
33.5-38 5 2 2 1 1 11
38.5-43 12 0 4 0 0 16
43.5-49 4 0 0 2 1 7
Total 37 42 11 5 5 100
Figure (4-19) bar graph showed cross tabulation between age and clinical
history .
39
Table (4-20) show cross tabulation between age and cause of failure .
Causes of failure Total
PID myoma unknown trauma SCH LUCD
age
13-18 4 0 15 1 3 0 23
18.5-23 7 0 10 1 2 0 20
23.5-28 8 0 1 1 1 1 12
28.5-33 7 2 1 1 0 0 11
33.5-38 6 1 4 0 0 0 11
38.5-43 9 1 4 0 2 0 16
43.5-49 3 1 3 0 0 0 7
Total 44 5 38 4 8 1 100
Figure (4-20) bar graph showed cross tabulation between age and cause of
failure .
40
Table (4-21) show cross tabulation between age and type of miscarriage.
Type of miscarriage Total
complete incomplete missed threaten
age
13-18 10 6 4 3 23
18.5-23 9 6 3 2 20
23.5-28 6 5 0 1 12
28.5-33 2 5 4 0 11
33.5-38 5 5 1 0 11
38.5-43 7 5 3 1 16
43.5-49 6 0 1 0 7
Total 45 32 16 7 100
Figure (4-21) bar graph showed cross tabulation between age and type of
miscarriage.
41
Table (4-22) show cross tabulation between age and parity.
parity Total
multiparty primary para2
age
13-18 2 21 0 23
18.5-23 4 13 3 20
23.5-28 8 2 2 12
28.5-33 11 0 0 11
33.5-38 9 2 0 11
38.5-43 16 0 0 16
43.5-49 7 0 0 7
Total 57 38 5 100
figure (4-22) bar graph showed cross tabulation between age and parity.
43
Chapter Five
Discussion, Conclusion & Recommendations
42
5.1 Discussion:
This study is intended in evaluation of early pregnancy failure using
ultrasound. A total 100 patients were investigated by ultrasound in north
Kurdufan state. During period extended from February 2017 to December
2017.
The peak incidence of early pregnancy failure showed a especial relationship
between early pregnancy failure and PID where (44%) of cases were in
women with PID ; and (38%) of cases with the unknown causes . we found
the relation between clinical history and cause of failure which found
finding suggested the limited role of ultrasound in discovering the exact
cause for early pregnancy failure.
In this study showed 27 patients with mild pain, 25 patients with moderate
pain, 24 patient with sever pain and 24 patients with no pain. We found the
relation between severity of pain and duration of vaginal bleeding 15 patients
have had sever bleeding. Which while 13 patients with mild vaginal bleeding
have not had pain. Also found relation between cause of failure and severity
of pain we found 12 cases with PID have had sever pain because PID caused
pelvic pain.
All patients of early pregnancy failure were vaginal bleeding, where (49)
patients presented with sever bleeding , while 26 patients presented with
moderate bleeding and 25 patients presented with mild bleeding. In this
study we found the relation between the duration of vaginal bleeding and
type of miscarriage we found 39 patients of complete abortion which have
sever bleeding, were 6 patients of complete abortion which have moderate
bleeding .
The study revealed that the highest incidence of spontaneous abortion is
complete abortion (45%) followed by incomplete (32%) and then miss
43
abortion (16%) and finally threaten abortion (7%). The complete abortion is
more common in age from 13-28yrs which associated with unknown causes,
and incomplete abortion is more common in age from 28-49yrs which
associated with infection (PID).
The study shows 42 patients without clinical history, while 37 patients have
had previous failure.
The study show a relationship between early pregnancy and maternal illness,
where 5 patients have had uncontrolled diabetes mellitus, will 11 patients
have had hypertension. And 5 patients have had previous cesarean section.
The study also found that an association between the incidence of early
pregnancy and other factors e.g. uterine fibroid, trauma, SCH, and IUCD. It
was found 8 cases failed due to SCH, 5 cases from them had uterine fibroid
and 4 cases trauma while one case of pregnant women failed due to IUCD.
The study showed that 55 patients of failed pregnancy were aging from 13-
28yrs, while 45 patients from 28-49yrs finding in this area girls marriage in
early age.
In this study 57 patients multiparty pregnancy while 38 patients prima
pregnancy and 5 patient para2. We find strong relation with women who had
multiparty and early pregnancy failure than women who in the first
pregnancy.
44
5.2 Conclusion:
The most common type of early pregnancy failure is complete abortion and
lees common type is ectopic pregnancy. the study showed that ultrasound is
and easy and accurate method in early pregnancy failure diagnosis. Incidence
of early pregnancy failure is higher in women age below 28 years old 55%.
due to early marriage in this state.
In this study the incidence of early pregnancy failure among Kurdufan
women found 45% complete miscarriage were 32% incomplete miscarriage
were 16%, missed miscarriage and threaten miscarriage was 7%.
The study found that the incidence is high among the pregnant women with
age less than 28 years (55%), PID, mutigravidity and those with hypertension
and uncontrolled diabetes mellitus.
45
5.3 Recommendation:
Machine quality is very essential in ultrasound; bad quality machine
well effect the study negatively; so height resolution ultrasound
machine with ability to increase or decrease frequencies and deferent
probes are recommended.
In Kurdufan the early pregnancy failure due to PID is more common
than other causes of failure. so we need to treatment.
Ultrasound TV and TA scanning must be part of routine health care of
women.
In this study one of the major problems which I found during
collecting the data that women insist on giving wrong information
about their case. I ask every women to take her problem seriously in
account to help herself firstly and so helping us and everyone who
want to do other study in the same topic to perform his job properly.
46
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67
Appendixes
68
Appendix 1
Ultrasound image
Fig 1 : sagittal ultrasound of 25x show incomplete abortion
69
Fig 2 : sagittal ultrasound of 31 years show threaten abortion
with weak cardiac activity
70
Fig 3 : sagittal ultrasound of 18 years show incomplete
abortion (distorted sac)
71
Fig 4 : sagittal ultrasound of 22 years show miss abortion
(without cardiac activity)
72
Fig 5 : sagittal ultrasound of 24 years show incomplete
abortion (distorted sac)
73
Fig 6 : sagittal ultrasound of 41 years show incomplete
abortion (with retain product)
74
Fig 7 : sagittal ultrasound of 41 years show incomplete
abortion (molar pregnancy)
75
Fig 8 : sagittal ultrasound of 41 years show complete
abortion
76
Fig 9 : sagittal ultrasound of 41 years show incomplete
abortion (with retain product)
77
Fig 10 : sagittal ultrasound of 41 years show incomplete
abortion (with retain product)
78
Appendices 2
National Ribat University
Faculty of Graduate Studies and scientific research
Study of early pregnancy failure among in North Kurdofan
State Using Ultrasonography
Data Collection Sheet
Age
Duration of vaginal bleeding
Mild ( ) moderate ( ) sever ( )
Severity of pain :
Mild ( ) moderate ( ) sever ( )
No pain ( )
Clinical history :
Hypertensive ( ) diabetic( ) healthy( )
Cesarean section( ) previous failure( )
Cause of failure :
Myoma ( ) IUCD( ) PID( ) SCH( )
Trauma( ) unknown( )
Type of mischarge :
Complete( ) incomplete( ) missed( ) threaten( )
Parity
Prima ( ) para .2. ( ) multipara ( )