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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


and type of miscarriage.

51


and parity

52

Table (4-11) show cross tabulation between clinical history


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


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


duration of VB

44

Figure (4-3) showed the frequency distribution of 45


clinical history

46


cause of failure

47


type of miscarriage

48


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


duration of VB and parity

52


clinical history and severity of the pain

53


clinical history and type of miscarriage

54

Figure (4-13) bar graph showed cross tabulation between the

clinical history and the parity

55


cause of failure and severity of the pain

56


cause of the failure and type of miscarriage

57


cause of failure and parity

58

Figure (4-17)bar graph showed cross tabulation between age

and duration of VB.

59


age and severity of pain.

60


age and clinical history.

61


age and cause of failure.

62


age and type of miscarriage.

63


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

http://www.pregnancyandconceptionimages.com/

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)

http://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)

http://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


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


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

http://www.locationoftheectopicpregnancyimages.com/

http://www.ectopicpregnancyultrasoundimages.com/

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


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


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


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


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


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


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


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


abortion (distorted sac)

73


abortion (with retain product)

74


abortion (molar pregnancy)

75

Fig 8 : sagittal ultrasound of 41 years show complete

abortion

76



77



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 ( )

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