Spontaneous abortion by mikesanye


									Spontaneous Abortion

        Vandana Sharma, M.D
               April 30, 2004
 Pt. 27 yr.. old G3 P2002, walks into clinic
  with vaginal bleeding
 What would you ask her?
 What tests would you order?
 What follow-up would she need?
Differential Diagnosis
   Bleeding in the first trimester
    –   Physiologic
    –   Pathologic
   Ectopic pregnancy
   Spontaneous abortion
   Cervical or vaginal Pathology
    –   Polyp
    –   Infection
    –   Neoplasia
Risk Factors
   Age
   smoking
   Alcohol
   Drugs
   Caffeine
   Analgesics
   Gravidity
   Previous Miscarriage
   Fever
   Trauma
   Maternal Exposure to Teratogens
Types of Spontaneous Abortions
   Threatened Abortion
   Inevitable Abortion
   Incomplete Abortion
   Septic Abortion
   Missed Abortion
   Blighted ovum or Anembryonic Pregnancy
    –   Failure or absence of an embryo at a very early stage of

 Pregnancy   that ends spontaneously
  before the fetus has reached a viable
  gestational age.
 Corresponds to a gestational age of 20
  to 22 weeks.
Clinical Manifestation
   History of Amenorrhea
   Vaginal bleeding
    –   spotting or heavy
    –   intermittent or constant
    –   light or dark
    –   brief or lengthy (several weeks in duration)
    –   heavier and more persistent bleeding (carries a poor
   Abdominal pain
   Most common complication of early pregnancy.
   Approximately 10 to 20 percent of clinically
    recognized pregnancies under 20 weeks of
    gestation will undergo spontaneous abortion.
    –   80 percent of these occur in the first 12 weeks of
   Loss of unrecognized or sub clinical pregnancies
    is much higher - between 50% and 75%
   Over all 12% of clinically recognized pregnancies
    ended in spontaneous abortion.

 Clinicalassessment
 Quantitative beta hCG
 Ultrasonography
Clinical Assessment
 History
 Physical exam
 Studies

 GC/Chl
 Wet Prep
 Beta HCG
 Hemoglobin
 Rh Status
   Plays an important role in the diagnosis and
    management of first trimester bleeding
   Criteria for Definite diagnosis of nonviable IU
    pregnancy -
    –   Absence of fetal cardiac activity with C-R length of
    –   Absence of a fetal pole when the mean sac diameter is
        >25 mm by transabdominal US or >18 mm by the
        transvaginal technique.
Ultrasonogragphy                             (cont’d)

   Additional finding- predictive of impending
    pregnancy loss.
   An abnormal Yolk sac - large for gestational age,
    irregular, free floating in the gestational sac or
   Fetal HR <100 bpm at 5-7 wks gestation
   Small mean sac size
   Large subchorionic hematoma

 Counseling
 Expectant Management
 Medical Management
 Surgical Management
 Pre and post Counseling
 Panic and anxiety
 Guilt Feeling
Expectant Management
   As effective as medical or surgical treatment.
   Early pregnancy Failure <13 week gestation.
   Stable Vital signs
   No evidence of infection
   Majority of expulsions occur in the first 2 weeks of
   Uterine cavity evaluation by ultrasound
   Surgical evacuation is needed if retained tissue is > 15mm.
   Failure Spontaneous expulsion - Medical or surgical
Medical Management
   Prostaglandin E1 analog
    –   Oral - Low success rate
    –   vaginal - High success rate
        Recommendation: Misoprostol 400mcg every 4 hrs for 4 doses

   Combination of a progesterone antagonist
    and misoprostol
    –   Expensive
    –   Side effects
Medical Management
   Advantage
    –   Less Expensive
    –   Low incidence of side effects when used
    –   Ready availability
   Contra-indicated
    –   Asthma
    –   Glaucoma
Surgical Management
   D&C
    –   Conventional treatment for first or early second trimester
   Indications
    –   Evidence of incomplete abortion
    –   Heavy bleeding
    –   Intrauterine sepsis
    –   Patient’s preference
    –   Documented Fetal demise or blighted ovum.
   Risks
    –   Minimal, uterine perforation, interauterine adhesions, cervical
        trauma, infection and Anesthesia risks.
Examination of Tissue
   Crucial and underutilized skill in the management
    of first trimester bleeding problem.
   The main issue is whether the tissue is placenta -
    proving that pregnancy was intrauterine. Placental
    villi have a characteristic appearance best
    described as frond like or “seaweed floating under
    a dock”
   In all cases the tissue should be submitted for
    formal pathologic examination. In certain
    situations tissue is submitted for genetic studies.
Natural History
   One third of the products of conception from
    spontaneous abortions occurring at or before eight
    weeks of gestation are blighted. If embryo is
    found, there is 50% probability of it being
   Approximately 50% of miscarriages are
    cytogenetically abnormal.
   Earlier the gestational age at abortion, the higher
    the incidence of chromosomal defects.
Post Abortion Care
   Immediate Care after D&C
    –   Observation for Hemorrhage or change in vital
   General Care
    –   Women who are Rh(D) negative
    –   doxycycline 100 mg bid on the day of the
    –   Methylergonovine maleate 0.2 mg every 4 hours
        for five doses
    –   Pelvic rest - nothing per vagina for two wks
Post Abortion Family Planning
 Pregnancy can be deferred for two to three
  months however there is no greater risk of
  adverse outcome with a shorter pregnancy
 Contraception - Any type including IUD
  may be started immediately.
 Grief counseling is appropriate as needed.
Take Home Points
 Always do vaginal exam with sterile
 If not confident about passage of complete
  tissue, perform ultrasound
 Counseling and emotional support is
 Follow up on regular basis

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