6. Early pregnancy loss/Spontaneous abortion Flashcards
Define: Stillbirth (1)
Death that occurs following 20 wk gestation or weighing more than 500 g
Define: Therapeutic abortion (1)
Termination of pregnancy
Define: Spontaneous abortion/ miscarriage
Pregnancy which ends spontaneously before the fetus reaches 500 g or 20 wk gestation
Define: Intrauterine fetal demise (1)
Pregnancy that ends spontaneously after 10–20 wk
True or False
10% to 20% of clinically recognized pregnancies end in miscarriage.
True
Name the most frequent trisomies in clinical miscarriage (5)
16, 22, 21, 15, and 13
80% of miscarriages occur when? (1)
in the first 12 wk of pregnancy.
Name: Risk factors for pregnancy loss (8)
- GA (↑ risk with earlier age)
- Advanced maternal age
- Previous miscarriage
- Smoking
- EtOH
- Cocaine use
- > 1 alcoholic drink/d
- Caffeine (> 375 mg of caffeine)
Name etiologies of spontaneous abortion (9)
- Blighted or anembryonic pregnancy
- Chromosomal anomalies (50% )
- Teratogen exposure (e.g., maternal diabetes, mercury)
- Trauma (e.g., amniocentesis)
- Uterine factors (e.g., uterine septum, submucosal fibroids)
- Maternal infection/disease
- Maternal endocrinopathies (e.g., hypothyroidism)
- Thrombophilia
- Unexplained
Above 40 yr of age, the miscarriage rate is estimated at how much?
45%.
Describe approach to pregnancy loss (5)
- Stable orunstable?
- Assess general appearance, vital signs, and clinical status.
- First ensure the patient is hemodynamically stable. Bleeding during miscarriage can be severe.
- History
- Physical Exam
- Investigations
- Diagnosis and management: It is important to R/O ectopic pregnancy
Describe history of pregnancy loss (3)
- The patient Hx and physical exam characterizes the extent of bleeding and Sx of anemia and screens for possible causes of abnormal vaginal bleeding.
- It is especially important to determine:
- Estimated gestational age (based on LMP or U/S dating)
- Presence of abdo cramping and Hx of passing products of conception (liver-like material)
- Obstetrical Hx including number of prev. pregnancy losses
- Screen for possible causes for pregnancy loss
- Must exclude the urinary tract and GI tract as sources of bleeding
Describe physical exam of pregnancy loss (3)
- Vital signs and clinical status
- Abdo exam
- Speculum exam is important to look for products of conception and cervical dilation and to R/O non vaginal source of bleeding
Describe investigation of pregnancy loss (2)
- CBC, group and screen, serum b-hCG
- Endovaginal U/S can be useful to investigate location of pregnancy and to assess viability of pregnancy
Define: Missed abortion (2)
- Death of the fetus occurring in utero with retention of the pregnancy
- Anembryonic pregnancy: a type of missed abortion characterized by a gestational sac with no fetal pole
Name types of miscarriage (7)
- Missed abortion
- Complete abortion
- Incomplete abortion
- Threatened abortion
- Inevitable abortion
- Septic abortion
- Recurrent pregnancy loss
Describe RX: Missed abortion (3)
- D&C
- Misoprostol
- Expectant management
Define: Complete abortion (1)
Spontaneous expulsion of all fetal and placental tissue before 20 wk of gestation
Describe RX: Complete abortion (2)
- Ensure hemodynamic stability
- Supportive
Define: Incomplete abortion (1)
Incomplete expulsion of the products of conception before 20 wk of gestation
Describe RX: Incomplete abortion (2)
- D&C
- Misoprostol
Define: Threatened abortion (3)
- Bleeding occurring during the first 20 wk of gestation without the passage of tissue or cervical dilation
- In the presence of fetal cardiac activity, a high proportion of pregnancies continue.
- Occurs in 30% –40% of all pregnancies
Describe RX: Threated abortion (1)
Expectant management
Define: Inevitable abortion (2)
- Bleeding ± ROM accompanied by cramping and dilation of the cervix
- Gestational tissue may be seen through the internal os.
Describe RX: Inevitable abortion (3)
- D&C
- Misoprostol
- Expectant management
Define: Septic abortion (2)
- Infection of retained products of conception by S. aureus, GN bacilli, or gram positive cocci
- Infection can cause peritonitis and sepsis.
Describe RX: Septic abortion (2)
- IV Antibiotics
- D&C
Describe: Recurrent pregnancy loss (5)
- > 3 spontaneous consecutive rst trimester losses
- RPL affects 5% of couples attempting to conceive.
- In two-thirds of couples with RPL, one or more factors will be identified as being responsible.
- Infertility or advancing maternal age may prompt investigation for RPL after two miscarriages.
- In addition to taking the Hx above, additional information is required to screen for possible causes of RPL
Describe RX: Recurrent pregnancy loss (3)
- D&C
- Misoprostol
- Work-up for recurrent pregnancy loss
Describe: Recurrent Pregnancy Loss (RPL)
In addition to taking the Hx above, additional information is required to screen for possible causes of Recurrent Pregnancy Loss (RPL). Name them (6)
- Estimated gestation of each miscarriage (by U/S, LNMP, embryopathology if available)
- Features of autoimmune disorders
- Hx of infertility
- Endocrinologic Hx: Sx of thyroid disease, prolactinoma, or diabetes
- Toxicologic Hx (including tobacco, EtOH, and caffeine use)
- Hx of thrombosis
Close monitoring of the psychosocial well-being of
patients with RPL is essential, why? (1)
because these patients are susceptible to depression, anxiety, and heightened anger.
Name lab investigations for recurrent miscarriage (6)
TIE GAME
- Thrombophilic: Inherited coagulopathy leading to thrombosis of the intervillous space and spiral arteries
- Immunologie
- Endocrine: DM, Thyroid dysfunction, Hyperprolactinemia
- Genetic/chromosomal
- Anatomic: Septate uterus, Leiomyomas, Intrauterine synechiae (i.e., Asherman syndrome)
- Environmental/toxicologic
Name diagnostic tests for thrombophilic investigations for recurrent miscarriages (6)
- Factor V Leiden mutation
- Prothrombin gene mutation
- Homocysteine level
- Protein C activity
- Protein S activity
- Antithrombin activity
Name RX for thrombophilic factors for recurrent miscarriages (2)
- Heparin—LMWH or unfractionated
- Folicacid
Name diagnostic tests for immunologic investigations for recurrent miscarriages (3)
Antiphospholipid antibodies
- Anticardiolipin antibody (IgG/IgM)
- b2-glycoprotein 1 (IgG/IgM)
- Lupus anticoagulant
Name RX for immunologic factors for recurrent miscarriages (2)
- ASA
- Heparin
Name diagnostic tests for endocrine investigations for recurrent miscarriages (3)
- Fasting glucose or Hb(A1c)
- TSH (hypothyroidism)
- Prolactin PRL
Name RX for endocrine factors for recurrent miscarriages (3)
- Metformin, insulin, hypoglycemic diet
- Levothyroxine
- Bromocriptine, cabergoline
Name diagnostic tests for genetic/chromosomal investigations for recurrent miscarriages (1)
Cytogenetic analysis of both partners (e.g., balanced reciprocal translocation)
Name RX for genetic/chromosomal factors for recurrent miscarriages (3)
- Genetic counseling
- Donor gametes
- Preimplantation genetic Dx
Name diagnostic tests for anatomic investigations for recurrent miscarriages (2)
- Hysteroscopy
- Hysterosalpingogram (HSG)
Name RX for anatomic factors for recurrent miscarriages (2)
- Adhesiolysis
- Hysteroscopic resection of uterine septum
Name diagnostic tests for Environmental/toxicologic investigations for recurrent miscarriages (2)
- Review tobacco, ethanol, caffeine use
- Review exposure to toxins and chemicals
Name RX for environmental/toxicologic factors for recurrent miscarriages (1)
Eliminate consumption or exposure
Describe the definitive cause of fetal death (2)
- is unrecognized in > 25% of cases.
- However, numerous investigations are recommended following a stillbirth
Name Complications of D& C/D (5)
- Bleeding
- Cervical injury
- Uterine perforation
- Endometritis
- Retained products of conception
Name MATERNAL RFs for stillbirth (9)
- Extremes of maternal age
- Nulliparity
- Maternal smoking during pregnancy
- High prepregnancy weight
- Prior fetal loss
- Inadequate prenatal care
- Lower SES
- Reproductive tract infections
- Abdo trauma
- Maternal medical disorders:
- Thromboembolic disorders
- DM
- Hypertensive disorders
- Thrombophilia
- AI diseases
- Epilepsy
- Severe anemia
- Severe maternal heart disease
- Cholestasis of pregnancy
Name FHX RFs for stillbirth (5)
- Hx of recurrent spontaneous abortions
- VTE and/or PE
- Previous child born with a congenital anomaly, abnormal karyotype syndrome
- Child with documented developmental delay
- Consanguinity
Name FETAL CONDITIONS RFs for stillbirth (7)
- Congenital anomaly
- Fetal infection (TORCH)
- Fetal growth restriction
- Massive placental abruption
- Maternal-fetal hemorrhage
- Rh alloimmunization
- Multiple gestation
Name MATERNAL Investigating of stillbirth (9)
- CBC
- Blood group and antibody screen
- Hb (A1c)
- Kleihauer-Betke test
- TORCH infection serology: toxoplasma, rubella, cytomegalovirus, herpes virus, HIV, hepatitis virus, parvovirus B19
- Karyotype of both parents
- Hb electrophoresis (possible thalassemia)
- Antiplatelet antibodies (possible alloimmune thrombocytopenia)
- DIC screening (INR, PTT, fibrinogen)
- Thrombophilia screen 6–8 wk after delivery (as protein levels normally ↓ during pregnancy):
Name FETAL investigations of stillbirth (3)
- Autopsy (~25% of cases, no cause of death can be identi ed)
- Karyotype
- Cytogenetic studies (if have evidence of congenital malformation, IUGR, hydrops, ambiguous genitalia, or dysmorphic features)
Name PLACENTAL investigations of stillbirth (6)
Careful examination of the placenta:
- Chorionicity of the placenta
- Thrombosis of the cord/true knot in the cord
- Visible abruption, placental infarcts
- Placental vascular malformations (vasa previa)
- Signs of chorioamnionitis
- Bacterial culture of chorion (GBS, Listeria, E. coli)
Name methods of abortion: First trimester abortion (2)
- Vacuum curettage
- Misoprostol
Describe mechanism: Vacuum curettage (3)
- Cervical dilatation using metal dilators ± vaginal misoprostol before procedure
- A plastic vacuum cannula is placed in the uterus through the cervix and the products of conception are aspirated.
- Performed under general or local anesthesia, or with conscious sedation
Describe mechanism: Misoprostol (2)
- Analog of PGE1
- Vaginal administration of 800 mg × 2 (24 h apart) produces complete abortion in 91% of pregnancies up to 56 d of amenorrhea.
Name methods of abortion: Second-trimester abortion (> 13 wk) (3)
- D&E
- Labor induction
- Oxytocin
Describe mechanism: D&E (2)
- Prepare cervix with laminaria (hygroscopic dilator which expands as it absorbs moisture) ± misoprostol to dilate cervix
- A vacuum cannula is used to extract the fetus and placenta under general anesthetic.
Describe mechanism: Labor induction (2)
- Misoprostol administered vaginally may induce labor—400 mg administered vaginally q6h (highly effective).
- Dinoprostone (a PGE2 analog) may also be used.
Describe mechanism: Oxytocin (1)
Oxytocin may be used from 17–24 wk of pregnancy.
Name: Side effects and complications of misoprostol (6)
- Fever
- Nausea/vomiting
- Diarrhea
- Retained products of conception
- Bleeding
- Uterine rupture
Are health professionals are not required to perform abortions? (1)
No
Health professionals are not required to perform abortions, but have a duty to share all information and options with their patients, and make appropriate arrangements.
Describe link between uterine rupture and misoprostol (1)
a few case reports have been reported in patients given misoprostol who have had a previous C/S.
