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Essentials - Gynecology > 6. Early pregnancy loss/Spontaneous abortion > Flashcards

6. Early pregnancy loss/Spontaneous abortion Flashcards

1
Q

Define: Stillbirth (1)

A

Death that occurs following 20 wk gestation or weighing more than 500 g

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2
Q

Define: Therapeutic abortion (1)

A

Termination of pregnancy

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3
Q

Define: Spontaneous abortion/ miscarriage

A

Pregnancy which ends spontaneously before the fetus reaches 500 g or 20 wk gestation

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4
Q

Define: Intrauterine fetal demise (1)

A

Pregnancy that ends spontaneously after 10–20 wk

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5
Q

True or False

10% to 20% of clinically recognized pregnancies end in miscarriage.

A

True

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6
Q

Name the most frequent trisomies in clinical miscarriage (5)

A

16, 22, 21, 15, and 13

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7
Q

80% of miscarriages occur when? (1)

A

in the first 12 wk of pregnancy.

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8
Q

Name: Risk factors for pregnancy loss (8)

A
  • GA (↑ risk with earlier age)
  • Advanced maternal age
  • Previous miscarriage
  • Smoking
  • EtOH
  • Cocaine use
  • > 1 alcoholic drink/d
  • Caffeine (> 375 mg of caffeine)
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9
Q
A
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10
Q

Name etiologies of spontaneous abortion (9)

A
  • 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
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11
Q

Above 40 yr of age, the miscarriage rate is estimated at how much?

A

45%.

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12
Q

Describe approach to pregnancy loss (5)

A
  • 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
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13
Q

Describe history of pregnancy loss (3)

A
  • 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
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14
Q

Describe physical exam of pregnancy loss (3)

A
  • 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
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15
Q

Describe investigation of pregnancy loss (2)

A
  • CBC, group and screen, serum b-hCG
  • Endovaginal U/S can be useful to investigate location of pregnancy and to assess viability of pregnancy
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16
Q

Define: Missed abortion (2)

A
  • 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
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17
Q

Name types of miscarriage (7)

A
  • Missed abortion
  • Complete abortion
  • Incomplete abortion
  • Threatened abortion
  • Inevitable abortion
  • Septic abortion
  • Recurrent pregnancy loss
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18
Q

Describe RX: Missed abortion (3)

A
  • D&C
  • Misoprostol
  • Expectant management
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19
Q

Define: Complete abortion (1)

A

Spontaneous expulsion of all fetal and placental tissue before 20 wk of gestation

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20
Q

Describe RX: Complete abortion (2)

A
  • Ensure hemodynamic stability
  • Supportive
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21
Q

Define: Incomplete abortion (1)

A

Incomplete expulsion of the products of conception before 20 wk of gestation

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22
Q

Describe RX: Incomplete abortion (2)

A
  • D&C
  • Misoprostol
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23
Q

Define: Threatened abortion (3)

A
  • 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
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24
Q

Describe RX: Threated abortion (1)

A

Expectant management

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25
Define: Inevitable abortion (2)
* Bleeding ± ROM accompanied by cramping and dilation of the cervix * Gestational tissue may be seen through the internal os.
26
Describe RX: Inevitable abortion (3)
* D&C * Misoprostol * Expectant management
27
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.
28
Describe RX: Septic abortion (2)
* IV Antibiotics * D&C
29
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
30
Describe RX: Recurrent pregnancy loss (3)
* D&C * Misoprostol * Work-up for recurrent pregnancy loss
31
Describe: Recurrent Pregnancy Loss (RPL)
32
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
33
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.
34
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
35
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
36
Name RX for thrombophilic factors for recurrent miscarriages (2)
* Heparin—LMWH or unfractionated * Folicacid
37
Name diagnostic tests for immunologic investigations for recurrent miscarriages (3)
Antiphospholipid antibodies * Anticardiolipin antibody (IgG/IgM) * b2-glycoprotein 1 (IgG/IgM) * Lupus anticoagulant
38
Name RX for immunologic factors for recurrent miscarriages (2)
* ASA * Heparin
39
Name diagnostic tests for endocrine investigations for recurrent miscarriages (3)
* Fasting glucose or Hb(A1c) * TSH (hypothyroidism) * Prolactin PRL
40
Name RX for endocrine factors for recurrent miscarriages (3)
* Metformin, insulin, hypoglycemic diet * Levothyroxine * Bromocriptine, cabergoline
41
Name diagnostic tests for genetic/chromosomal investigations for recurrent miscarriages (1)
Cytogenetic analysis of both partners (e.g., balanced reciprocal translocation)
42
Name RX for genetic/chromosomal factors for recurrent miscarriages (3)
* Genetic counseling * Donor gametes * Preimplantation genetic Dx
43
Name diagnostic tests for anatomic investigations for recurrent miscarriages (2)
* Hysteroscopy * Hysterosalpingogram (HSG)
44
Name RX for anatomic factors for recurrent miscarriages (2)
* Adhesiolysis * Hysteroscopic resection of uterine septum
45
Name diagnostic tests for Environmental/toxicologic investigations for recurrent miscarriages (2)
* Review tobacco, ethanol, caffeine use * Review exposure to toxins and chemicals
46
Name RX for environmental/toxicologic factors for recurrent miscarriages (1)
Eliminate consumption or exposure
47
Describe the definitive cause of fetal death (2)
* is unrecognized in \> 25% of cases. * However, numerous investigations are recommended following a stillbirth
48
Name Complications of D& C/D (5)
* Bleeding * Cervical injury * Uterine perforation * Endometritis * Retained products of conception
49
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
50
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
51
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
52
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):
53
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)
54
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)
55
Name methods of abortion: First trimester abortion (2)
* Vacuum curettage * Misoprostol
56
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
57
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.
58
Name methods of abortion: Second-trimester abortion (\> 13 wk) (3)
* D&E * Labor induction * Oxytocin
59
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.
60
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.
61
Describe mechanism: Oxytocin (1)
Oxytocin may be used from 17–24 wk of pregnancy.
62
Name: Side effects and complications of misoprostol (6)
* Fever * Nausea/vomiting * Diarrhea * Retained products of conception * Bleeding * Uterine rupture
63
Are health professionals are not required to perform abortions? (1)
No ## Footnote 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.
64
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.

Essentials - Gynecology (14 decks)

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