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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
Q

Define: Inevitable abortion (2)

A
  • Bleeding ± ROM accompanied by cramping and dilation of the cervix
  • Gestational tissue may be seen through the internal os.
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26
Q

Describe RX: Inevitable abortion (3)

A
  • D&C
  • Misoprostol
  • Expectant management
27
Q

Define: Septic abortion (2)

A
  • Infection of retained products of conception by S. aureus, GN bacilli, or gram positive cocci
  • Infection can cause peritonitis and sepsis.
28
Q

Describe RX: Septic abortion (2)

A
  • IV Antibiotics
  • D&C
29
Q

Describe: Recurrent pregnancy loss (5)

A
  • > 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
Q

Describe RX: Recurrent pregnancy loss (3)

A
  • D&C
  • Misoprostol
  • Work-up for recurrent pregnancy loss
31
Q

Describe: Recurrent Pregnancy Loss (RPL)

A
32
Q

In addition to taking the Hx above, additional information is required to screen for possible causes of Recurrent Pregnancy Loss (RPL). Name them (6)

A
  • 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
Q

Close monitoring of the psychosocial well-being of
patients with RPL is essential, why? (1)

A

because these patients are susceptible to depression, anxiety, and heightened anger.

34
Q

Name lab investigations for recurrent miscarriage (6)

A

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
Q

Name diagnostic tests for thrombophilic investigations for recurrent miscarriages (6)

A
  • Factor V Leiden mutation
  • Prothrombin gene mutation
  • Homocysteine level
  • Protein C activity
  • Protein S activity
  • Antithrombin activity
36
Q

Name RX for thrombophilic factors for recurrent miscarriages (2)

A
  • Heparin—LMWH or unfractionated
  • Folicacid
37
Q

Name diagnostic tests for immunologic investigations for recurrent miscarriages (3)

A

Antiphospholipid antibodies

  • Anticardiolipin antibody (IgG/IgM)
  • b2-glycoprotein 1 (IgG/IgM)
  • Lupus anticoagulant
38
Q

Name RX for immunologic factors for recurrent miscarriages (2)

A
  • ASA
  • Heparin
39
Q

Name diagnostic tests for endocrine investigations for recurrent miscarriages (3)

A
  • Fasting glucose or Hb(A1c)
  • TSH (hypothyroidism)
  • Prolactin PRL
40
Q

Name RX for endocrine factors for recurrent miscarriages (3)

A
  • Metformin, insulin, hypoglycemic diet
  • Levothyroxine
  • Bromocriptine, cabergoline
41
Q

Name diagnostic tests for genetic/chromosomal investigations for recurrent miscarriages (1)

A

Cytogenetic analysis of both partners (e.g., balanced reciprocal translocation)

42
Q

Name RX for genetic/chromosomal factors for recurrent miscarriages (3)

A
  • Genetic counseling
  • Donor gametes
  • Preimplantation genetic Dx
43
Q

Name diagnostic tests for anatomic investigations for recurrent miscarriages (2)

A
  • Hysteroscopy
  • Hysterosalpingogram (HSG)
44
Q

Name RX for anatomic factors for recurrent miscarriages (2)

A
  • Adhesiolysis
  • Hysteroscopic resection of uterine septum
45
Q

Name diagnostic tests for Environmental/toxicologic investigations for recurrent miscarriages (2)

A
  • Review tobacco, ethanol, caffeine use
  • Review exposure to toxins and chemicals
46
Q

Name RX for environmental/toxicologic factors for recurrent miscarriages (1)

A

Eliminate consumption or exposure

47
Q

Describe the definitive cause of fetal death (2)

A
  • is unrecognized in > 25% of cases.
  • However, numerous investigations are recommended following a stillbirth
48
Q

Name Complications of D& C/D (5)

A
  • Bleeding
  • Cervical injury
  • Uterine perforation
  • Endometritis
  • Retained products of conception
49
Q

Name MATERNAL RFs for stillbirth (9)

A
  • 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
Q

Name FHX RFs for stillbirth (5)

A
  • 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
Q

Name FETAL CONDITIONS RFs for stillbirth (7)

A
  • Congenital anomaly
  • Fetal infection (TORCH)
  • Fetal growth restriction
  • Massive placental abruption
  • Maternal-fetal hemorrhage
  • Rh alloimmunization
  • Multiple gestation
52
Q

Name MATERNAL Investigating of stillbirth (9)

A
  • 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
Q

Name FETAL investigations of stillbirth (3)

A
  • 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
Q

Name PLACENTAL investigations of stillbirth (6)

A

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
Q

Name methods of abortion: First trimester abortion (2)

A
  • Vacuum curettage
  • Misoprostol
56
Q

Describe mechanism: Vacuum curettage (3)

A
  • 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
Q

Describe mechanism: Misoprostol (2)

A
  • 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
Q

Name methods of abortion: Second-trimester abortion (> 13 wk) (3)

A
  • D&E
  • Labor induction
  • Oxytocin
59
Q

Describe mechanism: D&E (2)

A
  • 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
Q

Describe mechanism: Labor induction (2)

A
  • Misoprostol administered vaginally may induce labor—400 mg administered vaginally q6h (highly effective).
  • Dinoprostone (a PGE2 analog) may also be used.
61
Q

Describe mechanism: Oxytocin (1)

A

Oxytocin may be used from 17–24 wk of pregnancy.

62
Q

Name: Side effects and complications of misoprostol (6)

A
  • Fever
  • Nausea/vomiting
  • Diarrhea
  • Retained products of conception
  • Bleeding
  • Uterine rupture
63
Q

Are health professionals are not required to perform abortions? (1)

A

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.

64
Q

Describe link between uterine rupture and misoprostol (1)

A

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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