Abortion Flashcards
Are spontaneous abortions very very common?
YES
What is abortion?
- TERMINATION of PREGNANCY either spontaneous “miscarriage” or intentionally before the fetus develops sufficiently to survive.
- termination prior to 20 weeks gestation or less than 500 g.
What are the 2 important questions we need to consider in the first trimester?
- Location (where is it)= Ultrasound.
2. Quality (B-hCG…)
What is your dDx for first trimester bleeding?
- extrauterine= ectopic
- intrauterine= early intrauterine pregnancy (IUP), threatend spontaneous abortion (SAb), inevitable SAb, complete SAb, Missed SAb, or blighted ovum (anembryonic pregnancy).
What 2 things will tell you what is happening to your patient?
- ultrasound
- B-hCG
What is the discriminatory zone?
- B-hCG titer at which intrauterine gestational sac is reliably seen with transvaginal US (1,500-2,000 mIU/mL).
What B-hCG dynamic indicates a normal pregnancy?
- doubling in 48 hours
What is the first anatomic structure that can be identified within the gestational sac?
- yolk sac (spherical with echogenic periphery and sonolucent center).
** What is a COMPLETE spontaneous abortion “miscarriage”?
- placenta detaches, bleeding, and expulsion of products of conception (POC), cervical os then closes.
** What is an INCOMPLETE spontaneous abortion “miscarriage”?
- placenta detaches, os opens, bleeding, may pass some of POC, os remains OPEN.
** What is a THREATENED spontaneous abortion “miscarriage”?
- bleeding but CERVIX is CLOSED, no expulsion of POC.
* sometimes this just goes away and everything is fine.
** What is an INEVITABLE spontaneous abortion “miscarriage”?
- fluid leaking, bleeding and CERVIX is DILATED, no expulsion of POC.
** What is a MISSED spontaneous abortion “miscarriage”?
- uterus retains the POC, no fetal heart tones (FHTs), os closed. No symptoms.
- usually detected on ultrasound/doppler at prenatal visit.
** What is RECURRENT spontaneous abortion “miscarriage”? (also called “habitual aborter”)
- 3 or more consecutive spontaneous abortions.
* must investigate as to why this happens. Usually chromosomal.
What major risk do mothers face with Missed Ab?
- DIC after 4-5 weeks :(
What is the pathophysiology of abortion?
- many different reasons, but hemorrhage begins into the decidua basilis followed by necrosis of the tissues adjacent to the bleeding.
- the ovum detaches, uterine contractions begin, and POC expelled.
When do 80% of most spontaneous abortions occur?
- 1st twelve weeks of gestation.
* half are from chromosomal anomalies (usually trisomy).
What increases incidence of abortion?
- age
- parity
- conception within 3 months of a full term delivery.
What are some causes of spontaneous abortion?
- infections
- hypothyroidism
- progesterone deficiency
- drugs and alcohol
- autoimmune: antiphospholipid antibodies (lupus, anticardiolipin antibody)= placental infarctions and thrombosis.
- thrombophilias
- Asherman’s syndrome
- insufficient cervix (habitual aborters).
How do you evaluate for a spontaneous abortion?
- focused PE:
- vaginal exam to see where bleeding is coming from.
- pelvic exam
- ULTRASOUND
- LABS
What labs should you order if you suspect spontaneous abortion?
- B-hCG
- blood count
- blood type (RHoGAM if indicated for Rh - status)
How do you manage/treat?
- observation
- medical (misoprostol or methotrexate)
- surgical (D&E)
- laminaria (seaweed that dilates the cervix)
- emotional support (don’t forget about dad)
- follow B-hCG until reaches zero.
What is elective and therapeutic termination/
- medical or surgical termination of pregnancy before time of fetal viability.
- THERAPEUTIC= if medically indicated (cervical cancer, heart disease, rape, incest, fetus with significant anatomical deformities not compatible with life).
- ELECTIVE= voluntary interruption of pregnancy before viability at the woman’s request with no medical indication.
On what is the termination procedure based?
- gestational age
How is termination performed?
- D&C or D&E= dilation and curettage/evacuation. Cervix is dilated and uterine contents are removed (scraped/suctioned out with a curette).
- Done up to 20 weeks in some states.
How late can you offer medical abortion?
- up to 49 days gestation (mioprostol +/- mifepristone)
What is Mifepristone? (PICMONIC)
- reverses the progesterone that acts by stabilizing the pregnancy and inhibiting contractions.
What is Misoprostol? (PICMONIC)
- prostaglandin that stimulates the myometrium to contract and expel POC.
What is methotrexate? (PICMONIC)
- antimetabolite that inhibits dihydrofolate reductase causing cell death.
How are 2nd trimester terminations handled?
- in the hospital with adequate IV access, surgery or medical. Consider pain control and beware of significant bleeding.
What is septic abortion?
- uterine infection during or immediately after a spontaneous abortion.
How do you treat a septic abortion?
- broad spectrum antibiotics
- evacuate any remaining POC and monitor for septicemia or DIC in hospital.
