Abortion Flashcards
nonviable intrauterine pregnancy (IUP) defines as
either an empty gestational sac or a gestational
sac containing an embryo or fetus without fetal heart activity within the first 12+6 weeks of gestation.
Trisomies typically result from
isolated nondisjunction
Most common abnormalities in 1st trimester abortions
are aneuploidy (trisomy) found in 50 to 60 percent; monosomy X, in 9 to 13 percent; and triploidy, in 11 to 12 percent
Triploidy is often associated with
hydropic or molar placental degeneration
Adverse outcomes that increased with threatened abortion
perinatal: - miscarriage - preterm delivery - PPROM/PROM - SGA/ FGR - IUFD/NND MATERNAL: - PP / AP - MROP - CS - higher recurrence rates in future pregnancies
INCOMPLETE ABORTION MANAGMENT:
three management options include curettage,
expectant management, or misoprostol (Cytotec), which is prostaglandin E1. The last two are deferred in clinically unstable women or those with uterine infection.
what is the failure rates Expectant management of spontaneous incomplete abortion
that approximate 25 percent
failure rates of Medical therapy in incomplete abortions
5 to 30 percent
Characteristic US findings of a complete abortion
minimally thickened endometrium without a gestational sac.
a complete abortion cannot be surely diagnosed unless:
(1) true products of conception are seen grossly
or (2) unless sonography confidently documents first an intrauterine pregnancy and then later an empty cavity.
In unclear settings, serial serum hCG level
measurements aid clarification. With complete abortion, these levels drop quickly
US Findings in missed abortion
- CRL ≥ 7 mm and no heartbeat
- MSD ≥ 25 mm and no embryo
- An initial US scan shows a gestational sac with yolk sac, and after ≥ 11 days no embryo with a heartbeat is seen
- An initial US scan shows a gestational sac without a yolk sac, and after ≥ 2 weeks no embryo with a heartbeat is seen + the MSD should have failed to double.
Preterm premature rupture of membranes (PPROM) at a previable gestational age incidence:
complicates 0.5 percent of pregnancies
Risks for spontaneous rupture at a previable gestation are
prior PPROM, prior second-trimester delivery, and tobacco use
what confirms the diagnosis of PPROM?
A gush of vaginal fluid that is seen pooling during sterile speculum examination
with second-trimester spontaneous PPROM at a
previable age, What percentage that a woman may deliver next week? percentage of delivery next 2-5 wks
40 to 50 percent of women will deliver within the first week, and 70 to 80 percent will do so after 2 to 5 weeks
Significant maternal complications attend previable PPROM
include chorioamnionitis, endometritis, sepsis, placental abruption, and retained placenta
(Waters, 2009). With bleeding, cramping, or fever, abortion is considered inevitable, and the uterus is evacuated.
Most bacteria causing septic abortion are part of the normal vaginal flora. Particularly worrisome are severe necrotizing infections and toxic shock syndrome caused by
group A streptococcus—S
pyogenes
what the percentage of Rh-D women got alloimmunized with spontaneous miscarriage if she doesn’t receive anti-D
2 percent
the American Society for Reproductive Medicine (2013)
now defines RPL as
two or more failed pregnancies confirmed by sonographic or histopathological examination.
The prevalence of cervical insufficiency is higher in inherited defects (in collagen assembly or synthesis)like….
Marfan syndrome or Ehler-Danlos syndrome
Primary RPL refers to
multiple losses in a woman who has never delivered a liveborn.
secondary RPL refers to
multiple pregnancy losses in a patient with a prior live birth.
the chances for a successful pregnancy are (….) percent even after five losses
> 50
Three widely accepted causes of RPL are
parental chromosomal abnormalities, antiphospholipid antibody syndrome, and structural uterine abnormalities.
Parental Chromosomal Abnormalities account for only ……..percent of RPL cases
2 to 4 %
Of abnormalities, reciprocal translocations are most common and followed by robertsonian translocations
Asherman syndrome result from destruction of large areas of endometrium. This can follow ?
uterine curettage, hysteroscopic surgeries, or uterine compression sutures.
……… percent of recurrent
miscarriages are caused by endocrine factors.
8 to 12%
the spontaneous loss rate in the second ranges
from 1.5 to 3 percent and, after 16 weeks, is only 1 percent
Cervical length screening is now recommended by both the ACOG (2016b) and the Society for MFM (2015) for women with prior preterm birth. Between
16- 24 weeks’ gestation, sonographic cervical measurement is completed every 2 weeks.
If an initial or subsequent cervical length is 25 to 29 mm, then a weekly interval is considered. If the cervical length measures <25 mm, cerclage is offered to this group of women.
Notably, for women without a history of preterm birth but with a short cervix incidentally identified sonographically, progesterone therapy is offered
instead of cerclage.
Presurgical Preparation for cervical cerclage (ideally done btw 12-14)
Preoperatively, screening for aneuploidy and obvious malformation is completed. Cervical secretions are tested for gonorrhea and chlamydial infection.
These and obvious cervical infections are treated.
McDonald cerclage procedure technique
with a no. 2 monofilament suture being placed in the body of the cervix very near the level of the internal os. Encirclement of the cervix, The suture is tightened around the cervical canal sufficiently to reduce the diameter of the canal to 5 to 10 mm, and then the suture is tied.
Modified Shirodkar cerclage technique
transverse incision is made in the mucosa overlying the anterior cervix, bladder is pushed cephalad. A 5-mm Mersilene tape on a swaged-on or Mayo needle is passed anterior to posterior. The tape is then directed posterior to anterior on the other side of the cervix. Allis clamps are placed so as to bunch the cervical tissue. This diminishes the distance that the needle must travel submucosally and aids tape placement. D. The tape is snugly tied anteriorly, after
ensuring that all slack has been taken up. The cervical mucosa is then closed with continuous stitches of chromic suture.
For uncomplicated pregnancies without labor, the cerclage is usually cut and removed at
37 weeks’ gestation. This balances the risk of preterm birth against that of cervical laceration from a cerclage in place with labor contractions.
With scheduled cesarean delivery, the cerclage may be removed at
37 weeks or deferred until the time of regional analgesia and delivery.
Transabdominal Cerclage reserved for cases with
severe cervical anatomical defects or prior transvaginal cerclage failure.
cervical preparation before evacuation
hygroscopic dilators, misoprostol 400 mcg sublingually, buccally, or placed into the posterior vaginal fornix 3 to 4 hours prior to surgery. also antiprogestin mifepristone, 200 mg given orally 24 to 48 hrs before surgery.
To prevent postabortal infection after a first- or second-trimester surgical evacuation,
prophylactic doxycycline, 100 mg orally 1 hour before and then 200 mg orally after, is provided (Achilles, 2011; ACOG, 2016a).
Cautions with medical abortion
current IUD; severe anemia, coagulopathy, or anticoagulant use; long-term systemic
corticosteroid therapy; chronic adrenal failure; inherited porphyria; severe liver, renal, pulmonary, or cardiovascular disease; or uncontrolled HTN.
Threatened Abortion increased risk of
. Preterm birth
. Placental previa
. Placental abruption
Whats the incidence of early pregnancy loss ?
10%. 80% of cases in the first trimester. For women aged 20-30»_space; 9-17%. At 35 yo 20%. At 40 yo 40%. At 45 yo 80%.
what is the failure rate of each line of management of incomplete abortion?
Curettage or expectant management or misoprostol. Expectant management has up to 25% failure rate. Medical management has a 5-30% failure rate. Curettage has up tp 100% successful rate.
What are the outcomes of PPROM in the pre-viable age?
40-50% of patients will deliver in the first week. 70-80% will do so after 2-5 weeks.
What are the complications of PPROM in the pre-viable age?
Chorioamnionitis. Endometritis, Sepsis. Placental abruption. Retained products of conception.
is there any role of expectant management in pre-viable PPROM?
Yes, if there are no complications as mentioned above. In a well counseled patient. But in 50-80% of surviving infants will suffer from long-term sequelae.
What are the recommendations regarding Anti-D administration post abortion?
ACOG recommends to be given at 300 micrograms IM for all gestational ages. 50 micrograms if less than 12 weeks and 300 micrograms if more than 13 weeks. If surgical evacuation was done it should be given afterwards immediately, but If medical termination was done , it can be given within 72 hours.
is Expectant management approved in the a 2nd trimester miscarriage ? for up to how many weeks is Expectant management ? Up tp 8 weeks.
No , because of the lack of safety studies.
Expectant management Up tp 8 weeks.
Are antibiotics ( Doxycycline ) recommended pre op for surgical evacuation of EPL?
Yes , a single preoperative dose is recommended to prevent infection. Dose: 200 mg , 1 hour before the surgery. Or 100 mg Pre op followed by 200 mg after the procedure. Decrease the risk of infection by 40%.
for how long should the patient abstain from intercourse after EPL?
1-2 weeks to reduce the risk of infection.
What is the risk of uterine perforation in induced 2nd trimester abortions?
0.28% in a women with a previous c section. 0.04% in women without a prior c section.
What are the risk factors for hemorrhage?
Advanced maternal age.
Insufficient cervical dilation Use of general anesthesia.
A medical history of more than one cesarean delivery.
Aneuploidy accounts … % of 2nd trimester losses and ….. of stillbirth and early childhood deaths
20%, 6-8 %
