Abortion: Spontanous, Induced, Elective Flashcards
Pregnancy loss general overview
Any loss of pregnancy before 20 weeks
50-70% of spontaneous conceptions result in first trimester pregnancy lost
66% of implanted pregnancies that miscarry do so before clinical recognition
- most pregnancy losses occur before week 9
10-15% of pregnancy losses are “clinically recognized” (patient know they were pregnant and know they lost the pregnancy)
Factors that increase risk of pregnancy loss
- maternal age increased
- prior history of fetal loss
Pregnancy loss causes
50% are due to chromosomal abnormalities (most common collective group cause of pregnancy loss)
- need to get a karyotyping or microarray to diagnosis
- Autosomal trisomy is the most common cause with chromosome 6 trisomy being most tied to spontaneous abortions
- majority of the trisomy are caused by errors in oocyte maternal meiosis 1 (nondisjunction occurred)
Can be polyplodiy as well (triplody or tetraplodity)
Can be monosomy X (Turner syndrome)
- most common single chromosomal abnormality of spontaneous abortion
- 80% = loss of paternal sex chromsome
Unknown causes of pregnancy loss
Accounts for 30-50% of first trimester losses
Is distressing to patient
Recurrent pregnancy loss (RPL)
2 consecutive losses +
If. 2 = formal evaluation in over the age of 40 is usually required
If 3 = must work up for antiphospholipid syndrome and other evaluation criteria
- giving aspirin have shown decreased risk of early pregnancy loss
Types of spontaneous abortions
Spontaneous abortion = any loss <20 weeks gravida
Threatened abortion = uterine bleeding from gestation <20 weeks with a closed cervix and fetal cardiac activity
Missed abortion = intrauterine pregnancy <20 weeks without fetal cardiac activity and closed cervix
Incomplete abortion = intrauterine pregnancy <20 weeks with passage of some fetal tissue with cervix dilation
Inevitable abortion = intrauterine pregnancy <20 weeks with cervical dilation without expulsion of any dental tissues
Complete = <20 weeks with cervical dilation and complete expulsion of all fetal and placental tissue form uterus
Septic abortion = any abortion at all with uterine infection present (accounts for 1-2%)
Normal findings of early pregnancy
Physical exam and symptoms can show
- enlarged uterus
- blue-hue on the cervix (Chadwick sign)
- breast tenderness
- nausea/vomiting
Ultrasound findings
- gestational sac @ 5 weeks (dark circle structure)
- yolk sac @ 5.5 weeks
- Fetal pole with cardiac activity @ 6 weeks
Can you make a diagnosis of spontaneous abortion of B-hCG levels alone
NO
- must get ultrasound and or medical history and PE also to confirm
Serum B-hCG levels used in spontaneous
While it cant be used alone to diagnose spontaneous abortion, it a very good predictor of potential abortion
Found in maternal serum as early as 8-10 days
Overall rates increase most in first 6 weeks
Levels above 1500 IU = should see gestation sac on TVUS
Levels above 3000 IU = should see gestation sac on TAUS
Peaks around 20 weeks >200,000 IU
Molar pregnancies and twin pregnancies can make this level > 500,000 IU
if the levels start to decline or plateaued before week 16 = may be a abortion
ACOG cutoff for early pregnancy loss
Mean gestation sac diameter is 21mm with no embryo
Crown rump length of 5.3mm and no heart beat
If gestational sac with no yolk sac or embryo is present = repeat US in 7 days and if still hasn’t changed = pregnancy loss
Concerning signs for pregnancy loss
- slow fetal heart rate <100 bpm
- significant intrachorionic hemorrhages
3 treatment options for spontaneous abortion
Expectant
- 80% of patients achieve complete expulsion if given time
- typically only done for first trimester losses however since risk of hemorrhage is high in 2nd or 3rd trimester
- give counseling and expectations = soaking 2 pads/hour for 2 hrs with cramping
- to confirm completion = reported symptoms, urine pregnancy test, B-HCG levels and ultrasound
Medical
- shortens time to completion in women who wish to avoid surgery
- typically used in first trimester losses
- 800 mg of misoprostol either vaginally or sublingual (usually causes complete expulsion in 71% of women in first dose and 84% with second dose
- ** can consider adding mifepristone 20mg orally 24 hrs before misoprostal if possible to even more increase the efficacy or misoprostol
Surgical
- dilation and curettage in 1st trimester
- dilation and evacuation in 2nd trimester
- ** need to give 200 mg doxycycline as per operative antibiotics before procedures
- can cause asherman syndrome (uterine adhesions) and increases risk of uterine perforation
Follow up treatment to spontaneous abortions
Can do UPT, B-HCG level and ultrasound to confirm completion
- *must assess alloimmunization risk for future pregnancy**
- if mother is Rh negative= give RhoGAM 50-300mcg FAS prophylaxis
Ask about desire to do another pregnancy
- if they dont want one = need to talk about contraceptions
- can place IUD at time of suction D/C as expulsion rates are not different if placed 2-6 weeks post operatively
Induced abortions
Elective = personal decision based on women choice
Therapeutic = performed to maintain a women’s health
- pulmonary HTN, significant CAD or HTN that is uncontrolled
both are intentional
Most are down in early first trimester (60% <10 weeks)
Methods for first trimester
- surgery = manual vacuum and section
- medication =. Misoprostol + mifepristone is the most effective but misoprostol alone is the most common due to cost (still 71% affective)
How does abortion medications work
Misoprostol
- prostaglandin E1 analog
- induces labor in the uterus and also causes cervical softening = ejection of developing fetus
- can be administered in multiple different ways
Mifepristone
- selective progesterone receptor antagonist
- binds to progesterone receptors with a higher affinity than progesterone BUT doesn’t activate it
- causes inability of uterine growth and nourishment = fetal death
Methotrexate
- NOT used really since it increases risk of ectopic pregnancy
- blocks thymidine synthesis by inhibiting dihydrofolate reductase enzymes
- acts on cytotrophoblasts and not the embryo by stopping implantation ont he cervix
PROM vs PPROM
PROM = premature rupture of membranes
- rupture of membranes before onset of labor
- seen in 15% of pregnancies
- risk factors: multiple parity, cigarette smoking, previous PROM or preterm delivery, ascending infection (most common)
PPROM = preterm premature rupture of membranes
- rupture of membranes before labor and before 37 weeks gestation
- seen in 2-5% of pregnancies
- presents with a sudden gash of pale yellow/clear fluid from vagina with a constant “leaking” sensation
Both treatment
- > 34 weeks = deliver fetus
- 22-33 weeks = bed rest, corticosteroids to help fetal lungs, antibiotics against GBS and plan the delivery. Can consider using tocolysis treatment (income that in + magnesium sulfate) to delay treatment but it is contraindicated in cervical dilation > 4 cm, chorioamnionits and placenta abruption
Second trimester induced abortion
> 13 weeks can be medical or elective reasons
Medical reasons
- preeclampsia
- previable PPROM
- infection
- maternal cardiovascular compromise
- maternal pulmonary compromise
Causes for delay treatment in elective abortions in 2nd trimester
- insurance reasons, delay/ obstacles with referrals, state laws are strict, diagnosis of major fetal and anatomic/genetic issues are present
Ways to do it: (more complicated but still safe)
1) surgical = dilation and evacuation (need to dilate cervix larger and higher risk of hemorrhage
2) medications = same as first trimester but also give oxytocin to really get the contractions going
- need to also use Foley catheters or Laminaria (seaweed sticks that dilate the cervix) to dilate the cervic
