intrauterine first and second trimester losses

Question 1

A 24 yo gravida 1, para 0 at 6 weeks gestational age (GA) complains of vaginal spotting and crampy suprapubic pain x 1 day. This is a planned pregnancy and she is very anxious. She states, “Could stress at work cause me to lose the baby?”

Answer 1

Your patient is examined and is found to have a closed internal os. Her blood type is A positive. The serum bHCG is 6,724 mIU/mL. Transvaginal ultrasound reveals an embryo measuring 6 weeks, 5 days estimated gestational age (EGA).
There is a fetal heartbeat.
You inform the patient of these results, and caution her of the risk of pregnancy loss. She expresses her understanding but is very relieved.

Question 2

abortion

Answer 2

-loss or termination <20 wks or weighs <500 gm
-miscarriage is a lay term -> avoid in documentation
-Pregnancy loss -> appropriate
-Voluntary / elective termination of pregnancy (VTOP or ETOP) -> abortion that pt seeks out
-Dobbs v. Jackson -> must be cautious about terms in the medical record

Question 3

1st trimester loss

Answer 3

-A nonviable, intrauterine pregnancy in the first 13 weeks with either:
-Empty gestational sac, OR
-gestational sac with embryo w/o fetal heart activity

-picture- risk of first trimester loss by maternal age
-by 40 you have a 40% change of loss

Question 4

1st trimester loss: epidemiology

Answer 4

-10% of pregnancies are lost -> 80% in 1st trimester
-More common in:
-AMA
-Prior hx of 1st trimester loss

-Most lost before pt knows of pregnancy (chemical pregnancy)
-Menses may be slightly heavier or longer than usual

-50% are due to chromosomal abnormalities:
-Trisomies (trisomy 21 [Down’s syndrome], and trisomies 13, 18, and 22) -> MCC
-Ds that cause loss -> infection, poorly controlled diabetes, thyroid ds, and lupus
-Radiation therapy
-Alcohol abuse
-Smoking
-Excessive caffeine use (>5 cups of coffee/day)
-Occupational toxic exposure

Question 5

types of 1st trimester spontaneous losses

Answer 5

-Threatened abortion
-Inevitable abortion
-Incomplete abortion
-Complete abortion
-Septic abortion
-Missed abortion

-threatened abortion -> inevitable abortion -> incomplete abortion -> complete abortion
-they can become each other

Question 6

remember the discriminatory zone?

Answer 6

-β-hCG at which intrauterine pregnancy (IUP) should be visible on US
-If β-hCG above threshold and no IUP is seen -> ectopic or early nonviable pregnancy should be suspected.

-IUP (visualization of a yolk sac or fetal pole) is visible at a bHCG of:
-1500 mIU/ml on transvaginal u/s
-6000 mIU/ml for transabdominal u/s

-ex. pt at 3,000 with no IUP seen on transvaginal -> ectopic or early nonviable suspected

Question 7

Answer 7

gestational sac seen on transvaginal US

Question 8

Answer 8

embryo with yolk sac

Question 9

Answer 9

yolk sac with fetal pole

Question 10

threatened abortion

Answer 10

-crampy pelvic pain and vaginal bleeding in first 20wks with intrauterine gestation and closed internal os
-how do you know its closed -> use your finger -> you cant open it with just your finger
-1st trimester vaginal bleeding occurs in 25% of pts -> can be yeast infection, sex, etc.

-scanty blood

Question 11

threatened abortion: hx and point of care testing

Answer 11

-amenorrhea or missed period
-vaginal bleeding
-crampy bilateral lower quadrant (BLQ) pain
-positive pregnancy test

Question 12

threatened abortion: PE findings

Answer 12

-Mild bilateral lower quadrant tenderness
-Blood in vaginal vault- Usually scanty
-Internal os is CLOSED
-Uterus is usually appropriately enlarged
-No significant adnexal masses or tenderness

Question 13

workup of threatened abortion

Answer 13

-urine and serum pregnancy test
-ABO, Rh
-pelvic US
-consider CBC if bleeding is heavy (usually not) -> its scanty bleeding but things can change (its a continuum sometimes)

Question 14

ultrasound findings: threatened abortion

Answer 14

-if the bHCG is past the discriminatory zone -> US is often consistent with +intrauterine pregnancy (IUP), perhaps with fetal cardiac activity visible depending on gestation age

Question 15

crown-rump length

Answer 15

-US measurement of embryo from top of head to bottom of torso
-measurable in eval of pt with a threatened abortion

-picture- the entire thing is an embryo

Question 16

management of threatened abortion

Answer 16

-if pt has a documented IUP on US that falls within parameters -> reassure pt and counsel about increased risk of spontaneous AB
-if there is no IUP on US -> r/o ectopic and counsel pt for threatened AB and ectopic dx

-administer Rho (D) immune globulin to all pts who are Rh negative

-observe- this is all you can do
-educate pt there is an increased risk of abortion throughout the pregnancy, ectopics

-if you have not documented an IUP via US -> you must provide ectopic precautions:
-Go to ED with: worsened pain, heavy vaginal bleeding, shoulder pain (irritation of the phrenic nerve if ectopic ruptures)
-Consider obtaining serum quantitative bHCG (doubles every 48hrs)
-Document that you provided ectopic precautions
-Important medicolegal matter

Question 17

inevitable and incomplete abortions

Answer 17

-inevitable ab: Rupture of amniotic sac or dilation of internal os prior to 20 wks
-if sac is ruptured -> no going back

-incomplete abortion: Passage of some products of conception prior to 20 wks

-Amenorrhea or missed period
-Vaginal bleeding
-heavier than threatened abortion
-May be profuse: ask about S&S of volume depletion and tampon / pad count
-significant bleeding = soaking 2 pads or more in a hour for > 2 hrs -> ER
-Crampy BLQ pain
-With incomplete AB: possible hx of passage of products of conception (POC)
-Positive urine pregnancy test

Question 18

rules

Answer 18

-If pt is bleeding into their shoes, that’s an impressive amount of blood loss
-If pt is bleeding into your shoes, the patient needs to be transfused

Question 19

inevitable and incomplete abortions: PE and data

Answer 19

-PE findings:
-Mild, moderate BLQ tenderness
-Blood in vaginal vault
-Internal os is OPEN!
-With incomplete AB: possible products of conception (POC) at os
-Uterus is usually appropriately enlarged
-No significant adnexal masses or tenderness

-Laboratory data:
-Obtain urine and serum bHCG
-CBC, ABO/Rh typing, possible type and crossmatch

Question 20

management of inevitable AB

Answer 20

-may manage expectantly -> but higher risk of septic abortion if rupture of amniotic sac

-medical and surgical management is same as incomplete AB

-be mindful of state laws that may well govern what you are able to offer in such cases

Question 21

initial management of suspected inevitable/incomplete AB

Answer 21

-check vitals; evaluate orthostatics

-if pt is orthostatic or bleeding heavily (soaking >2 pads/hr x 2 consecutive hrs), then:
-large bore IV
-Administer isotonic fluids (normal saline, lactated Ringer’s solution)
-Type and screen (for Rh status also)
-Possible type & crossmatch
-Obtain US of pelvis
-Measure gestational sac, if visible

Question 22

management of inevitable/incomplete abortion: medical

Answer 22

-helps empty the uterus -> contraction of uterus
-misoprostol with or w/o mifepristone
-misoprostol 800mcg orally x 1 dose if gestational sac is <2cm in diameter on US
-may repeat in 3 hrs and within 7 days if pt doesnt respond to 1st dose

-may also administer mifepristone 200mg:
-may be more effective in complete expulsion than with misoprostol alone
-> access can be problematic due to Dobbs v. Jackson

-pain meds:
-ketorolac
-morphine

-for Rh neg pts -> administer immune globulin

-expectant: watchful waiting (30mins); tincture of time, if bleeding is not heavy

Question 23

surgical management of inevitable/incomplete AB

Answer 23

-surgical: suction curettage (may be done in ED, office, or OR
->2cm gestational sac

-evacuation of uterus:
-manual vacuum aspiration- 1st line
-electrical vacuum suction curettage

-most clinicians will administer PO doxycycline x 1 single dose, x 3 days, or x 7 days with surgical evacuation of uterus

-aftercare:
-Check pathology
-Check Rh
-If negative, give Rho D immune globulin (RhoGAM) to prevent isoimmunization
-No sexual relations x 1-2 weeks
-May either attempt conception thereafter or may start contraception immediately after procedure

Question 24

manual vacuum aspiration (MVA)

Answer 24

-prior to MVA, suction curettage was performed
-MVA is portable; can be performed in ED; etc.
-less painful than suction curettage
-less disruptive to tissue for pathological analysis
-may be performed through 1st trimester

Question 25

electrical vacuum suction curettage

Answer 25

-May be performed if MVA is not available -Disadvantages: -More painful -Destructive to tissue; can make pathological analysis difficult -More difficult to perform for other types of abortions in very early 1st trimester -US guidance- make sure you dont perforate the uterus (softened during pregnancy)

Question 26

spontaneous abortion: hx and point of care testing

Answer 26

-Amenorrhea or missed period -Vaginal bleeding -May have been heavy -Is now improved -the pt went through the steps of threatened -> incomplete -> spontaneous -Crampy abdominal pain, now improved -Passage of POC -Point of care test- Positive urine pregnancy test

Question 27

spontaneous abortion: PE findings

Answer 27

-usually abdominal exam neg for significant tenderness -blood in vaginal vault- usually no active bleeding -internal os is closed (it was closed -> it opened -> and now its closed) -no passage of POC at present time -if the pt brings POC, send to pathology

Question 28

workup of spontaneous AB

Answer 28

-positive urine HCG -CBC, ABO/Rh (prior bleeding) -US to r/o threatened AB and/or ectopic as dx -possible serum bHCG

Question 29

spontaneous abortion: Aftercare

Answer 29

-check CBC -check Rh: -if neg -> give Rho (D) immune globulin -check pathology, if sent, to confirm that pt had IUP -OR: -follow bHCG if no pathology was sent; follow until neg -pelvic rest x 1-2 wks -may either attempt conception after waiting 1-2 wks to resume relations, or may start contraception immediately

Question 30

septic abortion

Answer 30

-Infection of uterine cavity and its contents before, during or after an abortion, whether spontaneous or induced, that may result in rapid and severe sepsis -retained contents of inevitable AB -physiologic effects of pregnancy that increase risk of sepsis: -Cardiac effects that worsen O2 delivery in septic shock -Increased risk of intrauterine infection due to increased uterine perfusion -Attenuated immune system -dont need to know the photo

Question 31

survival of sepsis in obstetric pts

Answer 31

-Pregnant pts with hypoxia, thrombocytopenia, renal and hepatic insufficiency, and who require pressors are: -Severely ill -At high risk of death

Question 32

risk factors and pathophysiology of septic abortion

Answer 32

-May occur after attempted termination of pregnancy (TOP) or after spontaneous loss -Bacteria enter uterus due to instrumentation or from persistent bleeding during spontaneous loss -Lower genital tract organisms ascend to endometrium -Anaerobes are more likely to infect the endometrium -Due to increased blood flow to pelvis -> 60% of pts with septic AB develop bacteremia -infection can lead to septic and toxic shock, and death, within hours

Question 33

common pathogens involved in septic shock

Answer 33

-Clostridium spp. -Group A Streptococcus -Staphylococcus aureus -Escherischia coli

Question 34

signs and symptoms of septic abortion

Answer 34

-Fever -Diarrhea and/or vomiting -Rash, especially with Streptococcus -> toxic shock syndrome -Abdominopelvic pain -Malodorous vaginal discharge -Cough -Dysuria

Question 35

evaluation of the pt with suspected septic AB

Answer 35

-Vital signs -Thorough abdominal and pelvic exams -Ultrasound of pelvis for retained products of conception -Anaerobic and aerobic cultures of cervix and uterus -Vaginal swabs for STIs -Blood and urine cultures -Serum lactate -Coagulation studies -BUN and creatinine

Question 36

management of septic AB

Answer 36

-Rapid recognition and tx are essential! -Start IV antibiotics -Gentamicin 5 mg/kg/day IV -Ampicillin 2 gm IV every 4 hours -Clindamycin 900 mg IV every 8 hours -Evacuation of uterine contents -Possible exploratory laparotomy and hysterectomy -> high risk already very sick -Careful and continuous reassessment -Consider ICU admission -Patients may require: -Intubation and mechanical ventilation -Central venous access -Vasopressors -IV antibiotics should be continued until the pt is asymptomatic and afebrile x 24 hours -Oral antibiotics may be provided x 10 days

Question 37

missed abortion

Answer 37

-Embryonic death without expulsion of uterine contents -Symptoms: NONE -Point of care testing: positive urine pregnancy test -PE findings -> Uterus small for dates -Ancillary testing -Positive urine bHCG -Plateau of serum bHCG, if obtained -Ultrasound c/w embryonic death (fetal pole or gestational sac without cardiac activity) -ABO/Rh

Question 38

management of missed abortion

Answer 38

-manual vacuum aspiration v. dilation and curettage -OR misoprostol, 600-800mcg, intravaginally or orally -> most pts will expel uterine contents within hours of administration of misoprostol -OR observation -> going home being pregnant with dead tissue is uncomfortable and not recommended -Rho(D) immune globulin for Rh negative pts -pelvic rest x 1-2 wks, if the pt has surgical management -may attempt conception after pelvic rest, or may use contraception immediately after management

Question 39

A 32 yo gravida 1, para 0 at 20 weeks GA presents with a sense of pelvic “heaviness” for 4 hours. She states, “I think maybe I broke my water about half an hour ago.”

Answer 39

Your patient delivers a previable fetus and the placenta two hours after admission. She receives appropriate counseling and is advised she will need a cerclage at 13 weeks if she decides to conceive again.

Question 40

cervical insufficiency

Answer 40

-MCC of 2nd trimester losses -Etiology is unknown -May include: -Hx of prior cervical surgery or innate deficiency of cervical collagen -History of uterine anomalies -Pts experience PAINLESS cervical dilation accomplished by uterine contractions -Frequently pts only are aware of a sense of heaviness, or of rupture of membranes (“breaking the water”)

Question 41

PE exam findings related to cervical insufficiency

Answer 41

-bimanual exam reveals significant or full dilation in 2nd trimester (not to the full extent) -"hourglassing membranes" seen on speculum exam or on US

Question 42

Answer 42

bulging membranes seen on speculum exam -this is going to dry out and rupture -put them in deep trendelinburg -> might go back in

Question 43

dx of cervical insufficiency

Answer 43

-hx of painless dilation with expulsion of pregnancy in 2nd trimester, typically prior to 24 wks -dx is typically made only at time of presentation, or retrospectively -no way of knowing unless we check

Question 44

Answer 44

-US image of bulging or hourglassing membranes -takes the path of least resistance -> where all the space is

Question 45

Answer 45

cervical insufficiency at 18 wks

Question 46

cervical insufficiency: management

Answer 46

-emergency cerclage (sew it shut) -infection may ensue -an important cause of failure -elective cerclage at 13-16 wks in a subsequent pregnancy -> higher risk -we do it at 13-16wks bc if its a first trimester loss -> we want it out

Question 47

Answer 47

cerclage seen on transvaginal US

Question 48

removal of cerclage

Answer 48

-If successful, remove cerclage at 36 weeks in office -If pt experiences preterm labor or preterm premature rupture of membranes, then remove with evidence of same (21-23wks) -Rupture of membranes -Cervical dilation

Question 49

which of the following is the most appropriate management of a 22 year old pt at 11 wks EGA with an incomplete abortion with a gestational sac measuring 3 cm

Answer 49

-watchful waiting -mifepristone 200mg PO x 1 -misoprostol 800mcg x 1 -suction curettage!!!! -> too big