Module 9: (b) Early Pregnancy Loss

Question 1

Spontaneous Abortions (miscarriage)

Answer 1

1. Pregnancy that ends before 20 weeks
2. Up to 25% of pregnancies end in SAB
3. Classified by passage of products of conception (POC)
   - Threatened abortion - any vaginal bleeding - CLOSED cervix
   - Inevitable abortion - Bleeding + Dilation, No passage of POC
   - Incomplete abortion - partial expulsion of POC
   - Complete abortion - Expulsion of ALL POC
   - Missed abortion - Death of embryo or fetus, complete retention of POC

Question 2

SAB - 2nd Trimester Loss

Answer 2

1. 12-20 weeks
   - Caused by infection, trauma, maternal disease, anatomic abnormalities, cervical insufficiency, preterm labor
2. Treatment
   - D&E (dilation and evacuation
   - Induction of labor
3. Less Common

Question 3

SAB’s - 1st Trimester

Answer 3

1. 60-80% of all SABs are in the first trimester
   - Abnormal chromosomes cause 95% of SABs
2. Sx’s — vaginal bleeding, cramping, abdominal pain, decreased pregnancy Sx’s
3. Exam — VS’s and pelvic exam
4. Labs — CBC, quantitative HCG, Blood type, antibody screen
5. US for viability and r/o of Ectopic pregnancy
6. Treatment — Expectant, medication, surgical (D&C)
7. Provide Rhogam to Rh negative women
8. Offer contraception

Question 4

Treatment options for SAB

Answer 4

1. Expectant — Let “nature take its course” - Days to weeks to complete - might be inconvenient - Greatest risk for retained products
2. Medical — Use of misoprostol w/ or without mifepristone to aid in expulsion of POC
3. Surgical — Use of cervical dilation and suction w/ or w/out curettage of the uterus to remove POC

Question 5

Ectopic Pregnancy

Answer 5

1. > 95% are Tubal pregnancies
2. Heterotopic— Occurs in combination w/ an IUP ( <1 in 30,000 spontaneous pregnancies)
   - One egg implants normal while another is ectopic
3. 2% of all pregnancies are ectopic
   - High mortality

Question 6

Ectopic Pregnancy

-Important info

Answer 6

1. MUST R/O ectopic in
   - Pregnant patients w/out a confirmed intrauterine pregnancy
   - Vaginal bleeding/abdominal pain
2. Risk factors include — tubal scarring or impaired peristalsis of tube
   - Prior ectopic pregnancy, assisted reproduction, STI/PID, tubal surgery, exogenous hormone use, IUD use

Question 7

Ectopic Pregnancy S/Sx’s

Answer 7

1. Abdominal Pain - 100%
2. Delayed menses - 70-90%
3. Vaginal bleeding - 75%
4. Syncope - dizziness, lightheaded, and/or syncope
5. Signs — Absence of common signs of pregnancy, abdominal tenderness, palpable mass, hemodynamic instability
6. Pain can be REFERRED TO SHOULDER BLADE**

Question 8

Ectopic Pregnancy Assessment & Treatment

Answer 8

1. Assessment
   - Unilateral pelvic/low abdominal pain
   - Adnexal mass, adnexal tenderness, cervical bleeding
   - After rupture — Hypotension, tachycardia, peritoneal irritation/hemoperitaneum, secondary to large blood loss
   - Low beta HCG, inappropriate rise — usually double q48 hrs.
   - US w/ adnexal mass/extrauterine pregnancy
2. Treatment
   - Ruptured — Ensure hemodynamic stability - surgery
   - Methotrexate — Follow with serial beta HCG, Monitor for rupture

Question 9

Ectopic Pregnancy Management

Answer 9

1. Co-Management
   - Options driven by size and location of pregnancy
   - Emergency setting vs outpatient setting — One provider should have surgical capabilities
2. Medical — Methotrexate
3. Surgical — Salpingectomy or laparotomy

• This pregnancy WILL NOT progress normally and will not lead to birth. HIGH RISK for mortality