Spontaneous abortion, habitual abortion and ectopic pregnancy

Question 1

What is the annual number of births in Norway?

Answer 1

About 60 000.

Question 2

What is the definition of a spontaneous abortion?

Answer 2

Pregnancy loss before week 22 + 0. (The natural death of the fetus before is it able to survive independently.)

Question 3

What is the lowest gestational age for survival?

Answer 3

23 weeks (or fetal weight of 0,5 kg).

Question 4

Is a miscarriage more likely to occur before or after week 12?

Answer 4

Before week 12. (80 % of diagnosed spontaneous abortion occur before week 12.)

Question 5

What is the most common complication during early pregnancy?

Answer 5

Miscarriage.

Question 6

What are risk factors of spontaneous abortion?

Answer 6

Maternal age (> 30 years).
Overweight and underweight.
Alcohol consumption.
Smoking and caffeine. 
Anatomical factors.
Cervical insufficiency. 
Polycystic ovary syndrome (PCOS).
Hypothyroidism. 
Diabetes.

Question 7

What categories can causes of miscarriage be divided into? What kind of cause if most common?

Answer 7

Genetic, placental, anatomical, infectious, endocrine, immunological and other causes.
Genetic causes accounts for 50 % of all miscarriages.

Question 8

What are examples of placental causes of miscarriage?

Answer 8

Errors in implantation and hematological causes such as hemorrhage, thrombosis and infarction.

Question 9

What are examples of anatomical causes of miscarriage?

Answer 9

Anomalies in the uterus such as uterine septum or submucosal leiomyomas as well as insufficient cervix.

Question 10

What are examples of endocrine causes of miscarriage?

Answer 10

Endocrine disorders such as hypo- and hyperthyroidism, diabetes and PCOS.

Question 11

What are examples of “other” causes of miscarriage?

Answer 11

Maternal age, medications, lifestyle (or poverty) and intrauterine devices (IUD).

Question 12

What is the usual clinical presentation of a spontaneous abortion?

Answer 12

Vaginal bleeding. Positive pregnancy test. Sometimes pain, passage of fetal tissue and loss of pregnancy related symptoms. Or there could be no symptoms at all.

Question 13

What are differential diagnosis to spontaneous abortion?

Answer 13

Pregnancy related: Ectopic pregnancy. Gestational trophoblast disease.
Intact pregnancy with other causes of bleeding: Cervical polyp. Vaginitis. Cervical cancer or dysplasia. Cervical ulcer.

Question 14

What should be included in the clinical examination if spontaneous abortion is suspected?

Answer 14

Gynecological examination including inspection of external genitalia, speculum examination, bimanuell palpation and vaginal ultrasound.
Abdominal examination.
Blood pressure and pulse should be measured.
Be on the look for signs of infection. (Fever, purulent discharge and uterine tenderness. Septic abortion could be possible.)

Question 15

What lab tests should be taken if spontaneous abortion is suspected?

Answer 15

Hemogobline and hCG.

Infection parameters if indicated.

Question 16

Why is it important to perform a gynecological examination if spontaneous abortion is suspected?

Answer 16

To confirm that the uterus is the source of bleeding, and if not find the actual source.
Bleeding from a lesion in the vagina or cervix?
Assess the amount of bleeding.
Assess dilatation of the cervical os.
To determine if there is an ongoing bleeding or passage of fetal tissue.
To determine the size and position of the fetus.
To determine if there is tenderness of the fetus.

Question 17

You’re performing a vaginal ultrasound in a pregnant woman with vaginal bleeding. The size of the uterus isn’t in correspondence to gestational age. What are some possible explanations?

Answer 17

If too small: It could be a spontaneous abortion or an ectopic pregnancy.
If too large: It could be multiple fetuses or uterine leiomyomas.

Question 18

What are indication to refer a patient with vaginal bleeding to the hospital?

Answer 18

Heavy bleeding with reduced hemoglobin, tachycardia and hypotension.
Signs of infection / septic abortion.
Suspected ectopic pregnancy.
Suspected serious cause, other than spontaneous abortion, such as cervical cancer.

Question 19

What is meant by incomplete abortion?

Answer 19

Significant amounts of the placental tissue is retained after the fetus has passed. (Bleeding can be severe and cause hypovolemic shock.) More common past 12 weeks of pregnancy.

Question 20

What is a septic abortion?

Answer 20

Any abortion complicated by infection.

Question 21

What blood test can be used to confirm the probability of miscarriage?

Answer 21

Serum-hCG. If a spontaneous abortion has occured S-hCG should gradually decline.
(During a normal viable pregnancy S-hCG doubles within 48 hours the first 10-12 weeks.)

Question 22

True or false: It is not possible to determine whether a pregnancy is normal or not based on a single serum-hCG level.

Answer 22

True. Because there is a wide range of normal levels at each week of pregnancy. The normal range for week 4 is for instance 1 000 - 10 000 IU/L.

Question 23

Which cells produce hCG? What is the function of hCG during the beginning of pregnancy?

Answer 23

Syncytiotrophoblasts in the placenta produce hCG. hCG promotes the maintenance of corpus luteum during the beginning of pregnancy.

Question 24

True or false: The level of serum-hCG increases gradually throughout the entire course of the pregnancy.

Answer 24

False. The level of serum-hCG peaks around week 10-12 of gestation.

Question 25

What is the treatment for complete spontaneous abortion?

Answer 25

No treatment is needed.

Question 26

What characterizes a threatening abortion?

Answer 26

Vaginal bleeding, but a viable fetus and no dilatation of the cervical os. The exact etiology of the bleeding can often not be determined and is frequently attributed to marginal separation of the placenta.

Question 27

How is a threatening abortion treated/managed?

Answer 27

Avoiding vigorous physical activity, heavy lifting and sexual intercourse while bleeding is recommended.

Question 28

What are the main types of spontaneous abortions?

Answer 28

Complete spontaneous abortion, incomplete spontaneous abortion and threatening spontaneous abortion.

Question 29

What are the three types of incomplete spontaneous abortion? In what types is there likely pain?

Answer 29

1. Products of contraception in the uterus. Ongoing vaginal bleeding.
2. “Empty sac” or anembryonic pregnancy. Intrauterine gestational sac without fetus.
3. “Missed abortion.” Nonviable fetus that has not yet been passed. Closed cervical os.

Type 1 is most commonly associated with pain.

Question 30

What is the treatment for incomplete spontaneous abortion?

Answer 30

If the pregnancy was post week 9 hospital admission is indicated, if not:
Waitful watch: Control with ultrasound after a week.
Medical treatment: Cytotec perorally or vaginally. Painrelief and anti-emetics as needed.

New pregnancy test in 3-4 weeks.

If the problems does not resolve itself and medical treatment fails, or if the patient is in great pain, has heavy bleeding or signs of infection surgical evacuation of the uterine cavity is indicated.

Question 31

What information should the patient receive after having a miscarriage?

Answer 31

When to seek medical help: It it normal to have vaginal bleeding and discharge up to 2 weeks after the miscarriage. If the bleeding lasts longer they should seek medical help. Other reasons for seeking medical help include heavy bleeding and signs of infection.

Emotional support: If the patient wants to you can have a follow-up session as emotional support.

When to try to conceive again: The patient should wait 1-2 normal menstrual cycles before trying to conceive again.

Question 32

What is meant by habitual abortion?

Answer 32

Recurrent loss of pregnancy. 3 or more consecutive spontaneous abortions before week 20 with the same partner (and without any other pregnancy outcome between).

Question 33

In how many cases is the specific etiology of spontaneous abortions determined? What about in the of habitual abortions?

Answer 33

In 30-40 % of cases the specific etiology is determined. Same as for habitual abortions.

Question 34

Where and how should a patient with habitual abortions be examined?

Answer 34

At the hospital by a specialist in gynecology and obstetrics.

The examination should include: Vaginal ultrasound, hysteroscopy (and sometimes laprascopy), karyotyping of the couple, and lab tests such as antiphospholipid antibodies (and TSH, fT4, anti-TPO, diabetes-testing, etc.)

Question 35

What is the most important treatable cause of habitual abortions?

Answer 35

Antiphospholid syndrome.

Question 36

What is antiphospholipid syndrome?

Answer 36

A disorder of the immune system that causes an increased risk of blood clots.

Diagnosis: One clinical event (i.e. thrombosis or pregnancy complication such as miscarriage or preterm labor due to placental disease) and two antibody blood tests spaced at least three months apart that confirm the presence of either lupus anticoagulant or anti-β2-glycoprotein-I, or anti-cardiolipin.

Question 37

What is the treatment for habitual abortion?

Answer 37

In idiopathic cases there is no documented treatment.

In cases of antiphospholipid syndrome medical treatment in the form of anticoagulants, ASA + LMWH (dalteparin), is an option.

In cases of uterine abnormalities hysteroscopic resection is an option.

Thyroid and diabetes disorders should be well regulated.

Question 38

What is an ectopic pregnancy?

Answer 38

Also referred to as an extrauterine pregnancy. A complication of pregnancy where the embryo attaches outside the uterus.

Question 39

What is the most common site for an ectopic pregnancy? What are some other possible sites?

Answer 39

98 % of ectopic pregnancies occur in the fallopian tubes. Apullar tubal pregnancy is the most common.

Other possible sites include cervical, cornual, ovarian, abdominal, c-section scar, hysterectomy scar and intramural.

Question 40

What is a heterotropic pregnancy?

Answer 40

Both extrauterine and intrauterine pregnancy at the same time - a very rare event.

Question 41

What are risk factors associated with ectopic pregnancy?

Answer 41

Previous ectopic pregnancy.
Tubal abnormalities, such as congenital malformations, post-surgical abnormalities, tumors or infection.
Previous genital infection, salpingitis, especially recurrent infections.
Intrauterine devices (IUD).
Infertility.
(Smoking?)

Question 42

What is the typical clinical presentation of ectopic pregnancy? When is usually the onset of symptoms?

Answer 42

Abdominal pain - often unilateral or referred.
Positive pregnancy test.
Vaginal bleeding.
The onset of symptoms usually occur 6-8 weeks after the last menstrual period.

Question 43

What are differential diagnoses to ectopic pregnancy?

Answer 43

Salpingitis.
Ovarian (or adnexal) torsion.
Threatened abortion.
Dysmenorrhea.
Appendicitis. 
Endometriosis.
Ruptured corpus luteum.
Necrosis of myoma.

Question 44

What examinations should be performed in general practice if ectopic pregnancy is suspected?

Answer 44

Assessment of hemodynamic stability. Hb, pulse, blood pressure.

Abdominal examination. Lower abominal tenderness and/or rebound tenderness.

Gynecological examination. Determine if the uterus is the source of the bleeding. Assess the volume of bleeding. Assess the cervical os - closed or dilated? Assess the size of the uterus.

Question 45

If ectopic pregnancy is suspected, should the patient be referred to a hospital? Why or why not?

Answer 45

Yes, the patient should be referred. Failure to diagnose ectopic pregnancy before tubal rupture limits the treatment options and increases maternal morbidity and mortality.

Question 46

What are symptoms of tubal rupture in an ectopic pregnancy?

Answer 46

Abrupt onset of severe abdominal pain and/or symptoms suggestive of ongoing blood loss (such as feeling faint or loss of consciousness).

Question 47

What is the most useful test to determine the location of the pregancy in cases of ectopic pregnancy? What are typical findings if the pregnancy is tubal?

Answer 47

Transvaginal ultrasound.

Typical findings are an empty uterine cavity, a so-called “donut-signs” and pathological rise in hCG.

Question 48

What is the management/treatment of ectopic pregnancies?

Answer 48

Watchful waiting can be done if the patient is hemodynamically stable and in a good general condition, there are no signs of intrabdominal bleeding and the hCG is low and/or declining. (hCG is monitored until indetectable.)

If not medical treatment with methotrexate or surgical treatment can be offered.

Question 49

What are indications for medical treatment of ectopic pregnancy?

Answer 49

Indications for watchful waiting are not fulfilled, and there is no significant pain, rupture, visible fetal heart beat or intrauterine pregnancy.
Serum-hCG < 5 000.
The woman has to be able to return for follow-up.

Question 50

What are indications for laparoscopy and laparotomy as treatment of ectopic pregnancy?

Answer 50

Laparoscopy: Significant pain, rupture, large adnexal mass, visible fetal heart beat and hCG > 5 000.

Laparotomy: Large hemorrhage.