Spontaneous Abortion/molar Flashcards
Spontaneous abortion
First Trimester Vaginal Bleeding
w abnormal findings
Usually occurs around the time of missed menses
Light spotting (1-2 pads/24 hrs) could be normal
Vaginal bleeding in the first trimester, occurs in 20-40% pregnancies
Light or heavy, intermittent or constant, painless or painful (take a good history!)
Abnormal Findings:
Bleeding associated with significant abdominal pain
Heavy menstrual bleeding
Soaking through 2 large pads in 1 hour for more than 2 hours
1st trimester Vaginal Bleeding
Differentials
Most common causes:
Ectopic Pregnancy (<2% but most serious/life threatening)
Early pregnancy loss (spontaneous abortions- 15-20% of all 1st trimester VB)
Implantation of the pregnancy (around 4 weeks)
Cervical, vaginal, or uterine pathology (Structural: Fibroids, polyps, or Inflammation/infection)
Very common to have post coital spotting throughout the pregnancy. This can be cervical or uterine, sometimes the cervix is hypervascularized
Spontaneous abortion
Spontaneous abortion
1st Tri: Vaginal Bleeding - Workup
Urine bhCG
Serum hCG
Pelvic exam
T&S , CBC?
transvaginal US
** Need to look in order to truly evaluate **
*Bleeding may be rectal vs urethral vs vaginal
*Bleeding + suspected pregnancy = Pelvic Exam
*Internal pelvic exam with speculum
–What do you see?
–Active bleeding from cervix vs old blood in vaginal vault
–Quantify: Clots, how many cc blood?
–1 speculum filled w/ blood = 15cc
Bimanual exam
–Internal cervical os dilation
–Fingertip 0.5cm
–1 finger = 1 cm
Spontaneous Abortion
general and RF
1 in 5 pregnancies (20%) result in miscarrige
Spontaneous abortion = miscarriage = early pregnancy loss
RISK FACTORS
Increasing maternal age (>35 y/o)
Prior pregnancy loss
Infection
Medication use: (NSAIDS) some w/ teratogenicity (MTX)
Substance use: smoking, caffeine, alcohol, cocaine
Medical conditions (metabolic and/or endocrine disorders)
–Coagulopathy OR thrombophilia
Etiology of Spontaneous abortion
maternal/fetal/paternal
Maternal
Medical Conditions
Antiphospholipid syndrome
Infections
CMV, Parvovirus B19, Toxoplasmosis, Chlamydia trachomatis
Anatomic Abnormalities
Congenital uterine anomalies
Intrauterine adhesions
Drug use (cocaine)
Cigarette smoking
Paternal
Increased paternal age
Paternal chromosomal abnormalities
Fetal
Chromosomal abnormalities (most common cause)
Turner syndrome (45,X, or 45, XO)
Autosomal trisomies (Down Syndrome - Trisomy 21)
Congenital abnormalities
Types of Spontaneous Abortions
Spontaneous abortion
Threatened Abortion
A state in which bleeding of intrauterine origin occurs WITHOUT cervical dilatation
+/- uterine contractions
20% will abort
80% will progress
Spontaneous abortion
Inevitable Abortion
Any bleeding of intrauterine origin WITH cervical dilation but without expulsion of products of conception (the pregnancy)
Spontaneous abortion
Incomplete Abortion
Bleeding + expulsion of some (but not all) products of conception
Usually associated with uterine contractions/cramping
Spontaneous abortion
Complete Abortion
Uterine bleeding and cramping WITH expulsion of all products of conception
Cervix is CLOSED after
Spontaneous abortion
Missed Abortion
Embryo / Fetus dies in utero before 20 weeks
On imaging + Fetal heart rate and confirmed intrauterine pregnancy
Follow up imaging, no fetal heart rate confirmed pregnancy loss
Cervical Os closed and pregnancy stops developing BUT it has not been expelled from uterus yet
Spontaneous abortion
Spontaneous abortion
Management of SAB
Expectant →
Bleeding precautions
Patient may pass products at home with no additional interventions
Failure rate 25%
If no bleeding/cramping within 4 weeks → surgical evacuation
Medical→
Misoprostol (prostaglandin) 600-800mg intravaginal or buccal administration
+/- Mifepristone
Taken at home, patient will have uterine cramping and passage of products and blood clots
Educate patient on warning signs and when to return to ED
Surgical →
Dilation and aspiration (D&A) curettage (D&C) or evacuation (D&E)
Scheduled ambulatory procedure
Removal of products from uterus
MVA (manual vacuum aspiration) in ED may be indicated
Spontaneous abortion
Septic Abortion
general, dx, tx
Any type of miscarriage (spontaneous or induced) that is complicated by intrauterine infection
Signs/Symptoms:
Pelvic/abdominal pain
Uterine tenderness
Purulent vaginal discharge
+/- vaginal bleeding
+/- systemic symptoms: fevers, chills, night sweats
Diagnosis:
STI testing (gonorrhea, chlamydia, trichomoniasis), blood cultures, CBC, T&S
Transvaginal or abdominal ultrasound of uterus
Treatment:
Recognize infection, administer empiric antibiotics and IV fluids, uterine evacuation
Spontaneous abortion
Recurrent Pregnancy Loss
Greater than or equal to 3 pregnancy losses before 20 weeks GA
*Causes:
*Genetic
*Infection (Toxo, CMV, HSV, Listeria) TORCH
*Immunologic: APLS = lupus anticoagulant or beta 2 glycoprotein 1 antibodies
*Endocrinologic: thyroid, hyperprolactinemia, poorly controlled DM, and progesterone insufficiency < 10ng/mL (luteal phase defect)
*Anatomic (congenital anomalies [uterine septum], cervical insufficiency, fibroids, polyps, asherman’s syndrome, DES exposure malformations
*Microbiologic
*Thrombophilic: factor V leiden, prothrombin gene mutation, hyperhomocysteinemia, methylenetetrahydrofolate reductase polymorphism (MTHFR), deficiencies in Protein S, Protein C and Antithrombin III
Spontaneous abortion
Subchorionic Hemorrhage/Hematoma
Vaginal bleeding in 1st trimester
Most common cause
Bleeding beneath the chorion membranes that enclose the embryo in the uterus (partial detachment of chorion membranes from the wall of the uterus)
Most have light vaginal bleeding, some can be asymptomatic
Conservative management
If mother stable and no large volume blood loss
Pelvic rest of follow-up sono
Spontaneous abortion
Second Trimester Loss
Usually maternal in origin
Causes
Anatomic - didelphic uterus has inadequate space for fetal development
Inadequate placental vascular supply
Cervical insufficiency
Painless cervical dilation
Can treat with cervical cerclage
Heterotopic Pregnancy
general and tx
Intra- and extra-uterine pregnancy simultaneously
Risk factors include infertility/ assisted reproductive technology treatment, plus and risk factors of ectopic pregnancy
Same presentation as ectopic pregnancy, likely have higher B-hCG levels
Treatment
Unruptured ectopic component: injection methotrexate using sonogram directly into gestational sac
Ruptured ectopic component: treat surgically with laparoscopic salpingectomy
Intrauterine pregnancy expected to continue normally with survival rate 70%
Gestational Trophoblastic Disease (GTD)
general
Spectrum of disease of abnormal placental trophoblast development
Trophoblast = cells forming the outer layer of blastocyst (provides nutrients to embryo) and develops into the placenta
Benign
Complete or incomplete (partial) mole
Malignant
Gestational Trophoblastic Neoplasia (GTN)
Choriocarcinoma
Molar Pregnancy / Hydatidiform Mole
When egg and sperm incorrectly fertilize and a tumor forms instead of a healthy placenta
Premalignant disease
Aberrant fertilization»_space; Abnormal chorionic villi with trophoblastic hyperplasia
Complete Hydatidiform Mole: haploid; sperm fertilizes an empty ovum (without chromosomes), or two sperm fertilize anuclear ovum
Sono: “Snowstorm” or “cluster of grapes”
Progression to malignancy common (20%)
Incomplete/Partial Hydatidiform Mole: Triploid; when an ovum with maternal chromosomes is fertilized by two sperm it forms partial mole- with abnormal triploid fetal tissue
May see fetal parts on sono (fetus not viable)
Progression to malignancy is rare
Molar Pregnancy
complete vs incomplete chromosomes
Complete: 46XX or 46XY
Incomplete: 69XXY or 69XXX
Molar Pregnancy
clin man
Clinical Presentation:
Enlarged uterus, nausea/vomiting, elevated bHCG
Vaginal bleeding (80-90%) before 16 weeks
Hyperemesis gravidarum
molar pregnancy
imaging and labs
Imaging: Snowstorm or swiss cheese appearance on ultrasound – solid collection of echoes with numerous small diffuse anechoic spaces that appear granular or snowstorm on appearance
Ultrasound sensitivity 70%, detection increases with increasing “gestational age”
Diagnosis: Complete mole w/ hcg > 100,000
molar pregnancy
management
Management: surgical removal (increased risk of rapidly development into choriocarcinoma)
Close follow up - monitor B-hCG levels to zero
