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