Spontaneous Abortion/molar Flashcards

1
Q

Spontaneous abortion

First Trimester Vaginal Bleeding

w abnormal findings

A

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

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2
Q

1st trimester Vaginal Bleeding

Differentials

A

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

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3
Q

Spontaneous abortion

A
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4
Q

Spontaneous abortion

1st Tri: Vaginal Bleeding - Workup

A

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

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5
Q

Spontaneous Abortion

general and RF

A

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

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6
Q

Etiology of Spontaneous abortion

maternal/fetal/paternal

A

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

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7
Q

Types of Spontaneous Abortions

A
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8
Q

Spontaneous abortion

Threatened Abortion

A

A state in which bleeding of intrauterine origin occurs WITHOUT cervical dilatation
+/- uterine contractions

20% will abort
80% will progress

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9
Q

Spontaneous abortion

Inevitable Abortion

A

Any bleeding of intrauterine origin WITH cervical dilation but without expulsion of products of conception (the pregnancy)

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10
Q

Spontaneous abortion

Incomplete Abortion

A

Bleeding + expulsion of some (but not all) products of conception

Usually associated with uterine contractions/cramping

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11
Q

Spontaneous abortion

Complete Abortion

A

Uterine bleeding and cramping WITH expulsion of all products of conception
Cervix is CLOSED after

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12
Q

Spontaneous abortion

Missed Abortion

A

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

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13
Q

Spontaneous abortion

A
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14
Q

Spontaneous abortion

Management of SAB

A

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

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15
Q

Spontaneous abortion

Septic Abortion

general, dx, tx

A

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

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16
Q

Spontaneous abortion

Recurrent Pregnancy Loss

A

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

17
Q

Spontaneous abortion

Subchorionic Hemorrhage/Hematoma

A

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

18
Q

Spontaneous abortion

Second Trimester Loss

A

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

19
Q

Heterotopic Pregnancy

general and tx

A

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%

20
Q

Gestational Trophoblastic Disease (GTD)

general

A

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

21
Q

Molar Pregnancy / Hydatidiform Mole

A

When egg and sperm incorrectly fertilize and a tumor forms instead of a healthy placenta

Premalignant disease
Aberrant fertilization&raquo_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

22
Q

Molar Pregnancy

complete vs incomplete chromosomes

A

Complete: 46XX or 46XY

Incomplete: 69XXY or 69XXX

23
Q

Molar Pregnancy

clin man

A

Clinical Presentation:
Enlarged uterus, nausea/vomiting, elevated bHCG
Vaginal bleeding (80-90%) before 16 weeks
Hyperemesis gravidarum

24
Q

molar pregnancy

imaging and labs

A

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

25
Q

molar pregnancy

management

A

Management: surgical removal (increased risk of rapidly development into choriocarcinoma)
Close follow up - monitor B-hCG levels to zero

26
Q
A