Spontaneous Abortion Ectopic Pregnancy and Fetal Death

FIRST-TRIMESTER BLEEDING

Differential Diagnosis

■ Spontaneous abortion

■ Ectopic pregnancy

■ Hydatidiform mole

■ Benign and malignant lesions (i.e., choriocarcinoma, cervical cancer) Workup

■ Vital signs (rule out shock/sepsis/illness)

■ Pelvic exam (look at cervix, source of bleed)

■ Beta-human chorionic gonadotropin (hCG) level, complete blood count (CBC), antibody screen

■ Ultrasound (US) (assess fetal viability; abdominal US detects fetal heart motion by > 7 weeks' gestational age [GA])

See Figure 10-1 for management algorithm.

Over 50% of pregnancies result in spontaneous abortion.

A fetus of < 20 weeks' gestational age (GA) or weighing < 500 g that is aborted = an "abortus."

SPONTANEOUS ABORTION

Spontaneous abortion is the termination of pregnancy resulting in expulsion of an immature, nonviable fetus:

■ Occurs in 50 to 75% of all pregnancies

■ Most are unrecognized because they occur before or at the time of the next expected menses.

■ Fifteen to 20% of clinically diagnosed pregnancies are lost in T1 or early T2.

Sixty percent of spontaneous abortions in the first trimester are a result of chromosomal abnormalities.

Severe Cramps?

Internal cervical os open?

Missed No —Abortion

Severe Cramps?

Internal cervical os open?

Inevitable Abortion

Production of Conception in Uterus?

Normal Sonogram?

Inevitable Abortion

Threatened

Abortion 1 '

Perform D&C

Production of Conception in Uterus?

Yes omplete bortion

Incomplete Abortion

FIGURE 10-1. Management of first-trimester bleeding.

(Redrawn, with permission, from Lindarkis NM, Lott S. Digging Up the Bones: Obstetrics and Gynecology. New York: McGraw-Hill, 1998:43.)

Etiologies

Chromosomal Abnormalities

Top etiologies of spontaneous abortion:

1) Chromosomal abnormalities

2) Unknown

3) Infection

4) Anatomic defects

5) Endocrine factors

■ Majority of abnormal karyotypes are numeric abnormalities as a result of errors during gametogenesis, fertilization, or the first division of the fertilized ovum.

Infectious Agents

Infectious agents in cervix, uterine cavity, or seminal fluid can cause abortions. These infections may be asymptomatic:

■ Toxoplasma gondii

■ Herpes simplex

■ Ureaplasma urealyticum

■ Mycoplasma hominis

Uterine Abnormalities

■ Septate/bicornuate uterus—25 to 30%

■ Cervical incompetence

■ Leiomyomas (especially submucosal)

■ Intrauterine adhesions (i.e., from curettage)

Endocrine Abnormalities

■ Progesterone deficiency

■ Polycystic ovarian syndrome (POS)—hypersecretion of luteinizing hormone (LH)

■ Diabetes—uncontrolled

Ninety-four percent of abortions occur in Tl.

Immunologic Factors

■ Lupus anticoagulant

■ Anticardiolipin antibody (antiphospholipid syndrome)

Environmental Factors

■ Tobacco—> 14 cigarettes/day increases abortion rates

■ Irradiation

■ Environmental toxin exposure

THREATENED ABORTION

Threatened abortion is vaginal bleeding that occurs in the first ZG weeks of pregnancy, without the passage of products of conception (POC) or rupture of membranes. Pregnancy continues, although up to 5G% result in loss of pregnancy.

Diagnosis

Speculum exam reveals blood coming from a closed cervical os, without am-niotic fluid or POC in the endocervical canal.

Management

Bed rest with sedation and without intercourse

INEVITABLE ABORTION

Inevitable abortion is vaginal bleeding, cramps, and cervical dilation. Expulsion of the POC is imminent.

Twenty to 50% of threatened abortions lead to loss of pregnancy.

Threatened abortion: Vaginal bleeding in first 20 weeks of pregnancy without passage of POC and without rupture of membranes

Diagnosis

Speculum exam reveals blood coming from an open cervical os. Menstrual-like cramps typically occur.

Management m Surgical evacuation of the uterus m Rh typing—D immunoglobulin (RhoGAM) is administered to Rh-negative, unsensitized patients to prevent isoimmunization.

Inevitable abortion is different from threatened abortion because it has cervical dilation.

INCOMPLETE ABORTION

Incomplete abortion is the passage of some, but not all, POC from the cervical os.

Diagnosis

Cramping and heavy bleeding Enlarged, boggy uterus

Dilated internal os with POC present in the endocervical canal or vagina

Management

Stabilization (i.e., IV fluids and oxytocin if heavy bleeding is present) Blood typing and crossmatching for possible transfusion if bleeding is brisk or low Hgb/patient symptomatic Rh typing

POC are removed from the endocervical canal and uterus with ring forceps. Suction dilation and curettage (D&C) is performed after vital signs have stabilized. Karyotyping of POC if loss is recurrent

COMPLETE ABORTION

Complete abortion is the complete passage of POC. Diagnosis

■ Uterus is well contracted.

■ Cervical os may be closed.

Management

Examine all POC for completeness and characteristics. Between 8 and 14 weeks, curettage is necessary because of the large possibility that the abortion was incomplete. Observe patient for further bleeding and fever.

MISSED ABORTION

Missed abortion is when the POC are retained after the fetus has expired. Diagnosis

■ The pregnant uterus fails to grow, and symptoms of pregnancy have disappeared.

■ Intermittent vaginal bleeding/spotting/brown discharge and a firm, closed cervix

■ Decline in quantitative beta-hCG

■ US confirms lack of fetal heartbeat.

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