Abortion

Question 1

Are spontaneous abortions very very common?

Answer 1

YES

Question 2

What is abortion?

Answer 2

• TERMINATION of PREGNANCY either spontaneous “miscarriage” or intentionally before the fetus develops sufficiently to survive.
• termination prior to 20 weeks gestation or less than 500 g.

Question 3

What are the 2 important questions we need to consider in the first trimester?

Answer 3

1. Location (where is it)= Ultrasound.

2. Quality (B-hCG…)

Question 4

What is your dDx for first trimester bleeding?

Answer 4

• extrauterine= ectopic
• intrauterine= early intrauterine pregnancy (IUP), threatend spontaneous abortion (SAb), inevitable SAb, complete SAb, Missed SAb, or blighted ovum (anembryonic pregnancy).

Question 5

What 2 things will tell you what is happening to your patient?

Answer 5

• ultrasound

- B-hCG

Question 6

What is the discriminatory zone?

Answer 6

• B-hCG titer at which intrauterine gestational sac is reliably seen with transvaginal US (1,500-2,000 mIU/mL).

Question 7

What B-hCG dynamic indicates a normal pregnancy?

Answer 7

• doubling in 48 hours

Question 8

What is the first anatomic structure that can be identified within the gestational sac?

Answer 8

• yolk sac (spherical with echogenic periphery and sonolucent center).

Question 9

** What is a COMPLETE spontaneous abortion “miscarriage”?

Answer 9

• placenta detaches, bleeding, and expulsion of products of conception (POC), cervical os then closes.

Question 10

** What is an INCOMPLETE spontaneous abortion “miscarriage”?

Answer 10

• placenta detaches, os opens, bleeding, may pass some of POC, os remains OPEN.

Question 11

** What is a THREATENED spontaneous abortion “miscarriage”?

Answer 11

• bleeding but CERVIX is CLOSED, no expulsion of POC.

* sometimes this just goes away and everything is fine.

Question 12

** What is an INEVITABLE spontaneous abortion “miscarriage”?

Answer 12

• fluid leaking, bleeding and CERVIX is DILATED, no expulsion of POC.

Question 13

** What is a MISSED spontaneous abortion “miscarriage”?

Answer 13

• uterus retains the POC, no fetal heart tones (FHTs), os closed. No symptoms.
• usually detected on ultrasound/doppler at prenatal visit.

Question 14

** What is RECURRENT spontaneous abortion “miscarriage”? (also called “habitual aborter”)

Answer 14

• 3 or more consecutive spontaneous abortions.

* must investigate as to why this happens. Usually chromosomal.

Question 15

What major risk do mothers face with Missed Ab?

Answer 15

• DIC after 4-5 weeks :(

Question 16

What is the pathophysiology of abortion?

Answer 16

• many different reasons, but hemorrhage begins into the decidua basilis followed by necrosis of the tissues adjacent to the bleeding.
• the ovum detaches, uterine contractions begin, and POC expelled.

Question 17

When do 80% of most spontaneous abortions occur?

Answer 17

• 1st twelve weeks of gestation.

* half are from chromosomal anomalies (usually trisomy).

Question 18

What increases incidence of abortion?

Answer 18

• age
• parity
• conception within 3 months of a full term delivery.

Question 19

What are some causes of spontaneous abortion?

Answer 19

• infections
• hypothyroidism
• progesterone deficiency
• drugs and alcohol
• autoimmune: antiphospholipid antibodies (lupus, anticardiolipin antibody)= placental infarctions and thrombosis.
• thrombophilias
• Asherman’s syndrome
• insufficient cervix (habitual aborters).

Question 20

How do you evaluate for a spontaneous abortion?

Answer 20

• focused PE:
• vaginal exam to see where bleeding is coming from.
• pelvic exam
• ULTRASOUND
• LABS

Question 21

What labs should you order if you suspect spontaneous abortion?

Answer 21

• B-hCG
• blood count
• blood type (RHoGAM if indicated for Rh - status)

Question 22

How do you manage/treat?

Answer 22

• observation
• medical (misoprostol or methotrexate)
• surgical (D&E)
• laminaria (seaweed that dilates the cervix)
• emotional support (don’t forget about dad)
• follow B-hCG until reaches zero.

Question 23

What is elective and therapeutic termination/

Answer 23

• medical or surgical termination of pregnancy before time of fetal viability.
• THERAPEUTIC= if medically indicated (cervical cancer, heart disease, rape, incest, fetus with significant anatomical deformities not compatible with life).
• ELECTIVE= voluntary interruption of pregnancy before viability at the woman’s request with no medical indication.

Question 24

On what is the termination procedure based?

Answer 24

• gestational age

Question 25

How is termination performed?

Answer 25

- D&C or D&E= dilation and curettage/evacuation. Cervix is dilated and uterine contents are removed (scraped/suctioned out with a curette). * Done up to 20 weeks in some states.

Question 26

How late can you offer medical abortion?

Answer 26

- up to 49 days gestation (mioprostol +/- mifepristone)

Question 27

What is Mifepristone? (PICMONIC)

Answer 27

- reverses the progesterone that acts by stabilizing the pregnancy and inhibiting contractions.

Question 28

What is Misoprostol? (PICMONIC)

Answer 28

- prostaglandin that stimulates the myometrium to contract and expel POC.

Question 29

What is methotrexate? (PICMONIC)

Answer 29

- antimetabolite that inhibits dihydrofolate reductase causing cell death.

Question 30

How are 2nd trimester terminations handled?

Answer 30

- in the hospital with adequate IV access, surgery or medical. Consider pain control and beware of significant bleeding.

Question 31

What is septic abortion?

Answer 31

- uterine infection during or immediately after a spontaneous abortion.

Question 32

How do you treat a septic abortion?

Answer 32

- broad spectrum antibiotics | - evacuate any remaining POC and monitor for septicemia or DIC in hospital.