Abortion

Question 1

Discriminatory zone

Answer 1

• hCG titer at which intrauterine gestational sac reliably seen w/ TVUS

Question 2

Types of spontaneous abortions

Answer 2

Spontaneous = w/o medical or mechanical intervention

“Miscarriage”

1. Complete = placenta detaches, bleeding and expulsion of products of conception (POC), cervical os then closes
2. Incomplete = placenta detaches, os opens, bleeding, may pass some of POC, os remains open
3. Threatened = bleeding but cervix is closed, no expulsion of poc
4. Inevitable = fluid leaking, bleeding and cervix is dilated, no expulsion of poc
5. Missed = uterus retains the POC, no fetal heart tones (FHTs), os closed, no symptoms

*usually deteached on US/Doppler at prenatal visit

6. Recurrent = 3 or more consecutive spontaneous abortions

*recurrent pregnancy loss is classically defined as the occurrence of 3 or more consecutive pregnancy loss; however, the American Society of Reproductive Medicine (ASRM) has recently redefined recurrent pregnancy loss as 2 or more pregnancy losses

*must investigae as to why this happens

Question 3

Threatened SAb

Answer 3

• Vaginal bleeding <20wks
• +/- pain
• Cervix closed
• 25-50% pregnancy loss

Question 4

Inevitable SAb

Answer 4

• Vaginal bleedin <20wks
• Cramping pain
• Cervix partially dilated
• POC not passed yet

Question 5

Incomplete SAb

Answer 5

• Vaginal bleeding <20wks
• Cramping pain
• Cervix dilated
• POC passed

Question 6

Complete SAb

Answer 6

• Vaginal bleeding <20wks stopped
• Cramping pain stopped
• Cervix closed
• All POC passed
• Uterus involutes
• No Sx of pregnancy
• Neg. pregnancy test

Question 7

Anembryonic pregnancy or blighted ovum

Answer 7

• Empty gestational sac

*differentiate pseudogestational sac (ectopic)

• Large size w/o embryo or yok sac
• Distorted shape
• Irregular contour
• Absence double decidual sac
• Abnormal position

Question 8

Missed Ab

Answer 8

• Refers to fetal death <20wks and retention of products of conception in uterus w/ closed cervical os
• Products usually retained greater than 8wks
• Risk DIC after 4-5wks

Question 9

SAb pathophysiology

Answer 9

• 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
• Later in the pregnancy the fetus undergoes maceration, the amniotic fluid is absorbed and the fetus is compressed

Question 10

SAb incidence

Answer 10

• 80% occurs in the first 12wks of gestation
• 50% are from chromosomal anomalies

*most common chromosomal abnormality = trisomy

• Incidence increases w/:

*age

*parity

*conception w/ in 3 months of a full term delivery

Question 11

Management/treatment of abortions

Answer 11

Offer pts options

• Observation
• Medical (misoprostol, methotrexate, mifepristone)
• Surgical (D and E)
• LaminariA (seaweed stick that can expand the cervix when absorbing water)
• Birth control if appropriate
• Follow bhcg weekly until it reaches zero
• Serial exams and US as indicated

Question 12

Medical vs Surgical Aborition chart

Answer 12