Nonviable Gestations

Question 1

the role of ultrasound

Answer 1

• A 5-mm sonolucent gestational sac should be visible in endometrium by 5 menstrual weeks
• Normal sac consists of central blastocyst surrounded by double ring of echogenic chorionic villi and decidua
• Yolk sac is visible using transvaginal U/S by 6 weeks
• 2 - 5mm embryo or fetal pole visible by end of 6th week
• Once embryo exceeds 5mm should be able to detect cardiac activity by U/S (5.5-6wks)

Question 2

overall managment for 1st trimester bleeding

Answer 2

• Quantitative B-hcg >1800 to 2000 and…
• TVUS shows no gestational sac: Evaluate for ectopic pregnancy
• Bright endometrial stripe suggests complete SAB
• TVUS shows a gestational sac: Follow for Threatened Abortion
• Subchorionic Hemorrhage - hematoma between chorion and uterine wall (4-30% risk of miscarriage depending on size)
• Gestational sac >2 cm should contain an embryo
• Embryo>5 mm in crown-rump should have heart beat
• Risk of miscarriage if heartbeat present:
  
  • Maternal age under 35 years: 2.1%
  • Maternal age over 35 years:16.1%
• Quantitative B-hcg <1800 to 2000….
• Patient unstable
  
  • Presumed to be ectopic pregnancy
  • Immediate consult obstetrics for possible surgery
• Patient stable
  
  • Follow serial quantitative b-hcg every 48 hours
  • Confirm quantitative b-hcg doubles in 48 hours
  • Confirm intrauterine pregnancy when B - hcg > 1800 - 2000

Question 3

Threatened abortion

Answer 3

• Defined: Bleeding before 20 weeks’ gestation in the presence of an embryo with cardiac activity and CLOSED cervix
  
  • Presence of an intrauterine embryo with cardiac activity on ultrasound is reassuring
  • Essentially rules out ectopic pregnancy (although there is a 1:10,000 chance of heterotopic pregnancy)
  • Provider should caution patients to expect continued bleeding and possible impending miscarriage
  • Pelvic rest/Bed rest (not proven to improve outcome)

Question 4

Spontaneous abortion types: complete, incomplete, missed, septic, inevitable

Answer 4

• Defined: Spontaneous loss of a pregnancy before 20 weeks’ gestation
• Complete abortion - Complete passage of all products of conception
• Incomplete abortion - Occurs when some, but not all, of the products of conception have passed
• Embryonic demise (Missed abortion)
  
  • An embryo larger than 5 mm without cardiac activity
  • Retained non-viable conception products up to 4 weeks
• Septic abortion - Incomplete abortion associated with ascending infection of the endometrium, parametrium, adnexae, or peritoneum
• Inevitable abortion - Bleeding in the presence of a dilated cervix; indicates that passage of the conceptus is unavoidable

Question 5

vanishing twin

Answer 5

• A singleton pregnancy which results from a very early loss of one member of a multiple gestation.
• Often the product of assisted reproduction techniques
• Presents with vaginal bleeding
• Rates of early spontaneous pregnancy loss are similar in natural and ART pregnancies - 25% of singleton pregnancies, 35% twin pregnancies, and 55% of triplet pregnancies

Question 6

spontaneous abortion management

Answer 6

• Most first trimester miscarriages occur completely and spontaneously without intervention - patient reassurance/support is vital…
  
  • Consider intravenous hydration
  • Consider complications (e.g. septic abortion)
  • CBC
  • Blood type/AB screen - RhoGAM (rh-)
  • Follow serial quantitative b-hcgs until 0
• Observation indications
  
  • Gestational age under 8 weeks
  • Stable, reliable patient

Question 7

misoprostel

Answer 7

• Misoprostel (Cytotec) – used to induce abortion (medical abortion) when surgery is not available/desired –1^st/2^nd trimesters
  
  • Highly effective in missed SAB –complete expulsion 71% by day 3, 84% by day 8. Also used in incomplete and inevitable abortion. (also for labor induction and PPH)
    
    • Safety and efficacy established by large, randomized and controlled trials
    • Some women will still require surgical evacuation – F/U in 1-2 weeks
• Dosing in first trimester miscarriage:
  
  • Vaginal: 800 mcg intravaginally for 1 dose (may be repeated after 3 days if not effective)
  • Oral: 600 mcg PO x 1 dose (may be repeated after 3 days if not effective)

Question 8

dilatation and curettage indications

Answer 8

• Dilatation and Curettage Indications
  
  • Gestational age 8 to 14 weeks
  • Excessive intrauterine bleeding (>1 pad/hour) or pain
  • Prolonged symptoms or delayed passage of tissue - risk of Asherman’s syndrome
  • Can confirm intrauterine pregnancy (chorionic villi)
  • Pts usually given antibiotic prophylaxis

Question 9

Pitocin

Answer 9

• Pitocin
  
  • Prepare 40 units/Liter in D5LR
  • Start at 1u/double rate q 20-30 min
  • Endpoint - Contractions adequate
    
    • Avoid hyperstimulation - tetanic contractions
  • Prostaglandin (PG) Cervical Ripening
  • PGE2 intravaginal suppository
  • PG F2 alpha intraamniotic preparation

Question 10

Dilatation and evacuation (D and E) - 2nd trimester procedure

Answer 10

• Dilatation and Evacuation (D&E) - 2nd trimester procedure
  
  • 11% induced ABs performed in 2nd trimester, instruments necessary in addition to aspiration, use of laminaria
• Manage intrauterine bleeding
  
  • Remove products at cervix
  • IV NS with 30u Pitocin/Liter at 200 cc/hour
  • Methergine 0.2 mg PO qid for 6 doses prn bleeding

Question 11

spontanous abortion risk factors

Answer 11

• Maternal age - age 20 to 30 years (9 -17%), age 35 years (20%), age 40 years (40%), and age 45 years (80%)
• Gravidity ? - Some studies have shown an increased risk with increasing gravidity, but others have not
• Prolonged ovulation to implantation interval/prolonged time to conception
• Smoking, EtoH, cocaine, NSAIDS, caffeine
• Low folate level
• Extremes of maternal weight
• Fever
• Celiac disease

Question 12

SAB risk factors, continued

Answer 12

• Chromosomal abnormalities - 50% of all miscarriages (trisomies, monosomy X)
• Congenital anomalies - amniotic bands, teratogens (poor maternal glycemic control, isotretinoin, mercury)
• Trauma - CVS, amniocentesis, blunt trauma
• Uterine structural issues
• Maternal disease - TORCH infections, endocrinopathies
• Unexplained ??
  
  • Unexplained - In a study where embryoscopy, embryo biopsy, and karyotype were performed in more than 200 patients with missed abortion, 18% of embryos having a normal karyotype exhibited grossly abnormal developmental morphology

Question 13

Hydatidiform mole

Answer 13

• Tumor arising from fertilized ovum with loss of maternal chromosomes; made up of placental tissue only - can be partial or complete
• Risk factors: Nullips, women < 20, > 40, incidence of 1/1,200 pregnancies
• Low SES, dietary deficiencies: protein, folic acid, carotene
• Risk of choriocarcinoma: rare, but 1/2 of cases develop following molar pregnancies
• 80 % are benign

Question 14

diagnosis and evaluation of hydatidiform mole

Answer 14

• 1st/2nd trimester painless bleeding
• Passing vesicles
• Absent FHT
• Uterus too large for EGA
• Serial bHCG elevated
• Hyperthyroidism (5%)
• Diagnosis by ultrasound (characteristic “snowstorm” appearance and absence of fetal parts)
• Pre-eclampsia prior to 24 wks
• Severe hyperemesis

Question 15

treatment of hydatidiform mole

Answer 15

• Prompt evacuation of uterine contents (D&C) - r/o choriocarcinoma
• Monitored 6-12 months after evacuation
• Examinations for vaginal mets and appropriate involution of pelvic structures
• Serial quant HCG levels within 48 hours and q 1 - 2 months thereafter
• Effective contraception should be used throughout this period, avoid pregnancy for one year
• Risk of recurrence after 1 year remission is < 1%
• Risk of recurrence with subsequent pregnancies is 1-2%

Question 16

ectopic pregnancy

Answer 16

• Pregnancy outside the uterine cavity (most commonly in the fallopian tube) but may occur in the broad ligament, ovary, cervix, or elsewhere in the abdomen
• Occurs in 2 percent of reported pregnancies, usually 6-8 weeks from LMP
• Responsible for 4-10 percent of all U.S. maternal deaths

Question 17

ectopic pregnancy risk factors

Answer 17

• Current IUD
• History of ectopic pregnancy
• History of in utero exposure to diethylstilbestrol
• History of genital infection, including PID, CT/GC
• History of tubal surgery, including tubal ligation or reanastomosis of the tubes after tubal ligation
• In vitro fertilization
• Infertility
• Smoking

Question 18

ectopic pregnancy diagnosis and evaluation

Answer 18

• Vaginal Bleeding
  
  • 30% of patients with ectopic pregnancies have no vaginal bleeding
• Abdominal pain
  
  • Overall likelihood of EP is 39% in patient with abdominal pain and vaginal bleeding but no other risk factors
  • Increases to 54% if the patient has other risk factors
• Normal or slightly enlarged uterus
• Cervical motion tenderness
• Hypotension, syncope
• Palpable adnexal mass
• Diagnostic tests for ectopic pregnancy
• Urine preg test (doesn’t confirm IUP!)
• Ultrasonography - diagnostic test of choice
• Serum progesterone level - >25ng/ml can almost always exclude the presence of an extrauterine pregnancy
• B - hcg measurement - ectopic suspected if:
  
  • Transabdominal ultrasonography does not show an intrauterine gestational sac and the patient’s beta-hCG level is greater than 6,500 mIU per mL (6,500 IU per L)
  • OR if transvaginal ultrasonography does not show an intrauterine gestational sac and the patient’s beta-hCG level is 1,500 mIU per mL (1,500 IU per L) or greater
• Occasionally, diagnostic curettage used:
  
  • May detect chorionic villi
  • If chorionic villi are not detected ectopic pregnancy should be suspected
  • Should only be considered when B-hcg levels are falling or when levels are elevated and U/S does not show intrauterine pregnancy - In viable pregnancies hcg doubles in 48 hours
  • Will terminate a pregnancy that may de desired

Question 19

ectopic pregnancy differential

Answer 19

• Acute appendicitis
• Miscarriage
• Ovarian torsion
• Pelvic inflammatory disease
• Ruptured corpus luteum cyst or follicle
• Tubo-ovarian abscess
• UTI or Urinary calculi (twice as common in preg)
• Diverticulitis

Question 20

criteria for managing ectopic pregnancy: expectant, medical or surgical

Answer 20

• Expectant Management Indications
  
  • No evidence of tubal rupture
  • Minimal pain or bleeding
  • Patient reliable for follow-up
  • Starting β-hCG level less than 1,000 mIU per mL and falling
  • Ectopic or adnexal mass less than 3 cm or not detected
  • No embryonic heartbeat
• Medical Management Indications
  
  • Stable vital signs and few symptoms
  • No medical contraindication for methotrexate therapy (e.g., normal liver enzymes, CBC/platelet count)

Question 21

ectopic pregnancy medical management with methotrexate

Answer 21

• Medical Management with Methotrexate: (90% effective in appropriate pts)
  
  • Unruptured ectopic pregnancy
  • Absence of embryonic cardiac activity
  • Ectopic mass of 3.5 cm or less
  • Starting β-hCG levels less than 5,000 mIU per mL
  • Follow-up: β-hCG on the fourth and seventh posttreatment days, then weekly until undetectable, which usually takes several weeks
  • Special consideration: prompt availability of surgery if patient does not respond to treatment
• Dosage: single intramuscular dose of 1 mg per kg, max of 3 doses over 2 weeks - stops the growth of rapidly dividing cells
• Follow-up: β-hCG on the fourth and seventh posttreatment days, then weekly until undetectable, which usually takes several weeks
• Expected β-hCG changes: initial slight increase, then 15 percent decrease between days 4 and 7; if not, repeat dosage or move to surgery

Question 22

ectopic pregnancy surgical managment

Answer 22

• Surgical Management
• Indications:
  
  • Unstable/signs of hemoperitoneum
  • Uncertain diagnosis
  • Advanced ectopic pregnancy (high hCG levels, large mass, cardiac activity)
  • Patient unreliable for follow-up
  • Contraindications to observation or methotrexate
• Laparoscopy with salpingostomy, without fallopian tube removal, has become the preferred method of surgical treatment
• Laparoscopy has similar tubal patency and future fertility rates as medical treatment
• Salpingostomy has an estimated 8 to 9 % failure rate, which can be managed with methotrexate

Question 23

definition of fetal demise

Answer 23

• The delivery of a fetus showing no signs of life as indicated by the absence of breathing, heartbeat, umbilical cord pulsation, or definite movements of voluntary muscles – United States National Center for Health Statistics
  
  • Term “stillbirth” preferred among parent groups
  • No uniformity in regard to birth weight and gestational age criteria
  • Suggested requirement - fetal loss after 20 weeks gestational age (EGA), or of fetal weight of > 350 g when gestational age is unsure with no evidence of life at birth
  • Death occurring prior to 20 weeks gestation usually classified as a spontaneous abortion

Question 24

incidence and epidemiology of fetal demise

Answer 24

• Over 2.6 million stillbirths ≥28 weeks or 1000 g (15 per 1000 live births 2015) occur each year worldwide (likely an underestimation as there are little reliable data from low income regions where most of the stillbirths occur).
• In 2013, the U.S. infant mortality rate (5.9 infant deaths per 1,000 live births) ranked 27th in infant mortality among industrialized nations, behind most European countries, Canada, Australia, Israel, and Republic of Korea.
• In the US, black women have twice the rate of stillbirth compared to white women. In 2001-2002, the stillbirth rate in white, Hispanic, and black women was 1/202, 1/183, and 1/ 87, respectively
  
  • The PMR definition is the sum of fetal deaths (≥20 weeks gestation) plus neonatal deaths (ie, deaths within the first 28 days of birth) during a year divided by the sum of live births plus late fetal deaths during the same year, expressed per 1000 live births plus late fetal deaths.

Question 25

maternal causes of fetal demise

Answer 25

* Race * White, Latino, Asian, and Native American women rate of fetal demise \<6 per 1,000 * Non-Hispanic Black Women – 10.53 per 1,000 * Advanced maternal age (AMA) * screening for chromosomal abnormalities has contributed to lower rates of perinatal deaths associated with AMA * Multiple gestation * 4x higher than singletons * increased risk of IUGR, and fetal abnormalities * Previous pregnancy complications * e.g. preterm delivery, IUGR, previous fetal demise * Obesity * BMI \>30 - 5.5/1000 ; BMI \>40 - 11/1000 * Independent risk factor after controlling for smoking, gestational diabetes and preeclampsia * Smoking, drugs, alcohol * Low educational attainment * Diabetes * Preconception care and optimal glycemic control can lower risk of perinatal death * HTN – chronic, PIH, preeclampsia, eclampsia * Infection * Renal disease * Thyroid disorder * Cholestasis of pregnancy * Hemoglobinopathy * Systemic lupus erythematosus * Rh disease * Uterine rupture * Maternal trauma or death * Inherited thrombophilias * Antiphospholipid syndrome

Question 26

fetal causes of fetal demise

Answer 26

* Multiple gestations * Twin - twin transfusion * Intrauterine growth restrictions (uterine abnormalities) * Congenital abnormality * Abnormal karyotype in approximately 8-13% of fetal deaths * Most common are monosomy X, trisomy 21, trisomy 18 and trisomy 13 * Infection * e.g. parvovirus, cytomegalovirus, Listeria monocytogenes and syphilis * Hydrops fetalis - immune or non-immune

Question 27

placental causes

Answer 27

* Cord accident * Dx should be made with caution * cord abnormalities found in approx. 30% of normal births, and may be incidental * should be evidence of obstruction or circulatory compromise and other causes excluded * Placental abruption * Premature rupture of membranes * Vasa previa/velamentous insertion * Fetomaternal hemorrhage * Placental insufficiency

Question 28

commonly reported maternal risk factors and causes for stillbirth

Answer 28

* _All Countries_ * Congenital/Karyotypic anomalies * Growth restriction and placental abnormalities * Diseases - HTN/preeclampsia, DM, SLE, renal disease, thyroid disease, cholestasis * Infection - human parvovirus B19, Syphilis, streptococcal infection, listeria * Smoking * Multiple gestations * _Developing countries_ * Obstructed/prolonged labor (asphyxia, infection, birth injury) * Infections - syphilis and gram negative infections * HTN diseases * Congenital anomalies * Poor nutrition * Malaria * Sickle cell disease

Question 29

unexplained stillbirth

Answer 29

* An unexplained stillbirth is a fetal death that cannot be attributed to an identifiable fetal, placental, maternal, or obstetrical etiology. It accounts for 25 to 60 percent of all fetal deaths * In a population-based study of surveillance of stillbirths in the US between 2006 and 2008, 500 women consented to complete postmortem examinations of 512 stillborn neonates. A *probable* cause of death was found in only 60.9 percent of cases and a *possible or probable* cause was found in 76.2 percent of cases. * The largest study of unexplained stillbirth (n=196 cases) reported the following characteristics were independent risk factors: * maternal prepregnancy weight greater than 68 kg * birth weight ratio (ratio of birth weight to mean weight for gestational age) between 0.75 and 0.85 or over 1.15 * parity of three or more AND primiparity * cord loops * low socioeconomic status * maternal age 40 years or more.

Question 30

diagnosis of fetal demise

Answer 30

* History and physical * Reported decreased fetal movement, decreased pregnancy sxs, bleeding or contractions * Inability to obtain fetal heart tones not diagnostic * Must be confirmed by US examination * Diagnosed by visualization of fetal heart and absence of cardiac activity

Question 31

management of fetal demise

Answer 31

* Before 28 weeks vaginal misoprostol (Cytotec) most efficient method of induction * Induction accomplished with pre-induction cervical ripening followed by IV pitocin * ACOG states that prostaglandin E2 and misoprostol should not be used in women with hx of prior uterine incision due to risk of uterine rupture * Cesarean delivery reserved for unusual circumstances because it is associated with potential maternal morbidity without any fetal benefit

Question 32

evaluation of fetal demise

Answer 32

* Thorough maternal, FH, OB hx * Fetal autopsy, fetal karyotype * Placental evaluation * Indirect Coomb’s test * RPR, parvo testing, CBC/platelets, TSH * maternal-fetal hemorrhage (Kleinhauer-Betke) * Urine tox screen * Sometimes useful depending on circumstances: * Thrombophilia evaluation to include the following: * Lupus anticoagulant * Antiphospholipid (Anticardiolipin) antibodies * Factor V Leiden * Prothrombin mutation * Protein C, protein S and antithrombin III deficiency * Uncertain utility: * Hemoglobin A1C * TORCH titers * Placental cultures * Testing for other thrombophilias

Question 33

support for fetal demise

Answer 33

* Patient support should include emotional support and clear communication of test results * Referral to bereavement counselor, religious leader, peer support group or mental health professional, SANDS, Neptune Society * Feelings of guilt and/or anger common, post-partum depression * Be prepared for varied responses * Some parents may welcome discussion and find relief in autopsy results, some may not - honor cultural differences * Support and reassurance in subsequent pregnancies

Question 34

management of future pregnancies

Answer 34

* Evidence-based consensus for optimal management of future pregnancies following a fetal loss is lacking * Emotional preparedness of couple - grief process (i.e. support groups) Most women recover psychologically by 12 months. * Inter-pregnancy intervals of 12 to 36 months appear to be associated with lower risks of subsequent adverse pregnancy outcomes * PTSD more likely when conception occurs soon after the loss (observational studies) * For low-risk women with unexplained stillbirth, the risk of recurrence is 8 to 11 per 1000 births, and most of these deaths occur preterm; recurrence occurs at term in 1.8 per 1000 births. The subsequent pregnancy is at risk for abruption, preterm birth, and low birth weight. * Optimal management of chronic conditions * Detailed medical/obstetric hx., consideration of maternal serum screening for aneuploidy may be beneficial, w/u of previous stillbirth * Weight loss, smoking cessation * **1st trimester** - Dating U/S, first trimester combined testing * **2nd trimester** - U/S at 18-20 wks, Doppler velocimetry, quadruple screen or AFP * **3rd trimester** - U/S after 28 wks, kick counts from 28wks, Doppler velocimetry antenatal testing with weekly biophysical profile (BPP) starting at 32 to 36 week. ACOG recommends antepartum fetal testing 1-2 wees prior to previous stillbirth * **Delivery** - Elective induction at 39wks, or before with documented fetal lung maturity by amniocentesis