Differential Diagnosis Implantation of embryo into endometrium (normal) Spontaneous abortion Ectopic pregnancy Gestational trophoblastic disease Abnormal placentation (ie. placenta previa) usually does not cause bleeding until later in pregnancy
Spontaneous Abortion Definition: Passing of a pregnancy prior to 20 weeks gestation (aka: miscarriage) Half of pregnancies complicated by 1st trimester bleeding end in spontaneous abortion Causes separated into genetic and environmental (maternal) Genetic abnormalities in 50-70% of SAs Trisomy most common anomaly Other causes include maternal systemic disease (ie. diabetes, hypothyroidism, autoimmune dx), infection, maternal anatomic defects (ie. bicornuate uterus) Often, exact cause is unknown
Classification of SpontaneousAbortion Threatened: Vaginal bleeding without cervical dilation Incomplete: Vaginal bleeding with partial expulsion of products of conception (POC) + cervical dilation Missed: Embryonic demise prior to 20 wks without expulsion of POC +/- vaginal bleeding Complete: Vaginal bleeding + expulsion of all POC Inevitable: Vaginal bleeding + cervical dilation Septic: Any of the above + uterine infection
First-trimester Milestones 5 weeks: Gestational sac (~5mm) seen with TVUS 6 wks: Embryo (1-2mm) visible on TVUS Yolk sac: Seen with TVUS when GS>10mm (>20 w/ TAUS) Cardiac activity: Seen with TVUS when GS >18mm Normal gestational sac at arrow, endometrial (>25mm on TAUS) cavity at curved arrow Cardiac activity should always be seen when embryo >5mm
Normal US FindingsYolk sac (at arrow) within gestational sac Yolk sac (at curved arrow) with embryo (between X’s)
Normal US Findings Embryo (black arrow); amnion (small arrow) does not fuse with chorion (large arrow) until 12-16wks gestation.
Spontaneous Abortion Presentation: Varies greatly depending on type of abortion, but often presents with vaginal bleeding and uterine cramps or β-hCG: Falling or rising back pain. abnormally slow US findings vary depending on classification and cause of abortion Anembryonic pregnancy: large (>18mm) gestational sac without embryo
Abnormal US Findings: SpontaneousAbortionAbortion in progress: low-lying gestational sac (thick Missed abortion: embryo (at arrow) is relativelyarrow), decidual reaction and hemorrhage (mixed hyper- small compared to large gestational sac. Noand hypo-echoic material between arrowheads) cardiac activity was present.
Treatment There are no effective therapies for threatened abortion. Bedrest, although often prescribed, does not alter its course. Progesterone or sedatives should not be used Acetaminophen-based analgesia may be given to help relieve discomfort All patients should be counseled and reassured so that they understand the situation
Habitual Abortion defined as 2 to 3 or more consecutive pregnancy losses before 20 weeks of gestation ,each with a fetus weighing less than 500 g Etiology Eldery mom : advice Genetic Errors − Balanced rearrangements of parental chromosomes are found in approximately 2–5% of couples with repetitive abortions − Balanced translocations are the most common − 1st trimester − karyotype screening should be performed
Habitual Abortion Uterine Abnormalities − Generally, losses from anatomic abnormalities occur in the second trimester − causes of habitual abortion up to 15% − congenital uterine anomalies (Unicornuate and bicornuate uter), cervical incompetence, submucous leiomyomas, abnormalities due to DES exposure in utero Hormonal CausesUnicornuate and bicornuate − Hypothyroidism and hyperthyroidism, progesterone insufficiency, and uncontrolled diabetes mellitus. − Progesterone deficiency or luteal phase defect (LPD) is a controversial etiology of habitual abortion.
Habitual Abortion Infection − Mycoplasma hominis, Ureaplasma urealyticum, Toxoplasma gondii, C trachomatis, T pallidum, Borrelia burgdorferi, N gonorrhoeae, S agalactiae, L monocytogenes, herpes simplex, and cytomegalovirus. Immunologic Factors − Antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibodies) may damage platelets and vascular endothelium − PTT − Tx : heparin / low dose ASA
Missed Abortion—Early Pregnancy Failure Fetal death before 20 weeks of gestation without expulsion of any fetal or maternal tissue thereafter Dead products of conception that were retained for days, weeks, or even months [6 wks]in the uterus with a closed cervical os. Always preceded by embryofetal death Regression of changes of pregnancy
Missed Abortion—Early Pregnancy Failure[cont’] History is not diagnosis. -Early pregnancy appears to be normal, with amenorrhea, nausea and vomiting, breast changes, and uterine growth. -After embryonic death, there may or may not be vaginal bleeding or other symptoms of threatened abortion with persistent amenorrhea. With sonography, confirmation of an anembryonic gestation or of fetal or embryonic death is possible
Missed Abortion—Early Pregnancy Failure [cont’] Physical examination cannot help diagnosis. -Uterine size not to the gestational age; becomes smaller. -Absence of FHT -Mammary changes usually regress -Often lose a few pounds. -Have no symptoms during this period except persistent amenorrhea. -Vaginal bleeding may be seen in PV exam. Investigation as threatened abortion -β-hCG -USG;Embryonic demise ,Blighted ovum
Missed Abortion—Early Pregnancy Failure[cont’] Medical or surgical termination at the time of diagnosis. Not termination -Uterine size remains unchanged, and then gradually becomes smaller. -Mammary changes usually regress -Often lose a few pounds. -Have no symptoms during this period except persistent amenorrhea. If the missed abortion terminates spontaneously, and most do, the process of expulsion is the same as in any abortion
Septic abortionDefinition Any abortion associated with clinical evidences of infection of uterus and itscontents is called as septic abortion. Clinical evidences of infection are : Fever 38 C or more for at least 24 hr. Offensive or purulent vaginal discharge Lower abdominal pain, tenderness or mass. Tachycardia of more than 100 per min.
Septic abortionClinical Grading of septic abortion Grade 1 Infection localized to uterus Grade 2 Infection beyond uterus to parametrium, tubes, ovaries or pelvicperitoneum Grade 3 Generalized peritonitis and or endotoxic shock or ARF
Septic abortionSymptoms High fever, usually above 101 °F Chills Severe abdominal pain and/or cramping Prolonged or heavy vaginal bleeding Foul-smelling vaginal discharge Backache A cold or UTI may mimic many of the symptoms.
Septic abortion As the condition becomes more serious, signs of septic shock may appear,including: Hypotension Hypothermia Oliguria Respiratory distress (dyspnea) Septic shock may lead to kidney failure, bleeding tendency and DIC. Intestinal organs may also become infected, potentially causing scar tissuewith chronic pain, intestinal blockage, and infertility.
Septic abortionInvestigation1. CBC • Anemia, Plt count2. Coagulogram • Coagulation, DIC, Bleeding & Clotting time.3. Urine analysis and Urine culture • Bacteriological study for pus cells & culture.4. Uterine discharges gram stain and culture • Gram staining-aerobic & anaerobic culture & sensitivitydetermination.
Septic abortion5. Blood culture • Blood culture prior to antibiotic therapy.6. Serum electrolyte • Fluid & electrolytes disturbances.7. Chest X-ray • Pneumonia associated with spontaneous abortion • Air underneath the dome of diaphragm is an indication of perforationof uterus or intestines.
Septic abortion After successful treatment of a septic abortion, a woman may be tired for several weeks. In case of substantial bleeding, iron supplementation may be helpful. Sexual intercourse or use tampons should be avoided until recommended by the healthcare provider.
Tubal Pregnancy at USG Detailed view of ectopic (thick, brightly echogenic, ringlike structure outside the uterus) Tubal pregnancy circled in red 4.5 mm fetal pole (between cursors) in green Pregnancy yolk sac in blue
Tubal Pregnancy at laparoscope A right tubal ectopic pregnancy seen at laparoscopy The swollen right tube containing the ectopic pregnancy is on the right at E The stump of the left tube is seen at L - this woman had a previous tubal ligation
Malignant trophoblastic and aggressive cancer characterized by early hematogenous spread to the lungs พบเกิดตามหลัง hydatidiform moles, ทองปกติ, ทองนอกมดลูก, แทง ดังนั้นจึงเปนขอควรนึกถึงเสมอในกรณีที่ผปวยมีเลือดไหลออกจากชองคลอดไมหยุด ู ภายหลังการคลอดหรือแทง
Patient suffers from mole should be controlled for one year and Rise in β-hCG disturbed the follow up another one after CMT. Teratogenic effects from CMT Relapse GTN Woman that went on CMT will experience menopause 3 years early from normal one.
1. Evaluation2. Prophylactic CMT3. Evacuation4. Follow up & contraception
Only for high-risk group Not available to follow up Large for date Theca lutien cyst > 6 cm Hyperthyroidism Maternal age > 40 years hCG in blood > 100,000 mU/mL Prior molar pregnancy
Actinomycin D 12 ug/kg/day (IV) 5 days continuous Methotrexate 0.4 mL/kg/day (IV) 5 days continuous
Termination of pregnancy (if on CMT, do it in day 3) Suction & Curettage Hysterectomy Hysterotomy
1. History taking and pelvic examination2. hCG3. Chest X-ray4. Contraception