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Abortion & ectopic pregnancy by liza tarca, md

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Abortion & ectopic pregnancy by liza tarca, md

  1. 1. Liza Tarca-Cruz, MD
  2. 2.  Abortion (L – aboriri)  To miscarry  Premature birth before a live birth is possible (New Shorter Oxford Dictionary 2002) Pregnancy termination prior to 20 weeks gestation base on LMP  Fetus with birth weight of ≤ 500 grams  WHO NCHS, CDCP,
  3. 3.  31% of losses occur after implantation (Wilcox et al 1988)  Increases with parity, maternal and paternal age (Gracia 2005)  Frequency     <20 >40 <20 >40 years years years years doubles old – old – old – old – 12% 26% 12% 20% Maternal Paternal
  4. 4.  Abnormal Zygotic Development  Abnormality  Zygote, Embryo, Early Fetus, Placenta  40%  in the development of: are expelled SPONTANEOUSLY Aneuploid Abortion – before 8 weeks AOG  Chromosomal   95% maternal gametogenesis errors 5% paternal gametogenesis errors  Autosomal  abnormalities Trisomy most frequently identified(autosomes 13, 16, 18, 21,22)
  5. 5.  Monosomy  X (45X) 2nd most frequent (abortion & live female – Turner Syndrome)  Triploidy   Hydrophic placental (molar) degeneration Incomplete/Partial H. Mole – triploidy or trisomy chromosome 16  Tetraploid  Chromosomal   Structural Abnormalities Infrequently cause abortion Euploid Abortion – 13 weeks AOG  Abort later  Increase incidence with increase maternal age
  6. 6.  Infections  Syphilis  HIV  Group B Streptococci  Bacterial vaginosis  Endocrine Abnormalities  Hypothyroidism  Iodine deficiency  miscarriage  Diabetes  Mellitus Insulin dependent DM  metabolic control  Progesterone Deficiency (Luteal Phase Defect)
  7. 7.   Nutrition – does not cause abortion Drug Use & Environmental Factors  Tobacco   Increase risk of euploid abortion >14 sticks/day  Alcohol  First 8 weeks of pregnancy  Caffeine  >5 cups /day (500mg caffeine/day) – paraxanthine  Radiation  Contraceptives  IUD – septic abortion
  8. 8.  Environmental   Toxins Arsenic, Lead, Formaldehyde, Benzene, Ethylene Oxide, Nitrous Oxide Immunological Factors  Autoimmune (immunity against self) Antiphospholipid antibody (IgG, IgA, IgM isotype) – Lupus Anticoagulant & Anticardiolipin Antibody  placental thrombosis & infarction  prostacyclin (vasodilator inhibitor platelet aggregation)  inhibit protein C activation (coagulation & fibrin formation)   Alloimmune (immunity against another person)
  9. 9.   Inherited Thrombophilia Laparatomy  Removal of corpus luteum cyst < 10 weeks AOG  progesterone supplement   Physical Trauma Uterine Defects  Acquired   Leiomyoma (location not size) Asherman Syndrome (uterine synechiae)  Developmental  Abnormal mullerian duct formation/fusion or DES exposure
  10. 10.  Incompetent Cervix  Painless cervical dilatation in the 2nd trimester with prolapse & ballooning or members into vagina, followed by expulsion of immature fetus  “Funneling”  Etiology: previous trauma to cervix, abnormal cervical development  Treatment: CERCLAGE
  11. 11.  Surgical reinforcent of weak cervix by purse string suturing  Contraindication to Cerclage: bleeding, uterince contractions, ruptured BOW  12 to 16 weeks but not later than 23 weeks  Cervical examination: 1 to 2 weeks  Types:    McDonald Shirodkar Transabdominal cerclage – suture placed at uterine isthmus  Complications: infection, ruptured membranes
  12. 12.    80% - first 12 weeks ½ due to chromosomal anomalies BLIGHTED OVUM – embryo is degenerated or absent
  13. 13. Bleeding Uterine Contraction Cervix BOW Uterine size + +/- Close + C Inevitable +/- + Open - NC Curettage Imminent + + Open + C Expectant Incomplete + +/- Open - NC Completion Curettage +/- - Close - NC Observation +/spotting - Close +/- NC Expectant Medical PGE Curettage + +/- Open +/- C Threatened Complete Missed Habitual (Recurrent) Management Bedrest, Tocolysis Cerclage
  14. 14.   ≥3 consecutive spontaneous abortions Parental cytogenetic analysis, LAC, ACA
  15. 15.   Medical or surgical termination of pregnancy before the time of fetal viability Therapeutic abortion – for the purpose of saving the life of the mother
  16. 16.  SURGICAL  Cervical dilatation followed by uterine evacuation     Curettage – sharp or suction Vacuum aspiration (suction curettage) Dilatation and Evacuation (D&E) – 16 weeks Dilatation and Extraction (D&X)  Menstrual aspiration  Laparotomy   Hysterotomy Hysterectomy Complications: uterine perforation, cervical laceration, hemorrhage, infection, incomplete removal of the fetus & placenta
  17. 17.  MEDICAL  Intravenous oxytocin  Intra-amnionic hyperosmotic fluid  20% saline & 30% urea  Prostaglandin      E2, F2α, E1 and analogues Intra-amnionic injection Extraovular injection Vaginal insertion Parenteral injection Oral ingestion  Antiprogesterone – RU 486 (mifepristone) & epostane  Methotrexate – intramuscular & oral

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