1) First trimester fetal death refers to death of the fetus before 12 weeks of gestation, often called a miscarriage. About 80% of spontaneous pregnancy losses occur in the first trimester.
2) Chromosomal abnormalities account for about 50% of first trimester losses, with the most common being trisomy 16, monosomy X, and translocations. Other causes include diabetes, thyroid disorders, infections, and luteal phase defects.
3) Diagnosis involves history, ultrasound to check for cardiac activity, and beta-hcg levels. Management depends on stability of the woman and includes expectant, medical, or surgical options. Recurrent losses should be further evaluated and treated.
2. DEFINATION
First-trimester fetal death: Death of the
fetus in the first 12 weeks of gestation
Many prefer miscarriage to refer to
spontaneous fetal loss before viability.
Use of sonography and measurement of
serum human chorionic gonadotropin levels
allow identification of extremely early
pregnancies whose failure to be termed as
early pregnancy loss or early pregnancy
failure.
3. incidence
Of all pregnancies diagnosed from β-HCG
measurements 31% are lost.
Preclinical or silent-22% (2/3rd)
Clinical-12% (1/3rd)
About 80% of spontaneous pregnancy
losses occur in the first trimester; the
incidence decreases with each
gestational week.
Most of these occur <8 weeks.
4. classification
Can be classified as
Anembryonic gestation
Preclinical (2/3rd)
Biochemical pregnancy loss
Clinical(1/3rd)
Natural course of 1st trimester IUD
Missed abortion
Incomplete abortion
Complete abortion
Inevitable abortion
Septic abortion
5. Missed abortion
Presence of definitive
embryo without cardiac
activity
Expelled spontaneously in
about 4 weeks
Now readily diagnosed by
USG
CRL ≤ 6 mm: viability
uncertain, rescan in 7-10
days
CRL > 10 mm: delayed
miscarriage
50% due to chromosomal
abnormality
6. Anembryonic gestation (blighted ovum)
An intrauterine sac
without fetal tissue
present at more than
7.5 weeks of gestation
USG criteria
MSD ≤20 mm: viability
uncertain, rescan in 7-10
days
MSD >20 mm: blighted
ovum
Accounts for ½ of
pregnancy loss
8. Chromosomal abnormality
Autosomal trisomy
50% of all chromosomal anomalies
M.C. is trisomy 16
Polyploidy
Normosaic triploid/ tetraploidy
Results in partial mole
Tetraploidy non viable
Diploid/triploid mosaicism
Sex chromosome polysomy
Frequency increased in ICSI
9. Monosomy X
Single most common
chromosomal cause (15-
20%)
Maternal age not
contributory
80% of Monosomy X
abort rest are live born
with turner’s syndrome.
10. Autosomal Monosomy
Translocations
Inversions
Mendelian or polygenic factors
30-50% of 1st trimester pregnancy loss
showing no chromosomal abnormalities
Abortus have isolated structural defects
Confined placental mosaicism- mosaicism
restricted to placenta
Uniparental disomy- due to trisomic
rescue
11. Luteal phase defects
Defn.- Lag of >2 days in histologic
development of Endometrium to day of
menstrual cycle.
Mechanism
Inadequate progesterone secretion due to
deficient action of corpus luteum
Endometrium not responsive to progesterone
Estrogen primed endometrium unfavorable for
implantation
Early & recurrent pregnancy loss
13. Diabetes mellitus
Risk increases with loss of metabolic
control measured by HbA1c
Also with increased insulin resistance or
serum insulin levels
If diabetes is controlled in 1st 21 days of
conception & maintained throughout
pregnancy, abortion risk become
equivalent to non diabetic controls but
risk of congenital malformation remains
unchanged.
14. Influence of hyperglycemia
Implantation-inhibits trophoectoderm
differentiation
Embryogenesis- increases oxidative stress
affecting expression of critical genes
essential for embryogenesis
Miscarriage- increases premature
programmed cell death of key progenitor
cells of blastocyst
Organogenesis- activates the diacylglycerol-
protein kinase C cascade increasing
congenital defects
16. Asherman syndrome
Intrauterine adhesions- loss of endometrial
surface area resulting in either failure of
implantation or expulsion of products of
conception on further growth
Causes
Uterine curettage
Intrauterine surgery, e.g. myomectomy
Endometriosis
PID- tuberculosis, schistosomiasis
Infections related to intrauterine devices
21. Past history
Previous pregnancy loss
& their timing
Uterine surgery
Any febrile illness
Stillbirths
Malformed babies
Big size baby
Infertility
Menstrual history
Regularity of cycles
Any shortening of
cycles
22. Personal history
Age
Hypertension, diabetes mellitus, thyroid
disorders
Contraceptive use
Drug intake
Alcohol & smoking
Exposure to radiation
Family history
Diabetes mellitus
Genetic disease
23. Examination
Pallor
Temperature
Pulse
Blood pressure
Tachypnea /dyspnea
Body mass index
Neck swelling
Galactorrhea
P/A
Abdominal distension
Abdominal tenderness
Enlarged irregular
shaped uterus
P/S
Status of os
Bleeding
Discharge
POC’s in vagina
P/V
Uterine size
Status of os
Bleeding
POC’s in cervical canal
Adnexal mass
Adnexal tenderness
Uterine tenderness
25. Confirmation
USG- normal findings
5 wks- empty GS- MSD 10mm
5.5 wks- GS with yolk sac
6 wks- heart beat- embryo 3 mm- MSD 16 mm
6.5 wks-CRL 6mm
7 wks-CRL 10 mm
8 wks- CRL 16 mm- amniotic sac- fetal body
movements
β-HCG
1500(3000) U/ml- TVS(TAS) shows GS
2X in 48 hrs- normal intrauterine pregnancy
Fall- miscarriage
Low value or <2X rise- extrauterine pregnancy
High value- twin pregnancy or H. mole
26. Criteria for predicting non viability
Sac size (Nyberg criteria)
>20(8-TVS) mm without yolk sac
>25(16-TVS) mm without embryo
Failure of sac/embryo to grow at expected
rate (1.1 mm/day)
Embryo of 10 mm without cardiac activity
Loss of cardiac activity previously present
Failure of rise in β-HCG levels at expected
rate (2X in 48 hrs)
Yolk sac >6 mm with abnormal morphology
29. management
Hemodynamically
stable
• Patient’s choice
• Expectant
• Medical
• Surgical
Hemodynamically
unstable
• Stabilize vitals
• Arrange for
blood
• surgical
Septic abortion
• Broad spectrum
i.v. antibiotics
• surgical
expectant
• Wait and watch
• Up to 7 days
• No intervention
medical
• Misoprost
induction
surgical
• Manual vacuum
aspiration
• Electric vacuum
aspiration
• Dilatation &
evacuation
30.
31. Prenatal counseling
Early registration
Repeat abortion
Congenital malformation
Diet control
Regular follow up
Assisted reproductive techniques
Folic acid administration 3 month before
conception
Investigations and management accordingly
32. Prenatal investigations
HbA1c
TSH
Chorionic villous biopsy
Trophoectoderm biopsy
Preimplantation genomic diagnosis (PGD)
Luteal phase defects
Basal body temperature (BBT) chart
Follicular size USG
Sr. Progesterone level
• At D21 <10 ng/ml
• 3 measurements within D5-D9 after ovulation-
total <30 ng/ml, pooled concn. <9 ng/ml
Luteal phase endometrial biopsy
Sr. prolactin level
33. Management
Control of diabetes
Control of thyroid disorders
LPD
GnRH agonists
Clomiphene citrate
Progesterone support
• Oral
• Intramuscular
• Vaginal suppositories
• Vaginal gel
Bromocriptine