Spontaneous Abortion

Vandana Sharma, M.D

April 30, 2004

CASE

Pt. 27 yr.. old G3 P2002, walks into clinic with vaginal bleeding

What would you ask her? What tests would you order? What follow-up would she need?

Differential Diagnosis

Bleeding in the first trimester– Physiologic– Pathologic

Ectopic pregnancy Spontaneous abortion Cervical or vaginal Pathology

– Polyp– Infection– Neoplasia

Risk Factors Age smoking Alcohol Drugs Caffeine Analgesics Gravidity Previous Miscarriage Fever Trauma Maternal Exposure to Teratogens

Types of Spontaneous Abortions

Threatened Abortion Inevitable Abortion Incomplete Abortion Septic Abortion Missed Abortion Blighted ovum or Anembryonic Pregnancy

– Failure or absence of an embryo at a very early stage of pregnancy

SPONTANEOUS ABORTION

Pregnancy that ends spontaneously before the fetus has reached a viable gestational age.

Corresponds to a gestational age of 20 to 22 weeks.

Clinical Manifestation

History of Amenorrhea Vaginal bleeding

– spotting or heavy– intermittent or constant– light or dark– brief or lengthy (several weeks in duration)– heavier and more persistent bleeding (carries a poor

prognosis) Abdominal pain

Epidemiology

Most common complication of early pregnancy. Approximately 10 to 20 percent of clinically

recognized pregnancies under 20 weeks of gestation will undergo spontaneous abortion.– 80 percent of these occur in the first 12 weeks of gestation.

Loss of unrecognized or sub clinical pregnancies is much higher - between 50% and 75%

Over all 12% of clinically recognized pregnancies ended in spontaneous abortion.

Diagnosis

Clinical assessment Quantitative beta hCG Ultrasonography

Clinical Assessment

History Physical exam Studies

Labs

GC/Chl Wet Prep Beta HCG Hemoglobin Rh Status

Ultrasonograghy

Plays an important role in the diagnosis and management of first trimester bleeding

Criteria for Definite diagnosis of nonviable IU pregnancy -

– Absence of fetal cardiac activity with C-R length of >5mm.

– Absence of a fetal pole when the mean sac diameter is >25 mm by transabdominal US or >18 mm by the transvaginal technique.

Ultrasonogragphy (cont’d)

Additional finding- predictive of impending pregnancy loss.

An abnormal Yolk sac - large for gestational age, irregular, free floating in the gestational sac or calcified.

Fetal HR <100 bpm at 5-7 wks gestation Small mean sac size Large subchorionic hematoma

Management

Counseling Expectant Management Medical Management Surgical Management

Counseling

Pre and post Counseling Panic and anxiety Guilt Feeling

Expectant Management

As effective as medical or surgical treatment. Early pregnancy Failure <13 week gestation. Stable Vital signs No evidence of infection Majority of expulsions occur in the first 2 weeks of

diagnosis. Uterine cavity evaluation by ultrasound Surgical evacuation is needed if retained tissue is > 15mm. Failure Spontaneous expulsion - Medical or surgical

treatment.

Medical Management

Prostaglandin E1 analog– Oral - Low success rate– vaginal - High success rate Recommendation: Misoprostol 400mcg every 4 hrs for 4 doses

Combination of a progesterone antagonist and misoprostol– Expensive– Side effects

Medical Management

Advantage– Less Expensive– Low incidence of side effects when used

vaginally– Ready availability

Contra-indicated– Asthma– Glaucoma

Surgical Management

D & C– Conventional treatment for first or early second trimester miscarriage

Indications– Evidence of incomplete abortion– Heavy bleeding– Intrauterine sepsis– Patient’s preference– Documented Fetal demise or blighted ovum.

Risks– Minimal, uterine perforation, interauterine adhesions, cervical

trauma, infection and Anesthesia risks.

Examination of Tissue

Crucial and underutilized skill in the management of first trimester bleeding problem.

The main issue is whether the tissue is placenta - proving that pregnancy was intrauterine. Placental villi have a characteristic appearance best described as frond like or “seaweed floating under a dock”

In all cases the tissue should be submitted for formal pathologic examination. In certain situations tissue is submitted for genetic studies.

Natural History

One third of the products of conception from spontaneous abortions occurring at or before eight weeks of gestation are blighted. If embryo is found, there is 50% probability of it being abnormal/dysmorphic.

Approximately 50% of miscarriages are cytogenetically abnormal.

Earlier the gestational age at abortion, the higher the incidence of chromosomal defects.

Post Abortion Care

Immediate Care after D&C– Observation for Hemorrhage or change in vital signs.

General Care – Women who are Rh(D) negative– doxycycline 100 mg bid on the day of the procedure– Methylergonovine maleate 0.2 mg every 4 hours for

five doses– Pelvic rest - nothing per vagina for two wks

Post Abortion Family Planning

Pregnancy can be deferred for two to three months however there is no greater risk of adverse outcome with a shorter pregnancy interval.

Contraception - Any type including IUD may be started immediately.

Grief counseling is appropriate as needed.

Take Home Points

Always do vaginal exam with sterile speculum.

If not confident about passage of complete tissue, perform ultrasound

Counseling and emotional support is necessary

Follow up on regular basis