ABORTIONS

MADIHA SPONTANEOUS MISCARRIAGE. )

Presented by
Brig Prof & Head Dept of Gynae/Obs (Mamoona Mushtaq)

DEFINITION
The expulsion or extraction from its mother of a fetus before 24 completed weeks of gestation or an embryo weighing 500 gms or less.

Terminology
The medical term 'spontaneous abortion' should be replaced with the term 'miscarriage'

Other names : recurrent pregnancy loss (RPL), habitual abortions , habitual miscarriages, recurrent abortions , recurrent miscarriages.

Primary recurrent pregnancy loss" refers to couples that have never had a live birth, while "secondary RPL" refers to those who have had repetitive losses following a successful pregnancy

Types of Abortions
Spontaneous
Threatened abortion Missed abortion Incomplete abortion Inevitable abortion Complete abortion

Induced
Therapeutic abortion Criminal abortion

Classification
Threatened abortion: fetus is still viable, and the cervical os is closed. Inevitable abortion: fetus may still be alive but the cervical os is open. Incomplete abortion: some products of conception have been expelled already. Complete abortion: fetus and placental tissue have all been expelled. Missed abortion: the pregnancy has succumbed but has not been expelled

Complications of abortions
1. Haemorrhage 2. Sepsis 3. Coagulopathies/DIC 4. Trauma as a result of surgery 5. Shock 6. Psychological upsets

Differential diagnosis of abortions

Bleeding in early pregnancy
Ectopic pregnancy Molar pregnancy Incidental problems

Pain in early pregnancy

Ectopic pregnancy Infections
Uterine infections Extra uterine infections

Causes Causes of first- and secondtrimester miscarriage

Embryonic abnormalities account for 80-90% of first-trimester miscarriages.
Chromosomal abnormalities are the most common cause of spontaneous miscarriage. More than 90% of cytogenic and morphologic errors are eliminated through spontaneous miscarriage. Chromosomal abnormalities have been found in more than 75% of fetuses that miscarry in the first trimester.

Causes Causes of first- and secondtrimester miscarriage

The rate of chromosomal abnormalities increases with age, with a steep increase in women older than 35 years.

Trisomy chromosomes commonly are encountered, with trisomy 16 accounting for approximately a third of chromosomal abnormalities in early pregnancy.

Maternal factors account for the majority of second-trimester miscarriages. Chronic maternal health factors:
Maternal insulin-dependent diabetes mellitus (IDDM): As many as 30% of pregnancies in women with IDDM result in spontaneous miscarriage, predominantly in patients with poor glucose control in the first trimester. Severe hypertension Renal disease Systemic lupus erythematosus (SLE) Hypothyroidism and hyperthyroidism

Exogenous factors
Other factors that may contribute to miscarriage
Alcohol Tobacco Cocaine and other illicit drugs

Anatomic factors
: Congenital or acquired anatomic factors are reported to occur in 10-15% of women who have recurrent spontaneous miscarriages.
Congenital anatomic lesions include mllerian duct anomalies (eg, septate uterus, diethylstilbestrol [DES]-related anomalies). Mllerian duct lesions usually are found in second-trimester pregnancy loss. Anomalies of the uterine artery with compromised endometrial blood flow are congenital.

Aquired lesions
Acquired lesions include intrauterine adhesions (ie, synechiae), leiomyoma, and endometriosis. Other diseases or abnormalities of the reproductive system that may result in miscarriage include congenital or acquired uterine defects, fibroids, cervical incompetence, abnormal placental development, or grand multiparity.

Endocrine factors:
Endocrine factors potentially contribute to recurrent miscarriage in 10-20% of cases. Luteal phase insufficiency (ie, abnormal corpus luteum function with insufficient progesterone production) is implicated as the most common endocrine abnormality contributing to spontaneous miscarriage. Hypothyroidism, hypoprolactinemia, poor diabetic control, and polycystic ovarian syndrome are contributive factors in pregnancy loss.

Infectious factors:
Presumed infectious etiology may be found in 5% of cases. Bacterial, viral, parasitic, fungal, and zoonotic infections are associated with recurrent spontaneous miscarriage.

Immunologic factors:
Immunologic factors may contribute in up to 60% of recurrent spontaneous miscarriages. Both the developing embryo and the trophoblast may be considered immunologically foreign to the maternal immune system. Antiphospholipid antibody syndrome generally is responsible for more secondtrimester pregnancy losses than firsttrimester losses.

Miscellaneous factors
Miscellaneous factors may account for up to 3% of recurrent spontaneous miscarriages. Other contributing factors implicated in sporadic and recurrent spontaneous abortions include environment, drugs, placental abnormalities, medical illnesses, and male-related causes.

Diagnosis of abortions
History Physical examination Investigations

Clinical History
Patients with spontaneous miscarriage usually present to the ED with vaginal bleeding, abdominal pain, or both. Vaginal bleeding may vary from slight spotting to a severe life-threatening hemorrhage.

The patient's history should include the number of pads or tampons used. Hasan et al found that heavy bleeding in the first trimester, particularly when associated with abdominal pain, is associated with higher risk of miscarriage.5

Clinical History
Presence of blood clots or tissue may be an important sign indicating progression of spontaneous miscarriage. Abdominal pain is usually located in the suprapubic area or in one or both lower quadrants. Pain may radiate to the lower back, buttocks, genitalia, and perineum.

The patient's history should also include the following

Date of last menstrual period (LMP)
Estimated length of gestation Sonogram results, if previously performed Bleeding disorders Previous miscarriage or elective abortions

Other symptoms, such as fever or chills, are more characteristic of a septic miscarriage or abortion. Consider any woman of childbearing age with vaginal bleeding pregnant until proven otherwise.

Physical
Pelvic examination should focus on determining the source of bleeding.
Blood from cervical os Intensity of bleeding Presence of clots or tissue fragments Cervical motion tenderness (presence increases suspicion for ectopic pregnancy) Status of internal cervical os: open indicates inevitable or possibly incomplete miscarriage; closed indicates threatened miscarriage. Uterine size and tenderness, as well as adnexal tenderness or masses

Signs of threatened miscarriage

:
Vital signs should be within reference ranges unless infection is present or hemorrhage has caused hypovolemia. The abdomen usually is soft and nontender. Pelvic examination reveals a closed internal cervical os. The bimanual examination is unremarkable.

Signs of incomplete miscarriage

:
The cervix may appear dilated and effaced, or it may be closed. Bimanual examination may reveal an enlarged and soft uterus. On pelvic examination, products of conception may be partially present in the uterus, may protrude from the external os, or may be present in the vagina. Bleeding and cramping usually persist.

Complete miscarriage
: On pelvic examination, the cervix should be closed, and the uterus should be contracted. :

Missed miscarriage
Vital signs usually are within reference ranges. Abdominal examination may or may not reveal a palpable uterus. If palpable, the uterus usually is small for the presumed gestational age. Fetal heart tones are inaudible or unseen on sonogram. The cervical os is closed upon pelvic examination. The uterus may feel soft and enlarged.

Investigations
Basic investigations
1. 2. 3. 4. 5.

Hb % Urine R/E Crossmatch blood Serum HCG Ultrasound pelvis

The role of ultrasound scan

1. 2. 3. 4. 5.

To diagnose the viability of fetus Confirm the gestational age Rule out congenital anomalies of the fetus Whether pregnancy is intrauterine or extra uterine Diagnose local tumors & congenital anomalies of uterus

Media file 3: This endovaginal ultrasonographic image demonstrates a subchorionic hemorrhage (SH) less than half the gestational sac size.

Media file 2: This endovaginal longitudinal view demonstrates fluid within the uterus (Ut). Echogenic debris also is present within the endometrial cavity. This image shows a large pseudogestational sac of an ectopic pregnancy.

Presence of abnormal hyperechoic material within the uterine cavity, as depicted in the sonogram below

Media file 1: This image shows an endovaginal longitudinal view of a low-lying gestational sac (GS) within the uterus (Ut), representing an incomplete miscarriage

The gestational sac may be misshaped or collapsed, or it may be intact, containing a nonliving embryo. In addition, an irregular complex mass within the endometrial or endocervical canal may be present. Sonogram of an incomplete miscarriage is shown below.

Loss at 9-12 weeks: Sonographic diagnosis of embryonic demise is usually made on demonstration of an abnormal fetus. Sonographic evidence of a fetus lacking cardiac activity is the most specific indicator of embryonic demise. This is depicted in the sonogram below.

Size of the subchorionic hemorrhage should be taken into consideration, as greater size relates to an increased risk of spontaneous miscarriage. A large subchorionic hematoma (ie, surrounding greater than 50% of the gestational sac) is a poor prognostic indicator for the pregnancy outcome. A subchorionic hemorrhage is depicted below.

Media file 6: This endovaginal ultrasonogram reveals an irregular gestational sac with an amorphic fetal pole. No fetal cardiac activity was noted. This image represents a missed miscarriage or fetal demise.

1 Month
First Trimester At the end of four weeks: Baby is 1/4 inch in length Heart, digestive system, backbone and spinal cord begin to form Placenta (sometimes called "afterbirth") begins to develop The single fertilized egg is now 10,000 times larger than size at conception

Month 2
First Trimester At the end of 8 weeks: Baby is 1-1/8 inches long Heart is functioning Eyes, nose, lips, tongue, ears and teeth are forming Penis begins to appear in boys Baby is moving, although the mother can not yet feel movement

Month 3
First Trimester At the end of 12 weeks: Baby is 2 1/2 to 3 inches long Weight is about 1/2 to 1 ounce Baby develops recognizable form. Nails start to develop and earlobes are formed Arms, hands, fingers, legs, feet and toes are fully formed Eyes are almost fully developed Baby has developed most of his/her organs and tissues Baby's heart rate can be heard at 10 weeks with a special instrument called a Doppler

Treatment
Prehospital Care Maintain routine universal precautions in view of potentially heavy vaginal bleeding. Emergency medical services (EMS) personnel should be aware of the potential for hemorrhagic shock and should treat any hemodynamic instability.

Treatment
Obtain vital signs and establish an intravenous line in all pregnant patients who have abdominal pain and vaginal bleeding. If the patient is hypotensive, an intravenous bolus of normal saline (NS) is indicated for hemodynamic stabilization. Administer oxygen.

Encourage the patient to bring any passed tissue to the hospital for evaluation.

SPECIFIC MANAGEMENT

Emergency Department Care

Treat all patients with vaginal bleeding of any etiology as follows: Determine hemodynamic stability and treat instability. If the patient is in hemorrhagic shock, treatment includes the Trendelenburg position, oxygen, aggressive fluid resuscitation (at least 2 large-bore IV lines with lactated Ringer [LR] solution or normal saline, wide open), and hemotransfusion. Determine pregnancy status (qualitative and quantitative).

Emergency Department Care

Make laboratory determination of hematocrit (Hct) level and Rh status. Perform a pelvic examination to determine the rate of bleeding; presence of blood clots or products of conception; and condition of cervical os, cervix, uterus, and adnexa. Perform pelvic ultrasonography to determine intrauterine and/or extrauterine contents (fetal heart activity) and/or to clinically classify spontaneous miscarriage.

Diagnostic specific management

Inevitable miscarriage The goal of treatment is evacuation of the uterus to prevent complications (eg, further hemorrhage, infection).

Types of evacuation of uterus

Medical curettage Evacuation & curettage Manual evacuation Dilatation & curettage Suction & curettage

Incomplete miscarriage
If tissue, blood clots, or products of conception are found in the cervical os, remove them with ring forceps to facilitate uterine contractions and hemostasis. For the same reason, use oxytocin in cases of severe bleeding (10-20 mcg/L of NS, wide open). Administer RhoGAM to a gravid patient who is Rhnegative and is experiencing vaginal bleeding. Consider hemotransfusion in the case of severe bleeding, hemodynamic instability, or both. Consider treatment with misoprostol to facilitate completion of the miscarriage.

Complete miscarriage
Treatment of a patient who has had a complete miscarriage varies depending on the degree of certainty of the diagnosis. Diagnosing complete miscarriage in the ED can be difficult, unless an intact gestational sac was expelled. If pelvic examination produces fetal tissue (or material of similar appearance), send it to the laboratory for identification of possible products of conception.

Missed miscarriage
Treatment may vary depending on gestational age as follows: First trimester
Most patients pass the products of conception spontaneously. Coagulation defects secondary to a dead fetus are rare. Expectant management,8 suction curettage, or misoprostol for medical management to facilitate passage of products of conception may be performed.

Second trimester
The uterus is emptied by dilatation and evacuation. Alternatively, the uterus is emptied by induction of labor.

Consultations
Consultation with an obstetrician/gynecologist is indicated in all patients with the diagnosis of inevitable or incomplete miscarriage; patients with severe hemorrhage or patients who are hemodynamically unstable require immediate consultation for assistance with definitive treatment. Definitive treatment may be to evacuate the products of conception from the uterus with curettage.

Depending on hospital policy, curettage may be performed in the ED with subsequent observation of patients for 4-6 hours after curettage, and then discharge if no complications occur. Curettage is generally reserved for those patients who are at risk for hemodynamic instability due to the briskness of bleeding or for those in whom endometritis is a concern. However, most patients with inevitable or incomplete miscarriage are candidates for medical management with misoprosto

Medication
The goals of pharmacotherapy are to prevent complications and to reduce morbidity.

Immune globulins
This agent suppresses immune response and antibody formation.

Rho(D) Immune Globulin (RhoGAM)

In nonsensitized Rho(D)-negative mothers who are exposed to Rho(D) prevents antibody formation to Rhpositive red blood cells of the fetus caused by abortion, fetomaternal hemorrhage, abdominal trauma, amniocentesis, full-term delivery, or transfusion accident.

Adult >13 weeks GA: 300 mcg IM Pediatric <12 years: Not established >12 years: Administer as in adults

Oxytocic Agent
This agent has vasopressive effects and prevents postpartum bleeding.

Oxytocin (Pitocin, Syntocinon)

Produces rhythmic uterine contractions and can control postpartum bleeding or hemorrhage. Adult 10-40 U IV in 1000 mL of IV fluid at a rate enough to control uterine atony Adult 10-40 U IV in 1000 mL of IV fluid at a rate enough to control uterine atony Pediatric <12 years: Not established >12 years: Administer as in adults Prostaglandin These agents induce uterine contractions.

Misoprostol (Cytotec)
Not approved for use in pregnancy, yet is an invaluable medication widely used for cervical preparation for miscarriage, labor induction, and as a medical abortifacient. Provides safe, passive method of cervical dilatation and should be considered for facilitation of passage of products of conception in the setting of inevitable or incomplete miscarriage, preabortion ripening when prior uterine surgery (ie, LEEP, cesarean delivery) are known risk factors for uterine perforation during surgical abortion.

Can be administered orally or vaginally. Some studies show premoistened tablets placed vaginally help absorption. Patients can be instructed in selfadministration to help time the dose in synchrony with their abortion procedure. .

In a study by Singh of primigravid women (6-11 wk gestation), 93.3% achieved dilatation of the cervix of 8 mm or greater after 3 h postintravaginal misoprostol 400 mcg, whereas only 16.7% of women achieved this after 2 h of 600 mcg. The 600-mcg group had slightly greater adverse effects (eg, bleeding, abdominal pain, fever >38C).

Dosage intended for cervical ripening can induce abortion in some patients. Oral doses of 100-400 mcg can be combined with vaginal insertion of prostaglandins to enhance cervical dilatation

Adult Cervical ripening: 25-100 mcg (vaginally) for term pregnancies, lower doses may need to be repeated q4-6h Facilitation of miscarriage: 800 mcg PO or PV; many patients will need repeat dosing in 3 d Pediatric Not established