1. Spontaneous Abortion Vandana Sharma, M.D April 30, 2004

2. CASE n Pt. 27 yr.. old G3 P2002, walks into clinic with vaginal bleeding n What would you ask her? n What tests would you order? n What follow-up would she need?

3. Differential Diagnosis n Bleeding in the first trimester – Physiologic – Pathologic n Ectopic pregnancy n Spontaneous abortion n Cervical or vaginal Pathology – Polyp – Infection – Neoplasia

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

5. Types of Spontaneous Abortions n Threatened Abortion n Inevitable Abortion n Incomplete Abortion n Septic Abortion n Missed Abortion n Blighted ovum or Anembryonic Pregnancy – Failure or absence of an embryo at a very early stage of pregnancy

6. SPONTANEOUS ABORTION n Pregnancy that ends spontaneously before the fetus has reached a viable gestational age. n Corresponds to a gestational age of 20 to 22 weeks.

7. Clinical Manifestation n History of Amenorrhea n 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) n Abdominal pain

8. Epidemiology n Most common complication of early pregnancy. n 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. n Loss of unrecognized or sub clinical pregnancies is much higher - between 50% and 75% n Over all 12% of clinically recognized pregnancies ended in spontaneous abortion.

9. Diagnosis n Clinical assessment n Quantitative beta hCG n Ultrasonography

10. Clinical Assessment n History n Physical exam n Studies

11. Labs n GC/Chl n Wet Prep n Beta HCG n Hemoglobin n Rh Status

12. Ultrasonograghy n Plays an important role in the diagnosis and management of first trimester bleeding n 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.

13. Ultrasonogragphy (cont’d) n Additional finding- predictive of impending pregnancy loss. n An abnormal Yolk sac - large for gestational age, irregular, free floating in the gestational sac or calcified. n Fetal HR <100 bpm at 5-7 wks gestation n Small mean sac size n Large subchorionic hematoma

14. Management n Counseling n Expectant Management n Medical Management n Surgical Management

15. Counseling n Pre and post Counseling n Panic and anxiety n Guilt Feeling

16. Expectant Management n As effective as medical or surgical treatment. n Early pregnancy Failure <13 week gestation. n Stable Vital signs n No evidence of infection n Majority of expulsions occur in the first 2 weeks of diagnosis. n Uterine cavity evaluation by ultrasound n Surgical evacuation is needed if retained tissue is > 15mm. n Failure Spontaneous expulsion - Medical or surgical treatment.

17. Medical Management n Prostaglandin E1 analog – Oral - Low success rate – vaginal - High success rate Recommendation: Misoprostol 400mcg every 4 hrs for 4 doses n Combination of a progesterone antagonist and misoprostol – Expensive – Side effects

18. Medical Management n Advantage – Less Expensive – Low incidence of side effects when used vaginally – Ready availability n Contra-indicated – Asthma – Glaucoma

19. Surgical Management n D & C – Conventional treatment for first or early second trimester miscarriage n Indications – Evidence of incomplete abortion – Heavy bleeding – Intrauterine sepsis – Patient’s preference – Documented Fetal demise or blighted ovum. n Risks – Minimal, uterine perforation, interauterine adhesions, cervical trauma, infection and Anesthesia risks.

20. Examination of Tissue n Crucial and underutilized skill in the management of first trimester bleeding problem. n 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” n In all cases the tissue should be submitted for formal pathologic examination. In certain situations tissue is submitted for genetic studies.

21. Natural History n 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. n Approximately 50% of miscarriages are cytogenetically abnormal. n Earlier the gestational age at abortion, the higher the incidence of chromosomal defects.

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

23. Post Abortion Family Planning n Pregnancy can be deferred for two to three months however there is no greater risk of adverse outcome with a shorter pregnancy interval. n Contraception - Any type including IUD may be started immediately. n Grief counseling is appropriate as needed.

24. Take Home Points n Always do vaginal exam with sterile speculum. n If not confident about passage of complete tissue, perform ultrasound n Counseling and emotional support is necessary n Follow up on regular basis