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Spontaneous abortion PowerPoint Presentation

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Description : Check out this medical presentation on Obstetrics & Gynecology, which is titled "Spontaneous abortion", to know about spontaneous abortion, clinically recognised pregnancy loss before 20th week of gestation.

Tags : Obstetrics, Gynecology, Spontaneous abortion, pregnancy loss, before 20th week of gestation

Published on : Jul 12, 2021 | Views : 2338 | Downloads : 8

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Slide 1-

Spontaneous abortion Dr.Renu Singh
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Definition Clinically recognised pregnancy loss before 20th week of gestation Expulsion or extraction of an embryo or fetus weighing 500gm or less(WHO) Synonymous with miscarriage Latin :aboriri: to miscarry
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Incidence MC early pregnancy complication Frequency decreases with increasing gestational age Incidence:8-20%(clinically recognised pregnancies) Women who had a child: 5% incidence of miscarriage 80% spontaneous abortion :< 12 wks
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Risk factors Advanced maternal age Previous spontaneous abortion Medications & substances (smoking) Mechanisms responsible for abortion: not apparent Death of fetus precedes spont. expulsion, finding cause involves ascertaining the cause of fetal death
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Maternal age Most important risk factor in healthy women 30yrs:9-17% 35yrs:20% 40yrs:40% 45yrs: 80%
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Previous spontaneous abortion Previous successful pregnancy: 5% risk 1 miscarriage: 20% 2 consecutive miscarriages:28% ≥3 consecutive miscarriages:43%
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Medications or substances Heavy smoking(>10 cigarettes/day) : vasoconstrictive & antimetabolic effects of tobacco smoke Moderate to high alcohol consumption(>3 drinks/week) NSAIDS use(acetaminophen) :abnormal implantation & pregnancy failure due to antiprostaglandin effect
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Other factors Low plasma folate levels(≤2.19ng/ml): no specific evidence to support Extremes of maternal weight: prepregnancy BMI<18.5 OR >25kg/m2 Maternal fever:100°F(37.8°C), no evidence to support
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Etiology Fetal Maternal unexplained
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Etiology Foetal factors Chromosomal abnormalities(50% ), aneuplodies ,monosomy X,Triploidy Trisomy 16 : mc autosomal trisomy,lethal Abnormalities arise de novo Congenital anomalies Trauma: invasive prenatal diagnostic procedures
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Aetiology :Maternal factors Maternal endocrinopathies: hypothyroidism, insulin dependant diabetes Congenital or acquired uterine abnormalities: interfere with implantation & growth Maternal diseases: acute maternal infection (listeria, toxo, parvo B19,rubella,CMV) : inconclusive Radiation in therapeutic doses Hypercoagulable state(thrombophillias) : RPL
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Clinical presentation Vaginal bleeding Scant brown spotting to heavy vaginal bleeding Amount /pattern does not predict outcome May be accompanied by passage of fetal tissue Pelvic pain Crampy /dull in character Constant/intermittent Incidental finding on pelvic ultrasound in asymptomatic patient
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Diagnostic evaluation History Period of amenorrhea ,LMP/USG Physical examination: Complete pelvic examination: P/S,:source, amount of bleeding, dilated cervix, POC visible at Os/in vagina P/V: uterine size(consistent with GA) Pelvic ultrasound
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Pelvic ultrasound Most useful test in diagnostic evaluation of women with suspected spontaneous abortion Foetal cardiac activity: most important (5.5-6wks) Foetal heart rate Size & contour of G.sac Presence of yolk sac Best evaluated ,transvaginal approach(TVS)
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Pelvic USG: criteria for spontaneous abortion Gestational sac ≥ 25mm in mean diameter that does not contain a yolk sac or embryo An embryo with CRL ≥7 mm with no cardiac activity If the GS or embryo is smaller than these dimensions: repeat pelvic USG in 1-2 weeks
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Differential diagnosis Physiologic: placental sign Ectopic pregnancy Gestational trophoblastic disease Cervical/vaginal/uterine pathology Physical examination Transvaginal sonography(TVS) Serial quantitative ßhCG
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Lab evaluation Human chorionic gonadotropin: serial, quantitative, useful in inconclusive USG findings ABO ,Rh: need for 50/300µg anti D Haemoglobin/hematocrit Serum progesterone<5ng/ml(nonviable pregnancy)
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Post diagnostic classification Based upon the location of POC Degree of cervical dilatation(pelvic exam) Pelvic ultrasound Categorization impacts clinical management Threatened Inevitable Incomplete/complete Missed
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Threatened abortion Vaginal bleeding has occurred The cervical os is closed Diagnostic criteria for spontaneous abortion has not met Managed expectantly: until symptoms resolve or progresses
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Threatened abortion: m/m Expectant Progestin treatment: most promising, efficacy not established Bed rest: randomised trials have refuted the role Avoid vigorous activity Avoid heavy lifting Avoid sexual intercourse
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Threatened abortion :m/m Counsel about risk of miscarriage Return to hospital in case of additional vaginal bleeding, pelvic cramping or passage of tissue from vagina Repeat pelvic USG until a viable pregnancy is confirmed or excluded Viable pregnancy, resolved symptoms: prenatal care If symptoms continue: monitor for progression to inevitable, incomplete, or complete abortion
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Inevitable abortion Vaginal bleeding, typically accompanied by crampy pelvic pain Dilated cervix( internal os) Products of conception felt or visualised through the internal os
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Incomplete abortion Vaginal bleeding and/or pain present Cervix is dilated Products of conception partially expelled out Uterine size less than period of amenorrhea
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Missed abortion Non viable intrauterine pregnancy Cervical os is closed POC not expelled May notice that symptoms associated with early pregnancy have abated
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Management Complete evacuation of uterine contents(POC) Surgical methods: suction evacuation/suction curettage/dilation & evacuation Medical methods: Misoprostol,mifepristone Expectant All have similar efficacy
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Surgical evacuation Performed under IV sedation & paracervical block Prophylactic antibiotics Operating room/procedure room Potential complications Anaesthesia related, uterine perforation, cervical trauma, infection, intrauterine adhesions
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Medical methods Misoprostol: drug of choice Efficacy depends on dose & route of administration 400mcg vaginally every 4 hours for 4 doses Expulsion rate : 50-70% Low cost, low incidence of side effects, stable at room temperature, readily available, timing of use can be controlled by patient
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Misoprostol WHO consensus report on misoprostol regimen Missed abortion: 800mcg vaginally,or 600 mcg sublingually Incomplete abortion: 600mcg orally Expulsion rate: 70-90%
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Choosing the method Surgical evacuation : heavy bleeding, intrauterine sepsis, medical co morbidities, misoprostol is contraindicated Shorter time to completion of treatment Lowers risk of unplanned admissions Lower need for subsequent treatment
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Expectant m/m Stable vital signs No evidence of infection Offered after proper counseling If unsuccessful after 4 wks ,surgical evacuation is needed
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Complete abortion POC expelled completely from uterus & cervix Cervical os is closed Uterus small in size (GA) Resolved or minimal vaginal bleeding & pain Aim of t/t: ensure that bleeding is not excessive & all POC have expelled Theoretically does not need treatment
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Abortion : complications Hemorrhage Uterine perforation Retained products of conception Endometritis Septic abortion: abortion accompanying intrauterine infection
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Summary Clinically recognised pregnany losses <20 wks gestation Most common complication of early pregnancy Advanced maternal age, previous spontaneous abortion, maternal smoking: risk factors Mostly due to fetal structural/chromosomal abnormalities
Slide 36-

Summary Present with menstrual delay, vaginal bleeding& pelvic pain D/D: uterine or other genital tract bleeding in viable pregnancy, ectopic,& GTD Pelvic examination & pelvic ultrasound: key elements for diagnosis Spontaneous abortion diagnosed based on USG criteria Categorised as threatened/incomplete/missed
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Summary Preconceptual & prenatal counseling & care regarding modifiable aetiologies ,risk factors are most imp intervention Normal menstrual cycle resumes in 4-6 weeks hCG returns to normal 2-4wks
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Prevention of spont.abortion Preconception & prenatal counseling Routine screening & optimal disease control(diabetes, thyroid, thrombophilia) Correction of uterine structural anomalies(septum, submucosal myoma, intrauterine adhesions) prior to pregnancy Avoiding exposure to teratogen or infections Modifiable risk factors