Intrauterine demise- 1st trimester

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1 ST TRIMESTER INTRAUTERINE FETAL DEMISE DR. Archana Rathore

Transcript of Intrauterine demise- 1st trimester

Page 1: Intrauterine demise- 1st trimester

1ST TRIMESTER INTRAUTERINE FETAL DEMISE

DR. Archana Rathore

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DEFINATIONFirst-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.

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incidenceOf 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.

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classificationCan 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

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Missed abortion Presence of definitive

embryo without cardiac activity

Expelled spontaneously in about 4 weeks

Now readily diagnosed by USGCRL ≤ 6 mm: viability

uncertain, rescan in 7-10 days

CRL > 10 mm: delayed miscarriage

50% due to chromosomal abnormality

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Anembryonic gestation (blighted ovum)

An intrauterine sac without fetal tissue present at more than 7.5 weeks of gestation

USG criteriaMSD ≤20 mm: viability

uncertain, rescan in 7-10 days

MSD >20 mm: blighted ovum

Accounts for ½ of pregnancy loss

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causes Chromosomal abnormalities Luteal phase defects Thyroid disorders Diabetes mellitus Asherman syndrome Infections Others

Contraceptives Smoking Alcohol Radiation Trauma Drugs

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Chromosomal abnormalityAutosomal trisomy

50% of all chromosomal anomalies M.C. is trisomy 16

Polyploidy Normosaic triploid/ tetraploidy

Results in partial moleTetraploidy non viable

Diploid/triploid mosaicismSex chromosome polysomy

Frequency increased in ICSI

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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.

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Autosomal MonosomyTranslocationsInversionsMendelian 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

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Luteal phase defectsDefn.- 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

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Causes Hypothalamo-pituitary-ovarian axis

Decreased FSHAbnormal pattern of LH secretionDecreased LH & FSH surge at ovulation

Hyperprolactenemia Hypothyroidism Ovarian

PCOSRuptured corpus luteum

UterineFibroidUterine septaEndometriosis

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Diabetes mellitusRisk increases with loss of metabolic

control measured by HbA1cAlso with increased insulin resistance or

serum insulin levelsIf 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.

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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

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Thyroid disordersHypothyroidism

Thyroid peroxidase negativeHyperthyroidism

TSH 2.5-4 mIU/ml (3.6%) <2.5 mIU/ml (6.1%)

Autoimmune thyroidits: Thyroid antibodies

Antibody to thyroid peroxidaseAntibody to thyroglobulin

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Asherman syndromeIntrauterine 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

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Clinical presentation hypo or amenorrhea infertility repeated miscarriages

Diagnosis Hysteroscopy Hysterosalpingography (HSG) Sonosalpingography

Treatment: hysteroscopic resection

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infections

Viral Parvovirus B19 Cytomegalovirus Variola Varicella

Bacterial Ureaplasma Chlamydia

Parasitic Toxoplasma Malaria

Infections causing fever Salmonella Shigella E.coli

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diagnosisPresenting complaints

Amenorrhea Bleeding PV Passage of clots Passage of tissues Pain in abdomen Discharge PV Fever, chills, rigors

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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

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Personal history Age Hypertension, diabetes mellitus, thyroid

disorders Contraceptive use Drug intake Alcohol & smoking Exposure to radiation

Family history Diabetes mellitus Genetic disease

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Examination Pallor Temperature Pulse Blood pressure Tachypnea /dyspnea Body mass index Neck swelling Galactorrhea P/A

Abdominal distensionAbdominal

tendernessEnlarged 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

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Investigations Hemoglobin Blood group & Rh typing Peripheral smear for TLC, DLC Platelet count BT, CT, CRT Sickling Coagulation profile

PTaPTTFibrinogen level

Blood culture Intrauterine products culture

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Confirmation USG- normal findings

5 wks- empty GS- MSD 10mm5.5 wks- GS with yolk sac6 wks- heart beat- embryo 3 mm- MSD 16 mm6.5 wks-CRL 6mm7 wks-CRL 10 mm8 wks- CRL 16 mm- amniotic sac- fetal body

movements β-HCG

1500(3000) U/ml- TVS(TAS) shows GS2X in 48 hrs- normal intrauterine pregnancyFall- miscarriageLow value or <2X rise- extrauterine pregnancyHigh value- twin pregnancy or H. mole

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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

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Specific InvestigationsThyroid

Sr. TSH levels Sr. fT4 levels

Diabetes Blood sugar levels HbA1c levels Sr. insulin levels

Infections IgM, IgG antibodies HRP-2

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Chromosomal abnormalities Products of conception

HistopathologyCultureKaryotyping- FISH, array CGH, 24 chromosome

SNP Placenta- karyotyping Parents- karyotyping

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managementHemodynamic

ally 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

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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

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Prenatal investigations HbA1c TSH Chorionic villous biopsy Trophoectoderm biopsy Preimplantation genomic diagnosis (PGD) Luteal phase defects

Basal body temperature (BBT) chartFollicular size USGSr. 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 biopsySr. prolactin level

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Management Control of diabetes Control of thyroid disorders LPD

GnRH agonistsClomiphene citrateProgesterone support

• Oral• Intramuscular• Vaginal suppositories• Vaginal gel

Bromocriptine