Early Pregnancy Loss
Abigail Wolf, MDObstetrics and Gynecology
Thomas Jefferson Medical College
Early Pregnancy Loss
• Objectives:– Review basics of preconception care– Review normal early pregnancy– Develop a differential diagnosis of early
pregnancy loss including risk factors, presentation and management
– Define ectopic pregnancy including risk factors, presentation and management
Definition of Pregnancy
American College of Obstetricians &Gynecologists
OPRR Reports. 1983.Hughes EC. 1972.
Incidence of Early Pregnancy Loss
Griebel CP, et al. Am Fam Physician. 2005.; Everett C. BMJ. 1997.Smith NC. Contemp Rev Obstet Gynecol. 1988.; Stirrat GM. Lancet. 1990.
≤ 20 weeks’ gestation
600,000to 800,000annually
12%–24% ofpregnancies
Preconception• Female
– Assess gynecologic and obstetric history, family genetic history, medical history and medication use
– Perform physical exam– Increase folic acid, exercise
• Male– Assess obstetric history, family genetic history– Perform physical exam
• Both– Review vaccinations– Screen for HIV, STD and domestic violence– Counsel to avoid smoking, alcohol, drugs and obesity
Fertilization to Implantation
• Pronuclear Phase– Sperm and egg separate in egg cytoplasm
• Morula– Solid ball of totipotential cells
• Blastocyst– sphere of about 150 cells, with an outer layer
(the trophoblast), a fluid-filled cavity (the blastocoel), and a cluster of cells on the interior (the inner cell mass).
Implantation through first trimester
• Implantation occurs 6-9 days from conception
• At implantation the blastocyst contains about 250 cells
• At 12 weeks external genitalia are visible and the fetus begins to make urine
• The fetus is about 2.5 inches
29 year old G2P1001 with LMP 7 weeks ago presents complaining of vaginal bleeding.
Differential Diagnosis
Differential Diagnosis
• ECTOPIC PREGNANCY
• Threatened Abortion• Incomplete Abortion• Spontaneous Abortion• Inevitable abortion• Septic Abortion• Molar Pregnancy
• Trauma• Infection• Malignancy
Epidemiology of Abortion
• 15-20% of known human pregnancies end in clinically recognized abortion
• 22% of pregnancies end before pregnancy is clinically recognized
• Total pregnancy loss rate at least 31%• Approximately 50% of pregnancies are
unintended and approximately 50% of those end in elective abortion
Spontaneous/Complete Abortion• Definition: spontaneous passage of all
products of conception.• Approximately 50% of spontaneous
abortions are due to chromosomal abnormalities
• Other risk factors include:– Age– Infection– Toxic habits– Underlying medical illness– Uterine anomalies
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Spontaneous/Complete Abortion• Diagnosis: history of bleeding and passing
tissue, physical exam of closed cervix, ultrasound with no intra or extra-uterine pregnancy
• Management: usually resolves spontaneously, no further management needed
• Sequelae: none. After one SAB risk of second SAB is increased to 40%. Age also increases risk.
18
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Threatened Abortion• Definition: uterine bleeding without
cervical dilation or passage of tissue• Diagnosis: history (bleeding), physical
exam (cervix closed), ultrasound (fetal heart rate seen)
• Management: expectant management, serial Beta-hcg, ultrasound, pelvic rest
• Sequelae: Occurs in up to 25% of pregnancies. About half of those go on to viability but are at higher risk for preterm delivery and low birth weight. 19
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Missed Abortion• Definition: fetus dies but remains in the
uterus• Diagnosis: physical exam-closed cervix
and ultrasound-intrauterine pregnancy with no fetal heart beat
• Management: options include expectant management, medical induction of labor, surgical evacuation (EVA), manual vacuum evacuation (MVA)
• Sequelae: risk of hemorrhage with expectant/medical management 20
Missed abortion synonyms
• Embryonic Death: sonographically visualized embryo 4-15mm long without cardiac activity
• Intrauterine Fetal Death: sonographically visualized fetus >15mm long without cardiac activity
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Incomplete Abortion
• Definition: uterine bleeding and cramping with passage of some, but not all products of conception
• Diagnosis: history of bleeding and passing tissue, physical exam of open cervix, ultrasound with some intrauterine products
• Management: expectant, medical or surgical
• Sequelae: risk of uncontrolled bleeding22
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Elective AbortionDefinition: elective termination of pregnancy prior to viability
Management:
i. Medical
1.Mifepristone/misoprostol at less than 49 days from LMP
2.Misoprostol induction after intra-cardiac injection after 49 days
ii. Surgical
1.manual vacuum aspiration
2.electric vacuum aspiration
• Sequelae:
23
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Recurrent Abortion• Definition: loss of > or = 3 consecutive
pregnancies before 20 weeks• Diagnosis: by history, chart review may
be helpful for details• Management: Identify and treat
underlying causesuncontrolled diabetes mellitus
uterine cavity synechiae or other uterine defects
antiphospholipid antibody syndrome or other autoimmune disease
chromosomal abnormalities (parental) 24
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Septic Abortion
• Definition: any of the above accompanied by intra-uterine infection
• Diagnosis: any abortion with fever, elevated white blood count, fundal tenderness
• Management: requires uterine evacuation• Sequelae: uterine synechiae, systemic
infection, uterine perforation
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Molar Pregnancy
Definition:• A placental abnormality involving
swollen placental villi and trophoblastic hyperplasia
• Complete mole is 46XX all paternal cells, usually no fetus forms
• Incomplete mole is often 69XXY and presents with a chromosomally abnormal fetus
Molar Pregnancy
Diagnosis: Symptoms include vaginal bleeding,
nausea and vomiting, elevated blood pressure
Signs include tachycardia, tachypnea, hypertension, disproportionately large uterus for dates, ultrasound with snowstorm pattern.
Copyright ©Radiological Society of North America, 2001
Nalaboff, K. M. et al. Radiographics 2001;21:1409-1424
Figure 11. Molar pregnancy
Molar Pregnancy
• Management– Surgical evacuation of uterus– Close follow up with serial HCG until
negative 3 weeks in a row– Monthly HCG to verify negative for 6-12
months– Risk is development of persistent
gestational trophoblastic disease
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Molar Pregnancy
• Sequelae:– Risk of gestational trophoblastic disease
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Ectopic PregnancyDefinition
• Pregnancy that develops after implantation of the blastocyst anywhere other than the endometrium lining the uterine cavity
Ectopic Pregnancy
Types of Ectopic Pregnancies
• Tubal (>95%)• Abdominal cavity• Cervical• Ovarian• Heterotopic• Bilateral Ectopic
Risk factors for Ectopic Pregnancy
• High Risk
-previous ectopic pregnancy
-previous tubal surgery
-sterilization
-use of IUD
-documented tubal pathology
-In utero diethylstilbestrol exposure
Ectopic PregnancyDiagnosis
• Classic symptoms: -abdominal/pelvic pain -abnormal uterine bleeding/spotting -amenorrhea• Pregnancy associated symptoms• Symptoms due to rupture: syncope, shock• ~50% of women are asymptomatic before
tubal ruputure
Ectopic PregnancyPhysical findings
• Tenderness – abdominal, adnexal or cervical motion tenderness
• Adnexal mass• Orthostatic changes if ruptured• Often unremarkable
Surgical Management Ectopic Pregnancy
Laparoscopy or laparotomy
Indications:–Clinically unstable–Unable to comply with medical
management–Failure of medical treatment–Contraindications to methotrexate
Medical Management of Ectopic Pregnancy
Methotrexate
Indications:–Hemodynamically stable –Patient able to return for follow-up
care–Patient has no contraindications to
methotrexate –Unruptured mass ≤3.5 cm –No fetal cardiac activity–β-hCG less than 15,000
Management of Ectopic Pregnancy
Methotrexate
Contraindications
Breastfeeding
Immunodeficiency
Abnormal liver or kidney function
Known sensitivity to methotrexate
Gestational sac >3.5 cm
Cardiac activity
Clinical Case
• 29 year old G2P1001 with LMP 7 weeks ago presents complaining of vaginal bleeding.
Evaluation
• History– HPI: LMP, pain, bleeding (volume, tissue),
trauma– PGYN: menstrual history, Sexual
history/STD’s– OB history: D&E’s, recurrant Ab’s– PMH/PSH: bleeding disorders, surgical risk– Meds/Soc Hx/Fam Hx– ROS: Symptoms of acute blood loss/anemia
Evaluation
• Physical Exam– Vital signs– Abdominal exam: peritoneal signs?– Pelvic
• Speculum exam – trauma, lesions, products of conception, clot vs. active bleeding
• Bimanual – size of uterus, cervical dilation, adnexal masses, CMT
Evaluation
• Labs– quantitative HCG (human chorionic
gonadotropin– CBC– Type and screen– Coags? (if significant hemorrhage and risk of
DIC)– LFT’s, SMA-7? (if considering methotrexate
for treatment of ectopic)
Evaluation
• Radiology– ultrasound
Management
• Expectant Management– Await spontaneous passage of tissue
• Medical Management– Misoprostol (E1 prostaglandin analog)
• Surgical Management– Dilation and Currettage– Manual Vacuum Aspiration
Early Pregnancy Loss
– Review basics of preconception care– Review normal early pregnancy– Develop a differential diagnosis of early
pregnancy loss including risk factors, presentation and management
– Define ectopic pregnancy including risk factors, presentation and management
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