11/15/2010

1

AbortionAbortion(miscarriage)(miscarriage)

AbortionAbortion(miscarriage)(miscarriage)

Dr. Letta Sari Lintang SpOG

Departemen Obsteri & Ginekologi

FK – USU / RS. H. ADAM MALIK

DefinitionDefinitionDefinitionDefinition

The termination of pregnancy before the 20th week, when the fetus weight is less than 500 grams.

Early abortion: <12th week of pregnancyLate abortion: 12th-20 th week of pregnancy

Spontaneous abortionArtificial abortion

EtiologyEtiologyEtiologyEtiology

Genetic factors:chromosomal abnormal accounts 50～60%of the early abortions

• Numeral abnormalities:polyploidy, triploidy, monosomy

• Structural abnormalities:break, translocation, deletion

11/15/2010

2

EtiologyEtiologyEtiologyEtiology

Extrinsic factors• Chemical: mercury, lead, cadmium,

smoking,

• Physical: video display terminals,

radioactive materials, noise,

hyperthermia

EtiologyEtiologyEtiologyEtiology

Maternal factors

• General diseases:

infection, heart diseases, hypertension, anemia

• Reproductive organic diseases:

congenital uterine malformation, pelvic tumor, cervical incompetence

• Endocrine disorders:

LPD, hypothyroidism

• Injuries

EtiologyEtiologyEtiologyEtiology

Defects in the developing placenta

Immunologic factors: paternal histo-compatibility antigen , maternal cellular immunity regular disorder, deficiency of maternal blocking antibody

11/15/2010

3

PathologyPathologyPathologyPathology

The death of the embryo or rudimentary analog

Hemorrhage into the decidua basalis

Uterine contraction, dilation of the cervix

Expulsion of the products conception

PathologyPathologyPathologyPathology

Before the 8th week of the pregnancy, the abortus can be expelled completely

During the 8th-12th week of the pregnancy, retention of the tissue is common

After the 12th week of the pregnancy, the abortus may be expelled totally

Normal gestational sac at arrow, endometrial cavity at curved arrow

Yolk sac (at curved arrow) with embryo (between X’s)

Normal US Findings “Double decidual sac” sign

GS=gestational sac, DP=decidua parietalis, * = endometrial cavity, arrow=decidua capsularis

11/15/2010

4

Normal US Findings

Embryo (black arrow); amnion (small arrow) does not fuse with chorion (large arrow) until 12-16wks gestation.

Clinical subgroups Clinical subgroups of abortionof abortionClinical subgroups Clinical subgroups of abortionof abortion

Theatened miscarriage

Inevitable miscarriage

Incomplete miscarriage

Complete miscarriage

Abortion Complet Abortion

Anembryonic pregnancy: large (>18mm) gestational sac without embryo

►Presentation: Varies greatly depending on type of abortion, but often presents with vaginal bleeding and uterine cramps or back pain.

►β-hCG: Falling or rising abnormally slow

►US findings vary depending on classification and cause of abortion

11/15/2010

5

Abnormal US Findings: Spontaneous Abortion

Abortion in progress: low-lying gestational sac (thick arrow), decidual reaction and hemorrhage (mixed hyper- and hypo-echoic material between arrowheads)

Missed abortion: embryo (at arrow) is relatively small compared to large gestational sac. No cardiac activity was present.

Abnormal US Findings: Spontaneous Abortion

Patient presented with continued vaginal bleeding after spontaneous abortion. US shows retained products of conception.

Abnormally shaped gestational sac at 5 wks. Patient later had a complete spontaneous abortion.

The developing processesThe developing processesof the abortionof the abortionThe developing processesThe developing processesof the abortionof the abortion

Threatened miscarriage

Normal pregnancy Inevitable miscarriage

Complete miscarriage Incomplete miscarriage

Classifications and Classifications and characteristicscharacteristicsClassifications and Classifications and characteristicscharacteristics

conceptus Vaginal abdominal Cervix os Uterine Subgroups expulsion bleeding pain dilation enlargement

Threatened no ＋＋＋＋ －＋－＋－＋－＋ －－－－ compatiblemiscarriage

Inevitable no ＋＋＋＋ ＋＋＋＋ ＋＋＋＋ ＋＋＋＋ ＋＋＋＋ －－－－ compatible or miscarriage smaller

Incomplete part ＋＋＋＋ ＋＋＋＋＋＋＋＋ ＋＋＋＋ ＋＋＋＋ －－－－ smallermiscarriage

Complete all ＋＋＋＋－－－－ －－－－ －－－－ normalmiscarriage

11/15/2010

6

Alternative Alternative classificationclassificationAlternative Alternative classificationclassification

• Blighted ovum

• Missed miscarriage

• Live miscarriage

Classification of miscarriage

Normal pregnancyBlighted

ovum

Missedmiscarriage

Threatenedmiscarriage

Inevitablemiscarriage

Continuingpregnancy

Incompletemiscarriage

Completemiscarriage

Special subgroups:Special subgroups:

Missed MiscarriageMissed MiscarriageSpecial subgroups:Special subgroups:

Missed MiscarriageMissed Miscarriage

Expulsion of the conceptus does not occur

despite a prolonged period after embryonic

death.

Symptoms of pregnancy regress

Pregnancy test becomes negative

No fetal heart motion is detected

Uterine enlargement ceases

Special subgroups:

Recurrent miscarriageRecurrent miscarriageSpecial subgroups:

Recurrent miscarriageRecurrent miscarriage(Habitual abortion)

Three or more consecutive spontaneous losses

of pregnancy

First-trimester: LPD, hypothyroidism, chromosomal abnormalities, immunologic factors

Second-trimester: uterine malformations, cervical incompetence, myomas

11/15/2010

7

Special subgroups:

Septic miscarriageSeptic miscarriageSpecial subgroups:

Septic miscarriageSeptic miscarriage

Any type of spontaneous miscarriage is

complicated by infection

Endometritis, parametritis, peritonitis

Fever, abdominal tenderness, uterine pain

Septicemia, septic shock

DiagnosisDiagnosisDiagnosisDiagnosis

• History: amenorrhea, symptoms of pregnancy, vaginal bleeding……

• Examination: general and pelvic

• Ultrasounograph

• Pregnancy test, ß-HCG

• Others:

Differential diagnosisDifferential diagnosisDifferential diagnosisDifferential diagnosis

• Ectopic pregnancy

• Molar pregnancy

• Dysfunctional uterine bleeding (DUB)

• Pelvic infective diseases (PID)

• Acute appendicitis

Ectopic Pregnancy

•• 95% are in the 95% are in the fallopian tube fallopian tube (70% ampulla, 12% isthmus, 11% fimbria, 2% interstitial/cornual)

• Ovarian occurs about 3% of the time, abdominal 1% of the time and cervical <1% of the time

11/15/2010

8

Abnormal US Findings: Ectopic

Gestational sac (between arrowheads) and embryo (between calipers) outside of the uterus. Normal ovary is seen at arrow.

Pseudogestational sac of ectopic pregnancy. Note central location and absence of double decidual sign.

Anembryonic gestation

• No yolk sac or fetal pole

• Mean gestational sac diameter of 20 mm

ManagementManagementManagementManagement

Threatened miscarriage:

rest, follow-up

Inevitable & incomplete miscarriage:Evacuation of the uterus,vacuum or suction curettage, oxytocin iv, antibiotics

Complete miscarriage:

no further therapy is necessary.

Management

Missed miscarriageMissed miscarriageManagement

Missed miscarriageMissed miscarriage

First- trimester:suction curettage

The second-trimester:

D&E(dilation and evacuation)

D&C(dilation and curettage)

Induction of labor with intravaginal prostaglandin E2 or misoprostol

11/15/2010

9

Management

Recurrent miscarriageRecurrent miscarriageManagement

Recurrent miscarriageRecurrent miscarriage

A workup for possible causes of recurrent pregnancy loss (RPL): anatomic, hormonal,genetic,and autoimmune factors (underlying maternal factors)

Incompetent cervix: cerclage designed to reinforce the cervix at the level of the internal os at the end of the first trimester, the suture is removed after 37 weeks’ gestation

Management

Septic miscarriageSeptic miscarriageManagement

Septic miscarriageSeptic miscarriage

• Evacuation of the uterus within a few hours after antibiotics iv

• High-dose, broad-spectrum coverage antibiotics, aggressive use before, during, and after removal of necrotic tissue by curettage

• hysterectomy

Summary pointsSummary pointsSummary pointsSummary points

• The most frequent etiology of miscarriage is a chromosomal abnormality of the conceptus and most of the abortions occur in the first-trimester.

• The processes of the pathology decide the characteristics of the subgroups.

• Ultrasound is helpful in diagnosis.

Take-home Points

►Along with β-hCG, ultrasound is the mainstay in determining the cause of first-trimester vaginal bleeding

►Important causes of bleeding include: Ectopic pregnancy, spontaneous abortion, hydatidaform mole, subchorionic hematoma, and uterine AVM.

►It is vital to determine the cause of bleeding in order to select appropriate treatment

11/15/2010

10

ProblemProblem--based learning (3)based learning (3)ProblemProblem--based learning (3)based learning (3)

• On examination you find no abnormality on abdominal palpation and in particular, no tenderness. On vaginal examination, however, you find blood clot in the vagina and products of conception are present in the cervix, which is dilated. What is the diagnosis and how would you manage the situation?

The EndThe End