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1

What is the most common complication of early pregnancy?

Spontaneous abortion

2

1. What is a spontaneous abortion defined as?

2. What is considered a still birth?

3. 80% occur when?

1. Intrauterine pregnancy at less than 20 weeks

2, After 20 weeks considered still birth

3. About 80% occur in the first trimester

3

Etiology of Spontaneous Abortion
8

1. 60% result from chromosomal defects
15% associated with
2. Maternal trauma
3. Infections
4. Dietary deficiencies
5. Diabetes mellitus
6. Hypothyroidism
7. Anatomic malformations – incompetent cervix
8. 25% cannot be determined

4

Biggest Risk Factors For Spontaneous Abortion
3

1. Advanced maternal age

2. Previous spontaneous abortion

3. Maternal smoking

5

Symptoms of Spontaneous Abortion
5

1. Bleeding
(Bright red mostly, Heavy – saturating pads)

2. Midline cramping
3. Low back pain
4. Open or closed cervical os
5. Complete or partial expulsion of products of conception

6

Define the Subtypes of Spontaneous Abortion
1. Threatened?

2. Inevitable?

3. Incomplete?

4. Complete?

5. Missed?

1. Os closed, unpredictable outcome

2. Os open, products of conception have not passed, pregnancy cannot be saved

3. Os open, some products of conception have passed

4. Os may be open or closed, products of conception have passed

5. Pregnancy did not develop

7

Threatened Abortion
Signs
6

1. Slight bleeding
2. Abdominal cramping
3. Cervical os is CLOSED
4. Uterine size compatible with dates
5. No products of conception are passed
6. Prognosis is unpredictable

8

Treatment Measures
Threatened abortion?
9

1. Bed rest from 24 - 48 hours with gradual resumption of usual activities
2. No work, no child care responsibilities
3. Rest in horizontal position, except when bathing or using the toilet
4. No sexual intercourse
5. Antibiotics ONLY if there are signs of infection
6. Hormonal treatment is contraindicated
7. Hydration
8. Explicit instructions on when to report signs and symptoms
9. Definitive follow-up date

9

Inevitable Abortion
signs?
8

1. Moderate bleeding
2. Moderate to severe uterine cramping
3. Low back pain
4. Cervical os is DILATED
5. Membranes may or may not be ruptured
6. Uterine size is compatible with dates
7. Products of conception are not passed, but passage is inevitable
8. Prognosis is poor, pregnancy cannot be saved

10

Incomplete abortion signs?
7

1. Heavy bleeding
2. Moderate to severe abdominal cramping
3. Low back pain
4. Cervical os is DILATED
5. Uterine size is compatible with dates
6. Some portion of the productions of conception (usually the placenta) remain in the uterus
7. Pregnancy cannot be saved

11

Missed Abortion
signs?
6

1. Pregnancy ceased to develop, but products of conception have not been expelled
2. Symptoms of pregnancy disappear
3. Brownish vaginal discharge but no free bleeding
4. Pain does not develop
5. Cervix is semi-firm and slightly dilated
6. Uterus becomes smaller and irregularly softened

12

Treatment measures for Missed, Inevitable, or Incomplete abortion?
3

1. Counseling regarding fate of the pregnancy
2. Assess Rh factor and administer immunoglobulin to Rh negative, unsensitized woman
3. Planning for elective termination


13

Treatment measures for Missed, Inevitable, or Incomplete abortion:
How can we plan for elective termination?
3

1. Empty all products of conception to prevent infection and uterine hemorrhage with D&C
2. Insertion of laminaria to dilate the cervix followed by aspiration is the method of choice for missed abortion
3. Prostaglandin vaginal suppositories are an effective alternative

14

Complete Abortion
signs? 7

1. Bleeding may be heavy or minimal
2. Moderate to severe abdominal cramping
3. Low back pain
4. Fetus and placenta are completely expelled
5. Pain then ceases, but spotting may persist
6. Cervical os may be opened or closed
7. Uterus is normal pre-pregnancy size

15

1. Habitual Abortions
defined as?

2. Three previous pregnancies – _____% chance of carrying a fetus to viability

3. Four or more – _____% chance of carrying a fetus to viability

1. Considered recurrent pregnancy loss/habitual abortions if 3 previous pregnancies

2. 70-80

3. 65-70

16

Evaluation of Suspected Spontaneous Abortion
5

1. History
2. Physical exam including pelvic exam and visualization of cervix
3. +/- Fetal doppler
4. +/- Transvaginal ultrasound
5. +/- Laboratory evaluation

17

What labs would you do for a spontaneous abortion?
2

1. Serum hCG
2. Blood type and antibody screen if suspected RH negative mother

18

Work-up For Recurrent Pregnancy Loss
1. Most useful tests? 3

2. Less useful tests? 4

1. Most useful tests
-Assessment of uterine structure
-Rule out lupus (anticardiolipin antibody, lupus anticoagulant)
-TSH

2. Less useful tests
-Blood glucose
-Genetic (only if other testing is normal)
-Maternal and paternal
-Day 3 FSH levels
Progesterone levels

19

Follow-up of Spontaneous Abortion
1. When?

2. Use contraception until when?

1. GYN exam 2-3 weeks after termination

2. Use contraception for 3 months to allow complete maternal healing and regeneration of endometrial lining

20

What is a major cause of maternal death in the first trimester??

Ectopic Pregnancy

21

Ectopic Pregnancy
1. What is it?
2. Where are the four most common spots?
3. What is inevitable?

-Potentially life-threatening condition
-Incidence is 1 in 80 pregnancies

1. Implantation of fertilized ovum outside of the uterine cavity

2.
-Fallopian tube – most common site (98%)
-Cervix
-Ovary
-In the abdominal cavity

3. Rupture is inevitable

22

Ectopic Pregnancy
1. High risk factors? 5
2. What lowers your risk? 4

1. Risk Factors
-History of genital infections
-History of infertility
-History of tubal pregnancy (ligation or reconstruction)
-History of any ectopic pregnancy
Intrauterine devices
-Lower risk

2. Lower Risk
-Abdominal or pelvic surgery
-History of ruptured appendix
-Intrauterine exposure to DES
-Use of drugs that slow ovum transport (mini-pill)

23

Dietheylstilbesterol (DES)
1. What is it?
2. What was it shown to cause?
3. Daughters of women who took DES during pregnancy may have a slightly increased risk of what?

1. A synthetic form of estrogen
-From about 1940 to 1970, DES was given to pregnant women under the mistaken belief it would reduce the risk of pregnancy complications and losses

2. In 1971, DES was shown to cause a rare vaginal tumor in girls and young women who had been exposed to this drug in utero


3. breast cancer after age 40

24

Natural History of Ectopic Pregnancy
3

1. Rupture - associated with profound hemorrhage that can be fatal

2. Abortion – expulsion of the products of conception through the fimbria and absorption of the tissue

3. Some can spontaneously resolve

25

Classic Presentation of ectopic pregnancy?
7

1. 1-2 months of amenorrhea
2. Morning sickness
3. Breast tenderness
4. Diarrhea, urge to defecate
5. Malaise and syncope
6. Lower abdominal/pelvic pain
(Sudden and severe and Especially adnexal (lateralizing to one side))
7. Referral of pain to shoulder

26

Atypical Presentation
of ectopic pregnancy?
2

1. Vague or subacute symptoms
2. Menstrual irregularity

Remember, signs and symptoms do not always correlate with severity of condition

27

Physical Exam of ectopic pregnancy?
5

1. Vital signs may reveal orthostatic changes

2. Adnexal, cervical motion and/or abdominal tenderness on pelvic exam

Pelvic exam
3. Normal appearing cervix, marked tenderness
4. Vaginal vault may be bloody, usually brick red to brown in color
5. Tender adnexal mass may be palpated

28

Physical Exam of ectopic pregnancy: Which vital signs are abnormal?
2

1. Tachycardia,
2. hypotension

29

Physical Exam
1. First and foremost remember what?

2. What is the only thing that can save them once rupture with hemorrhage has occurred?

3. Pt with what things needs surgery before they bleed out? 3

1. Remember…this can kill your patient

2. Emergency surgery is the only thing that can save them once rupture with hemorrhage has occurred

3. Pt with
-tachycardia,
-hypotension and
-+ pregnancy test needs surgery before they bleed out

30

Differential for ectopic preg?
8

1. PID
2. Ovarian Cyst
3. Ovarian Tumor
4. Intrauterine Pregnancy
5. Recent spontaneous abortion
6. Early hydatidiform degeneration
7. Acute appendicitis
8. Other bowel related disorders