Early Pregnancy Loss Abigail Wolf, MD Obstetrics and Gynecology Thomas Jefferson Medical College

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).

Blastocyst

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.

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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:

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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