Abortions

FWC

Abortions

Complete Incomplete Inevitable Missed Induced (Termination of pregnancy) Septic Blighted ovum

Abortions

Threatened Recurrent Tubal

Definitions

Complete abortion-Complete expulsion of all fetal parts and placental tissue from the uterus before 20 weeks of gestation Incomplete abortion- Passage of some but not all fetal or placental tissue prior to 20 weeks gestation

Definitions

Inevitable abortion - Uterine bleeding from a gestation of less than 20 weeks accompanied by cervical dilation but without expulsion of any placental or fetal tissue through the cervix

Definitions

Missed abortion- Fetal death before 20 weeks of gestation without expulsion of any fetal or maternal tissue for at least 4 weeks thereafter Induced abortion- Intentional medical or surgical termination of a pregnancy before 20 weeks of gestation( elective or therapeutic)

Definitions

Septic abortion-Any type of abortion that is accompanied by uterine infection Blighted Ovum-A fertilized ovum in which development has become arrested and degeneration is present Threatened AB- Any bleeding in a gestation less than 20 weeks without cervical change

Definitions

Recurrent pregnancy loss-Three or more spontaneous pregnancy losses before 20 weeks of gestation Tugal abortion- expulsion of the conceptus through the open end of the tube into the abdominal cavity

Abortions

20-25% of all clinical recognized pregnancies spontaneously abort Some fertilized ova do not implant and never secrete HCG Approximately 40% of abortions occur prior to the time of expected menses

Abortions

About 80% of all abortions occur in the first trimester The rate of clinical abortion is fairly stable each week until 12 weeks, then falls off If conception occurs prior to 3 months after a delivery the incidence of abortion is increased

Abortions

If the prior pregnancy ended in an abortion the subsequent pregnancy is at higher risk to abort (20%) Prior pregnancy successful only 5% abort If all prior pregnancies were successful then only 3% abort

Abortions

A subchorionic bleed does not increase the risk of spontaneous abortion if fetal viability is confirmed If a women has multiple abortions they tend to abort at the same time

Abortions

About 30-40% of all pregnancies experience bleeding prior to 20 weeks, half of these pregnancies end in abortion The more days of bleeding the more likely the pregnancy will abort Bleeding increases the risk of preterm delivery and fetal anomolies

Causes of Abortions

Environmental Maternal Fetal (Genetic or chromosomal)

Fetal causes of Abortion

50% of all abortions are chromosomally abnormal ( The majority of these are numerical abnormalities like trisomy) Causes are from non dysjunction, fertilization abnormalities like digyny, dispermy, triploidy and tetraploidy, mosiacs ( only about 5% because of translocations)

Fetal causes of abortion

Of all chromosomal abnormalities 50% are autosomal trisomies ( most common trisomy is 16 ) Order of frequency 16-13-21-22 Second most common cause of chromosomal anomolies is monosomy X (45XO) 15-20% of all spontaneous ABs

Fetal causes of abortions

45XO is the single most common chromosomal anomoly Only 1/300 will survive

Translocations as a cause of Abs

If 1 parent carries a translocation 80% of the conceptions will end in abortion If a couple has 2 or more pregnancy losses they have about a 3% chance that one of them carries a translocation When abortions occur in chromosomally normal fetuses they tend to occur later in gestation

Other potential genetic causes of abortions

Couples that share HLA antigens have increase ab rates It may be that blocking antibodies fail to form Or with similar HLA types there may be recessive genes that are lethal Suspect chromosomes 3 and 6

Environmental causes of Abs

Infections Smoking Alcohol Radiation Toxins

Infections as cause of Abs

Endometritis (usually mixed anaerobic ) Toxoplasmosis Herpes Ureaplasma urealyticum in the endometrium( ? Mycoplasma hominis) ? Listeria monocytogenes

Smoking as a cause of Abs

Heavy smoking more than 17 cigarettes per day had a 1.7 times higher likelihood of aborting a chromosomally normal fetus Light smoking does not appear to increase the risk of Abs

Alcohol as a cause of Abs

Drinking 2 drinks per week increase the risk of abortion by 2 fold Daily alcohol ingestion increase risk of abortion by 3 fold

Irradiation as a cause of Abs

Lethal dose is 5 rads and is most sensitive at the time of implantation Radiation of less than 5 rads is unlikely to cause any effects

Environmental toxins as a cause of Abs

Anesthetic agents (poor evidence) Lead Arsenic Formaldehyde Benzene Ethylene oxide Little valid evidence to incriminate any

Maternal causes of Abs

Leiomyoma of the uterus Uterine anomolies Medical conditions Immunological causes Endocrinologic causes

Leiomyoma as cause of Abs

Approximately 25% of women have fibroids Submucous fibroids appear to cause the biggest problem Diagnosis with U/S, HSG, or hysteroscopy Treatment is myomectomy or hysteroscopic resection

Uterine anomolies as a cause of Abs

DES exposure- T shaped uterus (even if the uterus is normal at HSG they have a higher sp Ab rate) DES also associated with incompetent cervix No treatment for DES exposure except cerclage

Uterine anomolies as a cause of Abs

Uterine adhesions- can be partial or complete Can cause menstral changes or amenorrhea There is insufficient tissue to support the implanting embryo leading to Abs Most common cause is D&C then C/S, myomectomy, IUD, Radiation, infection,TB

Uterine anomolies

Diagnosis of adhesions is by HSG or hysteroscopy Treatment is hysteroscopy D&C followed by IUD or catheter and estrogen 2.5mg BID for 60 days

Uterine Anomolies

Malformation of the uterus- Uterus didelphys, unicornate uterus, bicornate uterus, uterine septum These can also be associated with incompetent cervix Unicornate uterus has 50% Ab rate Diagnosis by HSG or hysteroscopy

Uterine Anomolies

Bicornate uterus can be surgically corrected via laparotomy (pt requires C/S) Uterine septi can be hysteroscopically resected (pt can deliver vaginally)

Uterine Anomolies

Incompetent cervix- congenital or acquired Tx cerclage at 12-14 weeks Cause from multiple or aggressive cervical dilation Painless dilation and of effacement of the cervix ( 20% of 2nd trimester losses) Cerclage decrease loss rate from 80 to 20%

Medical conditions associated with abortions

Diabetes Severe malnutrition Hyperthyroidism

Endocrinologic causes of Abortions

Progesterone deficiency-progesterone stimulates the endometrium to become secretory if it does not then the embryo will not implant Corpus luteum produces progesterone until the placenta takes over Inadequate corpus luteum diagnosed with endometrial biopsy with 3 day discrepancy

Endocrine causes

Treatment of progesterone deficiency is with progesterone supp 25mg BID or Lozenges 50mg q day or daily injection with progesterone 12.5mg Treatment starts 1-3 days after ovulation Midcycle progesterone level less than 9

Endocrine causes

Thyroid antibodies present doubles the risk of abortions Hypo or Hyper thyroidism has not proven to increase the rate of abortions Hypothyroidism can cause anovulation

Endocrine causes

Diabetes mellitus- If well controlled there does not appear to be an increase in abortion rate If poorly controlled there is and increase in abortions and it correlates with the glycosolated hemoglobin

Immune factors as a cause of Abs

Lack of maternal blocking antibodies(not proven to be related to HLA) Lupus anticoagulant and Antiphospholipid antibodies-IgG and IgM Check activated partial thromboplastin time These antibodies are seen in women with lupus, subclinical immunologic dx, thrombosis and recurrent pregnancy loss

Immune factors

Pt with lupus and recurrent fetal loss have antiphospolipid antibodies 80% of the time Only 15% of lupus pt have antibodies when they dont show recurrent loss Rx- Aspirin, corticosteroids, heparin

Diagnosis of abortions

Ultrasound- Abdominal sac seen at HCG of 6500 Transvaginal- sac seen at 1500 HCG Transvaginal sac seen at 40 days after the FDLMP Dilated cervix HCG( normally doubles every 48 hours)

Abortions

Prior to 6 weeks gestation and after 14 weeks abortions is frequently complete Between 6-14 weeks almost always incomplete If retained past 6 weeks a consumptive coagulopathy can develop

Treatment

Septic abortions -are polymicrobial infections Cefoxitin+Vibramycin or Clindamycin+Gentamycin followed by D&C ( if past 14 weeks consider induction with some agent) Threatened abortion-Decrease physical activity avoid intercourse( no proof of benefit) Serial HCG and Ultrasound

Treatment

Inevitable and Incomplete abortionsEvacuation of the uterus (out patient) Methergine after Tubal Abortion- Difficult to diagnose may require laparoscopy, expectant management follow with HCGs and HSG

Treatment

Recurrent aborters-If a women has had 3 or more spontaneous abortions the fetus is chromosomally normal 80-90% of the time This points to environmental or maternal factors If no live births 50% chance of having a term gestation, if one birth 70% chance of live birth

Treatment of recurrent aborters

Treatment will be based on the etiology of the cause if found These pt tend to abort later in gestation TSH, midluteal progesterone, HSG,+/karyotype, antphospholipid antibodies, ureaplasma culture, and CBC 35-44% of these pt have no etiology

Treatment

Rho Gam if mother is Rh negative in all cases of bleeding and abortion prior to 8 weeds 50 micrograms IM after 8 weeks 300 micrograms IM Uterus does not have receptors for oxytocin this early