Transcript Management of Early Pregnancy Loss

Management of Early
Pregnancy Loss (EPL)
Management of early pregnancy loss
Assessment of the patient should include a full
history and examination. Investigations may
include:
 Pelvic ultrasound scan
 Full blood count
 Blood group and save serum
Incomplete, missed abortion:
 If bleeding is heavy, there is considerable pain,
then emergency medical attention is
recommended to be sought.
 Otherwise, there are three treatment options:
 Expectant management
 Medical management
 Surgical management
Expectant management
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With no treatment (watchful waiting), most of
these cases (65–80%) will pass naturally within
two to six weeks. This path avoids the side
effects and complications possible from
medications and surgery. This is mostly applied
to missed abortion and blighted ovum.
Medical management
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Misoprostol
Mifepristone plus Misoprostol
Methotrexate plus Misoprostol
There is no medical regimen for management of
early pregnancy loss that is FDA approved.
Misoprostol
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Prostoglandin E1 analogue
FDA approved for prevention of gastric ulcers
Used off-label for many ob/gyn indications
Labor induction
 Cervical ripening
 Medical abortion (with mifepristone)
 Prevention/treatment of post-partum hemorrhage
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Can be administered by oral, buccal, sublingual,
vaginal and rectal routes
Why misoprostol?
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Do something while still avoiding surgery
Cost effective
Few side effects (especially with vaginal)
Stable at room temperature
Readily available
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800 mcg. per vagina (or buccal)
Repeat x 1 at 12-24 hours if incomplete
Intervene with surgical management if:
Continued gestational sac
 Clinical symptoms
 Patient preference
 Time (?)
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Surgical management
Surgical treatment (most commonly vacuum aspiration,
sometimes referred to as a D&C or D&E) is the fastest
way to complete the miscarriage. It also shortens the
duration and heaviness of bleeding, and is the best
treatment for physical pain associated with the
miscarriage. In cases of repeated miscarriage , D&C is
also the best way to obtain tissue samples for pathology
examination. D&C, however, has a higher risk of
complications, including
 risk of injury to the cervix and uterus,
 perforation of the uterus,
 and potential scarring of the intrauterine lining.
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Who should have surgical management?
Unstable
 Infected
 Very heavy bleeding
 Anyone who wants immediate therapy
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Dilatation & curretage
Postmiscarriage care
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Anti D at time of diagnosis or surgery for non
sensitized Rh negative woman with Rh positive
husband
Pelvic rest for 2 weeks
No evidence for delaying conception
Expect light-moderate bleeding for 2 weeks
Menses return after 6 weeks
Negative BhCG values after 2-4 weeks
Appropriate grief counseling
Future miscarriage risk
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Increased risk of miscarriage in future pregnancy
20% after 1 SAb
 28% after 2 SAbs
 43% after 3+ SAbs
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Septic abortion
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A septic abortion or septic miscarriage is a
form of miscarriage that is associated with a
serious uterine infection. The infection carries
risk of spreading infection to other parts of the
body and cause septicemia, a grave risk to the
life of the woman.
The infection can occur during or just before or
after an abortion.
Symptoms
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In a woman with septic abortion, symptoms that
are related to the infection are mainly:
High fever, usually above 101 °F , chills
Severe abdominal pain and/or cramping /or
strong perineal pressure
Prolonged or heavy vaginal bleeding
Foul-smelling vaginal discharge
Backache or heavy back pressure
As the condition becomes more serious, signs of septic
shock may appear, including:
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hypotension
hypothermia
oliguria
Respiratory distress (dyspnea)
Septic shock may lead to kidney failure, bleeding diathesis,
and disseminated intravascular coagulation (DIC).
If the septic abortion is not treated quickly and
effectively, the woman may die.
Risk factors
The risk of a septic abortion is increased by mainly
the following factors:
 The fetal membranes surrounding the unborn
child have ruptured, sometimes without being
detected
 The woman has a sexually transmitted infection
such as chlamydia
 An intrauterine device (IUD) was left in place
during the pregnancy
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Tissue from the unborn child or placenta is left
inside the uterus after a miscarriage
Unsafe abortion was made to end the pregnancy
Mifepristone (RU-486) was used for a medical
abortion
Treatment
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The woman should have intravenous fluids to
maintain blood pressure and urine output.
Broad-spectrum intravenous antibiotics should
be given until the fever is gone.
A dilatation and curettage (D&C) may be
needed to clean the uterus of any residual tissue.
In cases so severe that abscesses have formed in
the ovaries and tubes, it may be necessary to
remove the uterus by hysterectomy, and possibly
other infected organs as well.
Recurrent pregnancy loss
Definition
3 or more consecutive pregnancy losses prior to 20
weeks
 not including ectopic, molar, biochemical
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causes
1. Uterine Pathology
10-50% of RPL via abnormal implantation and uterine
distention
 Mullerian anomalies of septate, bicornuate, didelphic
uteri (not arcuate)
 Submucous leimyoma >>intramural or subserous
 Intrauterine synechiae (Asherman’s)
 Cervical incompetence – midtrimester
Evaluation: Sonohysterography or Hysterosalpingogram;
2nd line tests include hysteroscopy, laparoscopy, or MRI
2. Hypercoagulable States
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Antiphospholipid syndrome
5-15 % of RPL, as well as late fetal death
 History of thromboembolism or pregnancy
complication with high titers of anti-cardiolipin
antibody and/or lupus anticoagulant
 Treat with heparin (5,OOO-10,000 units BID) and
aspirin .
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3. Endocrine Disorders
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15-60 % of RPL
Poorly controlled diabetes with HgA1c > 8
PCOS
Poorly controlled thyroid disease and potentially
subclinical hypothyroidism
Hyperprolactinemia
Historically luteal phase defects
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Diagnosis in question and suggested treatments not effective,
but source of progesterone trial
4. Immunologic Factors
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Alloimmune reaction of mother to “foreign”
tissue of embryo
HLA-mediated factors
5. Chromosomal Factors
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2-4% of RPL with chromosomal rearrangement:
 ½ balanced translocation; ¼ Robertsonian
translocation; other sporadic mutations,
inversions
 Evaluation: Parental karyotype and karyotype
of abortus if possible
 Treatment: Genetic counseling; IVF with
preimplantation screening of embryos or
gamete donation
6. Environmental Factors
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No good evidence for recurrent SAb
Sporadic pregnancy loss affected by
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Smoking, alcohol, anesthetic gases, caffeine >
300mg/day, obesity.
Cervical incompetence
Cervical incompetence is a medical condition in
which a pregnant woman's cervix begins to dilate
(widen) and efface (thin) before her pregnancy has
reached term.
Cervical incompetence may cause miscarriage or preterm
birth during the second and third trimesters. In a
woman with cervical incompetence, dilation and
effacement of the cervix may occur without pain or
uterine contractions. If the responses are not halted,
rupture of the membranes and birth of a premature
baby can result.
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Risk factors
history of conization (cervical biopsy),
 Diethylstilbestrol exposure, which can cause anatomical
defects, and
 uterine anomalies
Repeated procedures (such as mechanical dilation,
especially during late pregnancy) appear to create a risk.
Additionally, any significant trauma to the cervix can
weaken the tissues involved
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Symptoms of Cervical Incompetence
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Women with incompetent cervix typically
present with "silent" cervical dilation (i.e., with
minimal uterine contractions) between 16 and
28 weeks of gestation. When the cervix reaches
4 cm or more, active uterine contractions or
rupture of membranes may occur.
Diagnosis of Cervical Incompetence
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Cervical incompetence is an important, but undoubtedly
over-diagnosed, condition.
A diagnosis of cervical incompetence is usually made on the
basis of a woman's past pregnancy history. Classically this is
following one or more late second trimester or early third
trimeser losses . Usually they begin with a gradual painless
dilatation of the cervix, with membranes bulging into the vagina.
Transvaginal ultrasound (TVS) during pregnancy has shown some
promise. The usual length of the cervix is about 4cm as
measured on TVS. Women with a cervical length of less than
2.5cm have been found to have a 50% risk of preterm delivery
in one study. Other studies have looked at opening of the
internal section of the cervix ('funnelling' or 'beaking') in
response to pressure on the top of the uterus.
Treatment
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Cervical cerclage is the treatment that is offered. This involves
placing a stitch high up around the cervix to try & keep it closed.
The stitch can be placed either vaginally or via an abdominal
incision. The latter is usually used when vaginally placed stitches
fail. They are called McDonald or Shirodkar stitches. The
Shirodkar variant involves a bit more extensive surgery to ensure
the stitch is high up on the cervix.
This is usually performed after the twelfth week of pregnancy,
the time after which a woman is least likely to miscarry for other
reasons - but it is not done if there is rupture of the membranes
or infection.
The stitch is usually removed around 37 weeks and labour ensues
fairly rapidly if the diagnosis was correct. Abdominal cerclage
requires an elective caesarean section and the stitch is usually left
in-situ for future pregnancies.
Complications of the stitch include rupture of the membranes at
the time of placement, and increased risk of infection