3. Differential Diagnosis
Implantation of embryo into endometrium (normal)
Spontaneous abortion
Ectopic pregnancy
Gestational trophoblastic disease
Abnormal placentation (ie. placenta previa) usually does
not cause bleeding until later in pregnancy
5. Spontaneous Abortion
Definition: Passing of a pregnancy prior to 20 weeks
gestation (aka: miscarriage)
Half of pregnancies complicated by 1st trimester bleeding
end in spontaneous abortion
Causes separated into genetic and environmental
(maternal)
Genetic abnormalities in 50-70% of SAs
Trisomy most common anomaly
Other causes include maternal systemic disease (ie. diabetes,
hypothyroidism, autoimmune dx), infection, maternal anatomic
defects (ie. bicornuate uterus)
Often, exact cause is unknown
6. Classification of Spontaneous
Abortion
Threatened: Vaginal bleeding without cervical dilation
Incomplete: Vaginal bleeding with partial expulsion of products of
conception (POC) + cervical dilation
Missed: Embryonic demise prior to 20 wks without expulsion of POC
+/- vaginal bleeding
Complete: Vaginal bleeding + expulsion of all POC
Inevitable: Vaginal bleeding + cervical dilation
Septic: Any of the above + uterine infection
7. First-trimester Milestones
5 weeks: Gestational sac
(~5mm) seen with TVUS
6 wks: Embryo (1-2mm)
visible on TVUS
Yolk sac: Seen with TVUS
when GS>10mm (>20 w/
TAUS)
Cardiac activity: Seen with
TVUS when GS >18mm Normal gestational sac at arrow, endometrial
(>25mm on TAUS) cavity at curved arrow
Cardiac activity should
always be seen when
embryo >5mm
9. Normal US Findings
Yolk sac (at arrow) within gestational sac Yolk sac (at curved arrow) with embryo
(between X’s)
10. Normal US Findings
Embryo (black arrow); amnion (small arrow) does not fuse with chorion (large
arrow) until 12-16wks gestation.
11. Spontaneous Abortion
Presentation: Varies greatly
depending on type of abortion,
but often presents with vaginal
bleeding and uterine cramps or
β-hCG: Falling or rising
back pain.
abnormally slow
US findings vary depending on
classification and cause of
abortion
Anembryonic pregnancy: large (>18mm) gestational sac
without embryo
12. Abnormal US Findings: Spontaneous
Abortion
Abortion in progress: low-lying gestational sac (thick Missed abortion: embryo (at arrow) is relatively
arrow), decidual reaction and hemorrhage (mixed hyper- small compared to large gestational sac. No
and hypo-echoic material between arrowheads) cardiac activity was present.
14. Threatened Abortion
Threatened abortion is defined as vaginal
bleeding before 20 weeks of gestation
30-40% of all pregnant women
25-50% will progress to spontaneous abortion
16. Symptoms
Usually bleeding begins first
Cramping abdominal pain follows a few hours
to several days later
Presence of bleeding & pain
→ Poor prognosis for pregnancy continuation
17. Physical examination
Vital signs : normal
Abdomen usually is not tender
Cervix is closed
Bleeding can be seen coming from the os, and
usually there is no cervical motion or adnexal
tenderness
18. Investigation
การตรวจทั่วไป
CBC : ประเมินการเสียเลือด
Blood group : ตรวจทัง ABO และ Rh
้
UA : ประเมิน UTI
Wet smear : ถามีตกขาวผิดปกติ แนะนําใหพิจารณาตรวจหา
gonorrhea และ chlamydia
19. Investigation
การตรวจยืนยันการตั้งครรภ
Urine pregnancy test
Serial measurements of hCG
Ultrasonography : ควรตรวจทังสองวิธี
้
TAS : สามารถเห็นทังอุงเชิงกรานและชองทอง ทําใหตรวจพบ
้
กอนที่ปกมดลูกและเลือดออกในชองทองได
TVS : วินิจฉัยการตั้งครรภในโพรงมดลูกไดเร็วกวา TAS
ประมาณ 1 สัปดาห
21. Treatment
There are no effective therapies for threatened
abortion.
Bedrest, although often prescribed, does not alter its
course.
Progesterone or sedatives should not be used
Acetaminophen-based analgesia may be given to help
relieve discomfort
All patients should be counseled and reassured so
that they understand the situation
28. Complete Abortion
Definition
is an abortion (induced or spontaneous) in which all of the fetal
and placental material has been expelled from the uterus before
20 weeks or before a viable fetus
29. History
Vaginal bleeding
Abdominal pain
Passage of tissue
Vaginal bleeding and abdominal pain diminish after passage of
tissue
30. Physical Examination
Blood in vagina
Closed cervical os
No tender of cervix, uterus, adnexa or abdomen
Investigation
Ultrasound: empty uterus
31. Treatment
Follow up for complication
Infection
Anti D immunoglobulin in Rh negative patient
33. Habitual Abortion
defined as 2 to 3 or more consecutive pregnancy losses before 20
weeks of gestation ,each with a fetus weighing less than 500 g
Etiology
Eldery mom : advice
Genetic Errors
− Balanced rearrangements of parental chromosomes are found
in approximately 2–5% of couples with repetitive abortions
− Balanced translocations are the most common
− 1st trimester
− karyotype screening should be performed
34. Habitual Abortion
Uterine Abnormalities
− Generally, losses from anatomic abnormalities occur in the second
trimester
− causes of habitual abortion up to 15%
− congenital uterine anomalies (Unicornuate and bicornuate uter), cervical
incompetence, submucous leiomyomas, abnormalities due to DES
exposure in utero
Hormonal CausesUnicornuate and bicornuate
− Hypothyroidism and hyperthyroidism, progesterone insufficiency, and
uncontrolled diabetes mellitus.
− Progesterone deficiency or luteal phase defect (LPD) is a controversial
etiology of habitual abortion.
35. Habitual Abortion
Infection
− Mycoplasma hominis, Ureaplasma urealyticum, Toxoplasma
gondii, C trachomatis, T pallidum, Borrelia burgdorferi, N
gonorrhoeae, S agalactiae, L monocytogenes, herpes simplex,
and cytomegalovirus.
Immunologic Factors
− Antiphospholipid antibodies (lupus anticoagulant and
anticardiolipin antibodies) may damage platelets and vascular
endothelium
− PTT
− Tx : heparin / low dose ASA
37. Missed Abortion—Early Pregnancy
Failure
Fetal death before 20 weeks of gestation without expulsion
of any fetal or maternal tissue thereafter
Dead products of conception that were retained for days,
weeks, or even months [6 wks]in the uterus with a closed
cervical os.
Always preceded by embryofetal death
Regression of changes of pregnancy
38. Missed Abortion—Early Pregnancy Failure
[cont’]
History is not diagnosis.
-Early pregnancy appears to be normal, with amenorrhea, nausea
and vomiting, breast changes, and uterine growth.
-After embryonic death, there may or may not be vaginal
bleeding or other symptoms of threatened abortion with persistent
amenorrhea.
With sonography, confirmation of an anembryonic gestation or of fetal
or embryonic death is possible
39. Missed Abortion—Early Pregnancy Failure
[cont’]
Physical examination cannot help diagnosis.
-Uterine size not to the gestational age; becomes smaller.
-Absence of FHT
-Mammary changes usually regress
-Often lose a few pounds.
-Have no symptoms during this period except persistent amenorrhea.
-Vaginal bleeding may be seen in PV exam.
Investigation as threatened abortion
-β-hCG
-USG;Embryonic demise ,Blighted ovum
41. Missed Abortion—Early Pregnancy Failure
[cont’]
Medical or surgical termination at the time of diagnosis.
Not termination
-Uterine size remains unchanged, and then gradually
becomes smaller.
-Mammary changes usually regress
-Often lose a few pounds.
-Have no symptoms during this period except persistent
amenorrhea.
If the missed abortion terminates spontaneously, and most do,
the process of expulsion is the same as in any abortion
56. Septic abortion
STATESTICS
10% of all pregnancies end into abortion.
10% of all abortions admitted to hospital are septic.
% of maternal mortality is due to septic abortions.
57. Septic abortion
CAUSES
1. Predisposing factors
• Poor socio-economic condition
• Incomplete abortion
• Criminal abortion
2. Exciting factors
Presence of blood, blood clots & a dead ovum or fetus micro-organisms to
grow.
59. Septic abortion
Definition
Any abortion associated with clinical evidences of infection of uterus and its
contents is called as septic abortion.
Clinical evidences of infection are :
Fever 38 C or more for at least 24 hr.
Offensive or purulent vaginal discharge
Lower abdominal pain, tenderness or mass.
Tachycardia of more than 100 per min.
60. Septic abortion
Clinical Grading of septic abortion
Grade 1
Infection localized to uterus
Grade 2
Infection beyond uterus to parametrium, tubes, ovaries or pelvic
peritoneum
Grade 3
Generalized peritonitis and or endotoxic shock or ARF
61. Septic abortion
Symptoms
High fever, usually above 101 °F
Chills
Severe abdominal pain and/or cramping
Prolonged or heavy vaginal bleeding
Foul-smelling vaginal discharge
Backache
A cold or UTI may mimic many of the symptoms.
62. Septic abortion
As the condition becomes more serious, signs of septic shock may appear,
including:
Hypotension
Hypothermia
Oliguria
Respiratory distress (dyspnea)
Septic shock may lead to kidney failure, bleeding tendency and DIC.
Intestinal organs may also become infected, potentially causing scar tissue
with chronic pain, intestinal blockage, and infertility.
63. Septic abortion
Investigation
1. CBC
• Anemia, Plt count
2. Coagulogram
• Coagulation, DIC, Bleeding & Clotting time.
3. Urine analysis and Urine culture
• Bacteriological study for pus cells & culture.
4. Uterine discharges gram stain and culture
• Gram staining-aerobic & anaerobic culture & sensitivity
determination.
64. Septic abortion
5. Blood culture
• Blood culture prior to antibiotic therapy.
6. Serum electrolyte
• Fluid & electrolytes disturbances.
7. Chest X-ray
• Pneumonia associated with spontaneous abortion
• Air underneath the dome of diaphragm is an indication of perforation
of uterus or intestines.
68. Septic abortion
After successful treatment of a septic abortion, a woman
may be tired for several weeks.
In case of substantial bleeding, iron supplementation may be
helpful.
Sexual intercourse or use tampons should be avoided until
recommended by the healthcare provider.
81. Tubal Pregnancy at USG
Detailed view of ectopic (thick, brightly echogenic, ringlike
structure outside the uterus)
Tubal pregnancy circled in red
4.5 mm fetal pole (between cursors) in green
Pregnancy yolk sac in blue
82.
83. Tubal Pregnancy at laparoscope
A right tubal ectopic pregnancy seen at laparoscopy
The swollen right tube containing the ectopic pregnancy is on the right at E
The stump of the left tube is seen at L - this woman had a previous tubal
ligation
102. Malignant trophoblastic and aggressive cancer
characterized by early hematogenous spread to the lungs
พบเกิดตามหลัง hydatidiform moles, ทองปกติ, ทองนอกมดลูก, แทง
ดังนั้นจึงเปนขอควรนึกถึงเสมอในกรณีที่ผปวยมีเลือดไหลออกจากชองคลอดไมหยุด
ู
ภายหลังการคลอดหรือแทง
107. Patient suffers from mole should be controlled for one year and
Rise in β-hCG disturbed the follow up
another one after CMT.
Teratogenic effects from CMT
Relapse GTN
Woman that went on CMT will experience menopause 3
years early from normal one.
110. Only for high-risk group
Not available to follow up
Large for date
Theca lutien cyst > 6 cm
Hyperthyroidism
Maternal age > 40 years
hCG in blood > 100,000 mU/mL
Prior molar pregnancy
111. Actinomycin D
12 ug/kg/day (IV) 5 days continuous
Methotrexate
0.4 mL/kg/day (IV) 5 days continuous
112. Termination of pregnancy
(if on CMT, do it in day 3)
Suction & Curettage
Hysterectomy
Hysterotomy
113. 1. History taking and pelvic examination
2. hCG
3. Chest X-ray
4. Contraception