Podcast: Play in new window | Download

Spontaneous Abortion

• Abortion – termination of a pregnancy before the fetus develops sufficiently to survive
• Spontaneous – without medical or mechanical means of emptying the uterus
• Approximately 15% of pregnancies end in spontaneous abortion.
• 80% occur in the first 12 weeks of pregnancy.
• Causes
  • About half of all spontaneous abortions demonstrate chromosomal abnormalities
  • DM, hypothyroidism, progesterone deficiency, alcohol, smoking and autoimmune factors are other major contributors

Categories of Spontaneous Abortion

• Threatened abortion – cramping, bloody discharge (spotting), closed cervical os.  A small percentage will go on to spontaneous abortion.

• Inevitable Abortion – Obvious rupture of membranes and leaking of amniotic fluid in the first 12 weeks.  If this occurs with cervical dilation it will likely progress to miscarriage.
• Complete Abortion – Complete detachment of the placenta from the uterus and expulsion of the products of conception.  The cervical os will be closed once complete.
• Incomplete Abortion – Cervical os is open with some portion of the fetus and/or placenta remaining in the uterus.  
• Missed Abortion – The cervical os is closed and the terminated fetus remains in the uterus.  This may go unnoticed for several days or even weeks.
• Recurrent Abortion – Usually defined as 3 or more consecutive spontaneous abortions.  The prognosis for these women is good. The  majority of cases are thought to occur secondary to chance as the risk of a single spontaneous abortion is 15% the risk of having three in a row is 0.34%.

Labs

• Serial hCG titers
• U/S

Treatment

• Threatened and inevitable abortions are typically treated with bed rest, routine physical exam and U/S.  If Rh(-), they should be given immunoglobulin.
• If the fetus is terminated then the contents of the uterus must be emptied.  This is often done by D&C.

Ectopic Pregnancy

Ectopic Pregnancy – The implantation of a fertilized egg outside of the uterus.

This occurs in about 1 – 2.5% of pregnancies.  Roughly 80% of ectopic pregnancies occur in the fallopian tube.  

Risk Factors  

Anything that would block or slow the movement of the egg through the fallopian tubes

• History of surgery on the  fallopian tubes
• History of salpingitis
• History of pelvic inflammatory disease
• History of ectopic pregnancy
• History of endometriosis

Clinical Presentation

• Pain!
• Amenorrhea
• GI symptoms
• Lightheadedness
• Abnormal vaginal bleeding

Diagnostics

• Pelvic exam – may feel mass in 20% of ectopic pregnancies
• Pregnancy test
• Serum progesterone
• U/S

Treatment

• Methotrexate may be given if mass is < 4 cm and gestation is < 6 weeks in order to abort the fertilized egg.  
• Surgical removal of the ectopic most commonly done with laparoscopy.

Ruptured Ectopic

An ectopic pregnancy that results in the a tearing of a fallopian tube.  This can cause massive hemorrhage and is a surgical emergency.  

Clinical Presentation

• All of the symptoms of an ectopic pregnancy though more severe.
• Acute intense abdominal pain
• Shoulder pain due to peritoneal involvement
• Lightheadedness or dizziness secondary to significant blood loss

Treatment

• Requires immediate surgery.

Study Tip

Study in blocks that are less than four hours.

Studying works best in small consistent bursts.  6 hours in one study block on a Saturday is not the same as studying an hour a day for 6 days.  The 6 hours broken up throughout the week are worth far more than the six hours in one shot.  A well trained human brain can focus best for between 45 and 90 minutes at at time.  Studies have shown that even with good breaks, concentration maxes out at about four hours.    

That means the most time you can expect to spend doing your best work is 4 hours in a day.  That doesn’t mean you can’t keep working.  It just means you won’t be working as efficiently.

Review Questions

Q:  List 4 things in a patient’s history that might make you consider ectopic pregnancy.

A:  Previous ectopic, h/o PID, h/o endometriosis, h/o fallopian tube surgery,

Q:  What is the first line medical treatment for an ectopic pregnancy?

A:  Methotrexate

Q:  Define a threatened abortion.

A:  Cramping, bloody discharge (spotting), closed cervical os.

Q:  What term describes a situation where the fetal tissue is not viable, but remains in the uterus and the cervical os is closed on exam.

A:  Missed abortion

Q:  What percentage of pregnancies will spontaneously abort?

A:  15%