[MDCU] Abortion and ectopic pregnancy

What is the threshold of viability of a baby born in KCMH?

• GA 22 weeks

• Birth weight >500 g

Early pregnancy loss is defined as a nonviable intrauterine pregnancy with ___ occurring before GA ___

1. CRL >7 mm + no fetal heart beat

2. Gestational sac >25 mm

Occurs before GA 13 weeks

80% of spontaneous abortion occur before GA ___

GA 12 weeks

Chromosomal abnormality responsible for ___ % of abortions in the 1st trimester

55%

95% of autosomal trisomy resulting in spontaneous abortion is caused by ___?

Maternal gametogenesis error

Removal of corpus luteum before GA ___ most likely results in abortion

GA 10 weeks

What is the presentation of threatened abortion?

Uterine size = ___

• Vaginal bleeding

• Closed cervical os

• Uterine size = gestational age

___% of threatened abortion will result in actual abortion

50%

Except present cardiac activity (<5%)

The risk for the threatened abortion to actually abort will be significantly lower if ___

Fetal cardiac activity is present

50% → <5%

What is the management of threatened abortion?

• Speculum examination → ensure os close

• Ultrasound → viability & locate pregnancy

• Bed rest, abstinence, follow-up

What is the definition of blighted ovum?

Mean gestational sac diameter >25 mm with no embryo

What is the definition of embryonic death?

CRL >7 mm with no fetal heartbeat

What is the presentation of inevitable abortion?

• Vaginal bleeding

• Uterine contraction

• Cervical dilatation

• Gross rupture of membranes

What is the presentation of imminent abortion?

• Vaginal bleeding

• Uterine contraction

• Cervical dilatation

• Gross rupture of membranes

What is the management of inevitable abortion?

Termination of pregnancy based on uterine size

• <12 week : curettage

• >12 week : oxytocin 10-20 u drip in NSS 1,000

Incomplete abortion

• Os

• Uterine size

Partial expulsion of conceptive product

• Os open

• Uterine size < gestational age

What is the complication and management of incomplete abortion?

Severe bleeding

• Conservative + blood transfusion

• Uterine evacuation (D&C)

• Oxytocin

Missed abortion is defined as a dead products of conception that were retained for ___ with a closed cervical os.

>8 weeks

What are 4 signs & symptoms of missed abortion?

• Disappearing signs and symptoms of pregnancy

• Uterine size gradually becomes smaller

• Threatened abortion

• Persistent amenorrhea

Whais is the management of missed abortion

Termination of pregnancy

• Medabon

• D&C, MVA

• Complication: perforation, coagulopathy from tissue thromboplastin

What is the presentation of septic abortion?

Fever, pelvic pain, abortion

• Endomyometritis → peritonitis, septicemia

• DIC

Management of septic abortion

• __

• __

• __

• __

• __

• Resuscitation, blood transfusion

• Septic workup

• IV Gentamicin + Clindamycin

• Uterine evacuation after 4-6 hours

• TT + TAT

What is the presentation of cervical incompetence?

Painless cervical dilatation in 2nd trimester

What are risk factors of incompetent cervix?

• D&C

• Conization

• Exposure to DES in utero

Timing for elective and emergency cervical cerclage

• Elective GA 12-14

• Emergency GA <23

What is the most common cause of recurrent miscarriage?

Uterine anatomical defect, incompetent cervix

Which test should be done to investigate recurrent abortion?

• Hysteroscopy

• Thyroid function test (TSH, anti-TPO)

• Anti-phospholipid Ab

Which surgical technique should be used for TOP in the 1st trimester?

• D&C

• MVA

• Menstrual aspiration

Which surgical technique should be used for TOP in the 2nd trimester?

• Hysterotomy

• Hysterectomy

• Dilatation and extraction / evacuation

What are complications of dilatation & curettage?

• Uterine perforation

• Visceral organ injury

• Infection

• Incompetent cervix

• Uterine synechiae

What are drugs used for medical abortion?

• Prostaglandin E1 / E2 / F2a (Misoprostol)

• Anti-progesterone (Mifepristone)

• Oxytocin IV drip

What is the mechanism of action of misoprostol in abortion?

Cervical collagen degradation

Uterine contraction

What is the mechanism of action of mifepristone in abortion?

Anti-progestin → uterine contraction

What is the drug component of Medabon?

• Misoprostol 200 mcg

• Mifepristone 200 mg

What is the most common site of ectopic pregnancy?

Ampullary pregnancy

Interstitial pregnancy is defined as an implantation at ___

Proximal intramural portion of the tube

Cornual pregnancy is defined as an implantation at ___

Rudimentary horn of a uterus with a Müllerian anomaly

What are risk factors for heterotopic pregnancy?

• Previous ectopic pregnancy

• Tubal sterilization, IUD

• Tubal corrective surgery

• Documented tubal pathology

• ARTs

• Peritubal adhesion

What is the most common type of abortion in ampullary pregnancy?

Tubal abortion

What is the classic triad of tubal pregnancy?

• Missed period

• Pain (pelvic / abdominal)

• Vaginal bleeding

What are the signs of tubal pregnancy?

AT BUS

• Abdominal distension

• Tenderness (cervical motion, adnexal)

• Bulging of posterior fornix

• Uterine pushed to one side

• S&S of abdominal hemorrhage

Which test is used to diagnose ectopic pregnancy?

• Serial hCG

• TVS

Discriminatory level = 1,500-2,000 MIU/ml

Serum progesterone in ectopic pregnancy is ___ (↑ / ↓)

Progesterone ↓

Discriminatory level of β hCG

1,500 - 2,000 mIU/ml

ควรเห็น gestational sac แล้ว

Which sonographic finding, if present, implies an ectopic pregnancy?

• Positive β hCG assay

• Absent intrauterine pregnancy

• Free fluid in cul-de-sac

• Abnormal tubal mass (ring of fire)

What is the lowest increase of β hCG in intrauterine pregnancy after 48 hours of sampling?

53-66%

Normal = doubling time

What is the gold standard of diagnosis of ectopic pregnancy?

Laparoscopic diagnosis

What is the indication of salpingectomy?

• Ruptured ectopic pregnancy

• Combined pregnancy

What are contraindications for methotrexate in treatment of ectopic pregnancy?

“ABCD”

• Active intra-abdominal bleeding

• Breastfeeding

• Chronic liver / kidney / lung disease

• Disorder of blood

• Pregnancy

Patients eligible for methotrexate treatment of ectopic pregnancy

• β hCG <5,000 mIU/ml

• Size <3.5 cm

• No fetal cardiac activity

• Asymptomatic / mild symptom

Patients eligible for expectant treatment of ectopic pregnancy

• Tubal pregnancy only

• Declining hCG (initial <1,000)

• Size <3 cm

• No rupture / bleeding

Counseling for potential tubal rupture ***