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1 WHO ICMART GLOSSARY
2 DEFINITIONS
3 DEFINITIONS
4 DEFINITIONS
5 DEFINITIONS
6 SPONTANEOUS MISCARRIAGE (MISCARRIAGE) 60-70% of conceptions fail to achieve viability 50% lost before the first missed menses Biochemical pregnancy: hcg positive, no clinical signs 20% of pregnancies: early blood loss; 50% abortion Increased risk with advanced maternal age: 10% (< 25 yrs), 25% (> 40 yrs)
7 SPONTANEOUS ABORTION (MISCARRIAGE) 15-20% of clinical pregnancies 50-60%: CHROMOSOMAL ANOMALY % Trisomy (16) % Polyploidy -10% Monosomy (x)
8 THREATENED ABORTION/MISCARRIAGE Intrauterine viable pregnancy + intrauterine source of vaginal bleeding +/- pain Anamnesis: symptoms Clinical exam: speculum, bimanual Ultrasound (neg, subchorionic hematoma) Serum HCG Management: bed rest, no coitus, (progesterone), counselling
9 INEVITABLE ABORTION/MISCARRIAGE Idem + more pain Clinical exam: + cervical dilation 2-3 cm + sometimes placental tissue in cervix
10 INCOMPLETE ABORTION/MISCARRIAGE Incomplete = Some but not all of fetal/decidual tissue has passed throug cervical os Risk of Retention: --> bleeding, infection Signs: -prolonged bleeding after spontaneous abortion -persistent enlargement of uterus -persistent cervical dilation - infection: painful uterus, foul smelling discharge Treatment: Curettage, ergometrine 0.5 mg iv or im, antibiotics
11 COMPLETE ABORTION/MISCARRIAGE Signs: bleeding stops after miscarriage normal uterus, cervix closed ultrasound normal
12 SEPTIC ABORTION Often caused by induced abortion without medical precautions (or by incomplete abortion) Endometritis ---> PID----> septic shock, sepsis
13 MISSED ABORTION EARLY (< 20 WEEKS) INTRAUTERINE FETAL DEATH -no vaginal bleeding -symptoms/signs of pregnancy disappear -clin. exam/ ultrasound Management: Spontaneous evolution (may take 3 weeks), depending on gestational age and psychological factors Surgical curettage: < or =13 weeks, Medical curettage: > 13 weeks Prostaglandin misoprostol vaginal (
14 RECURRENT MISCARRIAGE = 2 or more clinically recognized miscarriages Causes: 1. genetics (translocation) 2. uterine anomaly (septum) 3. antiphospholipid syndrome 4. unexplained
15 INVESTIGATION RECURRENT MISCARRIAGE Anamnesis: -Familial history of recurrent spontaneous abortion, mors in utero, infertility, genetic disease -Gynecological history of DES exposure mother, cervix manipulations, PID, radiotherapy, anovulation and PCO -Smoking, Alcohol -Description of abortion: time, diagnosis of pregnancy, histology, karyotype Clinical examination: -Length, Weight, Body Mass Index, Metabolic Disease -Hirsutism, Galactorrhea -Cervix: DES, trauma, infection
16 Laboratory Investigation: 1. Karyotype of both partners 2. HSG: detect intrauterine contours, synechia, cx > 6 mm (? cervical incompetence) If required: hysteroscopy and laparoscopy 3. EMB in luteal phase (10 days after LH surge) not within 2 cycles of spontaneous miscarriage diagnosis of luteal insufficiency
17 Laboratory Investigation: 4. LH > 20 IU/L, PCO-like ovaria on US. 5. TSH (T4 if abnormal) 6. Immunology: Anticardiolipin antibodies, Antiphosphatidylserine antbodies (IgG and IgM), Lupus Anticoagulans. 7. Complet formule, Blood Group, Rhesus, Rubella, Toxoplasma 8. Cervical cultures for Mycoplasma, Ureaplasma, Chlamydia, Group B Streptococcus: only indicated if no other abnormalities or anamnesis of PROM or premature labor. 9. Not justified: Antinuclear antibodies, Antipaternal cytotoxic antibodies, HLA profile, MLC reactivity.
18 POSTCONCEPTION MANAGEMENT OF RECURRENT MISCARRIAGE Beta-HCG monitoring: positive 6 days after fertilization; in case of ongoing intrauterine pregnancy: should double each 2-3 days until 10 weeks Ultrasound monitoring: -when HCG titers of IU/L: each second week -exclude ectopic pregnancy (risk x 2), mola hydatiformis; reassure patient -No fetal pool or heart action after 7 weeks: anembryonic pregnancy -No heart action when gestational sac > 15 mm or CRL > 5 mm: missed abortion.
19 SECOND TRIMESTER ABORTION CAUSES: - UTERINE ANOMALY - CERVICAL INCOMPETENCE - FETAL ANOMALY - MULTIPLE PREGNANCY - INFECTION - L.E. INVESTIGATION: - PLACENTA/FETUS: HISTOPATHOLOGY, CULTURE, KARYOTYPE - HYSTEROSALPINGOGRAPHY - MATERNAL FACTOR TREATMENT: - UTERINE ANOMALY: RESECTION SEPTUM,... - CERVICAL CERCLAGE
20 ECTOPIC PREGNANCY Definition: pregnancy outside uterus Localisation: 98% tubal (ampullo-isthmic junction) 2%: ovary, intramural, cervical, pelvic peritoneum very rarely (ovarian stimulation): combined intra- and extrauterine pregnancy Prevalence: 1.5-2%,. Potentially life threatening
21 ECTOPIC PREGNANCY Physiopathology: delayed tubal transport, abnormal placentation with risk of intraabdominal bleeding Risk factors: absent in 50% previous PID: x 6-10 IUD: risk x 7 (relative!) previous tubal surgery/pelvic adhesions Infertility/ ART treatment OAC: no increased risk (? minipill)
22 EVOLUTION: 12% tubal abortion 80% tubal rupture (8-10 weeks) sometimes spontaneous regression rarely: chronic ectopic pregnancy, rarely: advanced abdominal pregnancy, mummification
23 DIAGNOSIS: MAY BE LIFE- SAVING! Risk factors Symptoms: 1. abnormal bleeding pattern hormonal, expulsion decidual cast) 2. 95%: pain, mostly unilateral, not cramping, sometimes with syncope, nausea, vomiting 3. tubal rupture with intra-abdominal bleeding +shock
24 DIAGNOSIS ECTOPIC PREGNANCY - SIGNS: no fever abdominal/bimanual: normal, slight tenderness, painful 30% adnexal mass, 50% adnexal tenderness rarely cullen + or percussion+ - LAB: Hb, Hct? bleeding WBC:? infection HCG:? doubling time
25 Barnhart et al, NEJ M 2009
26
27 DIAGNOSIS ECTOPIC PREGNANCY - VAGINAL ULTRASOUND:.Lack of gestational sac at HCG > iu/ml (5 weeks GA).Adnexal mass - LAPAROSCOPY: early diagnosis DD: torsion, bleeding of functional cl, abortion, pid, appendicitis,...
28 TREATMENT: - SURGICAL: RADICAL: SALPINGECTOMY (laparoscopy, laparotomy) CONSERVATIVE (laparoscopy): Indication: preserve fertility, not ruptured Technique: linear salpingotomy. aspiration (ampulla) Risks: 15% persistent trophoblast ---> MTX medical treatment Fertility prognosis: 84% subsequent tubal patency 70% subsequent intrauterine pregnancy 12% subsequent ectopic pregnancy - MEDICAL: MTX: single dose or multiple dose
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