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1、SPONTANEOUS ABORTIONINTRODUCTION Loss of pregnancy 20 weeks or 500g Incidence of 15% of clinically recognized pregnancies Incidence of 30 - 50% of overall pregnancies Rates dramatically decrease after documentation of FHR with 8wk U/S (3-5%) PV bleeding occurs in 25% of pregnancies PV bleeding (earl
2、y) leads to abortion rate of 30 - 50% 80% of abortions occur in the 1st trimester Definitions ( 25 mm with no fetal poleComplete abortion cannot be diagnosed unless an intact gestational sac is seen, pathologic confirmation of POCs on D&C specimen, or conversion of pregnancy test to negative (4weeks
3、)CLINICAL FEATURES History Gestational age, LMP, ectopic RF, syncope, blood type Pain, bleeding, fever, cramps Threatened abortion has dull ache b/c uterus not contracting; inevitable and incomplete have crampy pain b/c uterus is contracting; no pain w/ complete Physical Exam Vitals: stable? orthost
4、atic changes? fever? Abdomenal exam: masses, peritonitis, tenderness Pelvic: cervix open, bleeding, tissue, uterus size/tenderness, adnexal mass or tenderness, remove tissue present in vagina or cervix, may probe cervix gently if open to search for tissue and to see if internal os is open (not in 2n
5、d b/c risk of low placenta) Investigations CBC, Type and screen (? needs rhogam): crossmatch if unstable BHCG: urine qualatative, serum quantitative Blood cultures if fever/septic Saline preparation of tissue: chorionic villi, present in 50%, rules out ectopic except in rare circumstance of co-exist
6、ing ectopic and IUP Other: CA-125, low progesterone, low urinary HCG have been used as indicators of miscarriage Ultrasound all should get an ultrasound b/c of possibility of ectopic no FHR = fetal loss only if length 15mm or gest sac 25mm unstable: to OR without ultrasound stable: urgent ultrasound
7、 or RTED in am for ultrasound (significant pain or bleeding should not be sent home) NO FHR: careful distinction b/w fetal loss vs too early to see fhr Differential Diagnosis: PV bleed Early pregnant: abortion, ectopic, “normal pregnancy bleeding”, corpus luteum cyst, molar pregnancy Late pregnant:
8、abruption, placenta previa, vasa previa, uterine rupture, PTL NonPregnant: PID, DUB, anovulatory bleeding, trauma, etc Ovarian torsion: adnexa pain bleeding, increased risk in early pregnancyMANAGEMENT Make sure to give Rhogam to all Rh-ve patients (50ug 1st trimester, 300ug thereafter) May require
9、urgent OR for D&C or laparotomy/laparoscopy with heavy bleeding Ultrasound for all: safe for u/s within 48hrs if minimal pain, minimal bleeding, easy to RTED, no strong risks for ectopic, no strong findings of ectopic (unilateral pain, tenderness, mass) Threatened Abortion Discharge home NO D&C Seri
10、al U/S and BHCG if no definitive IUP seen on u/s (r/o out ectopic) Inevitable/Incomplete Abortion D&C for: significant bleeding or pain, suspected infection, patient preference Observation: rule out ectopic and let nature take its course, ensure follow up Complete Abortion (presumed) Send tissue to
11、pathology; usually NOT obviously POCs D&C: significant bleeding, pt preference, infected (some do routinely) Observation: BHCG level 1000, no endometrial tissue on U/S, mild bleeding, gestational age 8 wks Follow serial BHCG b/c could be ectopic Missed Abortion D&C: significant bleeding, pain, pt pr
12、eference (decreased risk of infection, bl) Observation: same as above Septic Abortion Admission for Mx of sepsis with iv Abx and fluids/etc Gram +ves, -ves, anaerobes, STD bugs: clindamycin + gentamycin Needs D&C as emergent procedure Discharge Advice RTED: pain, bleeding, syncope, fevers F/U: for u
13、ltrasound, serial BHCG, pregnancy test at 4wks to r/o retained POCs Education: reassurance, normal ADLs OK for threatened abortion, no sexual activity or tampons while bleeding, keep tissue if passing any, common problem, not the fault of the patient Hemorrhagic Shock from presumed Miscarriage Large ivs, fluid, +/- blood, crossmatch, check coags, STAT O/G consult Oxytocin 20 - 40 units/ 1L NS: run at 500-1000 ml/hr Uterine contraction and vasoconstriction Methyergonovine 02. Mg im/po/iv Vasoconstriction and increased uterine contractions Wa
