Final case protocol 'abortion

UPH – Dr. Jose G. Tamayo Medical UniversityDEPARTMENT OF OBSTETRICS &

GYNECOLOGY

OB-GYNE CASEPRESENTATION

ABEGAIL M. ATIENZAOB-GYNE CLERK

GENERALDATA

single

G3P2 (1112)

26y/o

Filipino

Catholic

Admitted for the first time onJuly 11, 2013 at 10:36 AM

CHIEFCOMPLAINT

VaginalBleeding

Residing at Pacita, Laguna

(-) Diabetes Mellitus(-) Hypertension(-) Previous hospitalization(-) Previous surgical operation

PAST MEDICAL HISTORY

(+) Bronchial Asthma, Mild Intermittent

Last Attack: 12 years old

(+) Hypertension –Both Parents(-) Diabetes Mellitus(-) Asthma(-) Cancer(-) Pulmonary Tuberculosis

FAMILY HISTORY

(+) waitress(+) single(+) living in with a 27 year old laborer

PERSONAL & SOCIAL HISTORY

(-) smoker(-) alcoholic drinker(-) allergy to food/drugs

M

MENSTRUAL HISTORY

12 years old, lasting for 5 daysI 28-30 days interval

D 5 days duration

A 3-4 regular napkin pads/day, fully-soakedS (-) dysmenorrhea

(+) 1st coitus at 18 years old(+) with single partner

SEXUAL HISTORY

(-) post-coital bleeding(-) dyspareunia

(-) history of contraceptive use

CONTRACEPTIVE HISTORY

GYNECOLOGICAL HISTORY

(-) leukorrhea(-) vaginal pruritus(-) pap smear

OB Score: G3P2 (1112)

OBSTETRICAL HISTORY

G1 2007 Live baby boy Premature10days incubated

7 lbs. Family Care Hospital

G2 2009 Live baby girl Normal spontaneous delivery

6 lbs. Gavino Alvarez Lying In

G3 2013 Present pregnancy

LMP: April 15, 2013 PMP: March 2013 AOG: 12 3/7 weeks AOG by LMP EDC: January 20, 2014

5 Weeks amenorrhea (+) Pregnancy Test 1st prenatal check up at a

health center Urinalysis done - revealed

normal result Given Ferrous Sulfate and

Multivitamins Lost to follow up

PRE-NATAL HISTORY

3 DAYS PTA

Vaginal Bleeding

consuming 3 fully-soaked regular napkin pads

with episodes of blood clots

NO MEDICATIONS TAKEN.NO CONSULTATION DONE.

• Vaginal bleeding• Consuming 1 fully-soaked

regular napkin pad

• sought consult at the ER• advised for admission

1 DAY PTA(JULY 10, 2013)

ADMITTED

REVIEW OF SYSTEMSCNS: (-) loss of consciousness, (-) headache,

(-) dizzinessCVS: (-) chest pain, (-) palpitation,(-) easy fatigabilityRESP: (-) dyspnea, (-) cough/colds, (-) wheezingGIT: (-) vomiting, (-) nausea (-) heartburn, (-) diarrhea/constipationGUT: (-) dysuria, (-) polyuria, (-) hematuriaHEMA: (-) bleeding tendencies,(-) easy bruisabilityMS: (-) limitation of movements

PHYSICAL EXAMINATIONGeneral Survey: conscious, coherent, ambulatory, agitated and

not in cardiorespiratory distress.Vital Signs: BP: 120/80 mmHg RR: 19 cpm

HR: 80 bpm Temp.: 36.70CSkin: warm to touch, good skin turgor, no pallor, no jaundiceHEENT/Neck:

Eyes: anicteric sclerae, pink palpebral conjuctivaeEars: no mass, no tenderness, no dischargeNose: (-) nasal flaring, (-) nasoaural dischargeMouth: moist lips & oral mucosa, (-) tonsilopharyngeal congestionNeck: (-) cervical lymphadenopathy

Chest/Lungs: symmetrical expansion, (-) retractions, clear breath soundsHeart: adynamic precordium, regular rate and rhythm, no murmurAbdomen: flabby, normoactive bowel sounds, non-tenderExtremities: grossly normal, full and equal pulses, CRT <2 sec.

Pelvic ExaminationI: parous introitus

SE: cervix violaceous, smooth, (+) placental tissues plugging per os

IE: cervix open, uterus at 12 weeks size, (-) bilateral adnexal mass and tenderness, (-) cervical motion tenderness

ADMITTING DIAGNOSISG3P2 (1112) Incomplete Abortion

12 3/7 weeks AOGNon-Septic, Non-Induced

Anemia secondary to Acute Blood Loss

• Incomplete Abortion = cervical os open

• Non septic non induced= no intake of abortifacient

• Anemia secondary to Acute blood loss= vaginal bleedingHgb threshold1 g/dL = 0.6206 mmol/L

Hb threshold (g/dl)11.0

Hb threshold (mmol/l)6.8

BASIS FOR DIAGNOSIS

Chief Complaint of VAGINAL BLEEDING

SALIENT FEATURES

Pelvic Exam: cervical os open, (+) placental tissues plugging per os

Uterus at 12 weeks size

3 days history of vaginal bleeding, consuming 3 fully-soaked regular napkin pads

No medications taken

26 y/o G3P2(1112)

LMP: April 15, 2013 AOG: 12 3/7 weeks (+) pregnancy test at

5 weeks amenorrhea Irregular pre-natal

check-up (lost to follow-up)

No abortifacients taken

Incomplete Abortion

Ectopic Pregnancy Hydatidiform Mole Threatened Abortion Inevitable Abortion Complete Abortion

DIFFERENTIAL DIAGNOSIS

DIFFERENTIAL DIAGNOSIS

ECTOPIC PREGNANCYRule In: 5 weeks amenorrhea Vaginal bleeding Positive Pregnancy Test Usually occurs <28 weeks AOG Presence of gestational sac in TV-UTZ

Rule Out: No abdominal pain noted (usually

hypogastric, colicky in character) No palpable adnexal mass (-) Wiggling tenderness or cervical

motion tenderness

HYDATIDIFORM MOLERule In: (+) Pregnancy Test Vaginal bleeding Absence of fetal heart tones upon

doppler ultrasound

Rule Out: Uterus inconsistent with gestational

age No hyperemesis No increased BP and proteinuria (Pre-

eclampsia) Sandstorm appearance in UTZ

Ectopic Pregnancy

• implantation of a fertilized egg in a location outside of the uterine cavity, including the ff:– fallopian tubes (approximately 97.7%),– cervix, ovary,– cornual region of the uterus,– abdominal cavity.– Of tubal pregnancies, the ampulla is the most

common site of implantation (80%), followed by the isthmus (12%), fimbria (5%), cornua (2%), and interstitia (2-3%).

Hydatidiform Mole

• a rare mass or growth that forms inside the womb (uterus) at the beginning of a pregnancy

• a type gestational trophoblastic disease (GTD) A cancerous form of GTD is called choriocarcinoma.

DIFFERENTIAL DIAGNOSIS

THREATENED ABORTIONRule In: (+) Pregnancy Test Vaginal bleeding (-) Uterine contraction

Rule Out: Usually presents with

closed cervix (-) Uterine size

compatible with gestational age

(-) Intact bag of water FHT was no longer

appreciated

INEVITABLE ABORTIONRule In: Vaginal bleeding Open cervical os Uterine size is

incompatible with gestational age

Rule Out: (-) Uterine

Contraction Bag of water is usually

ruptured but BOW in this case was not appreciated

No FHT

COMPLETE ABORTIONRule In: No uterine contraction

noted Vaginal bleeding Uterine size

incompatible with gestational age

BOW not appreciated

Rule Out: Absent signs of

pregnancy Closed cervical os

INCOMPLETE ABORTION

RULE IN

5 weeks amenorrhea Positive Pregnancy Test No uterine contraction 3 day history of vaginal bleeding Open cervical os Uterine size incompatible with

gestational age Bag of water not appreciated Retained tissues characterized as

“meaty material”

BACKGROUND

Internal cervical os opens and allows passage of blood

Fetus and placenta may remain entirely in utero or may partially extrude through the dilated os

Vaginal bleeding Absence of fetal heart tones

upon doppler ultrasound Bleeding ensues when the

placenta, in whole or in part, detaches from the uterus

ABO and RH Typing:“O” Rh (D) Positive

HBSAg Screening :Non Reactive

LABORATORY WORK-UPS

CBC with Platelet Count

LABORATORY WORK-UPS

WBC: 15.4 RBC: 1.77 RDW: 12.5

Neutrophils: 12.2 HGB: 85 MCV: 98.9

Lymphocyte: 15.6% Hct: .175 MCH: 32.3

Monocytes: 4.41% Eosinophils: .282% MCHC: 327.

Basophils: .705% Platelet: 473

S O A P

Stable vital signs(+) palmar pallor(+) pale palpebral

conjunctiva

conscious, coherent, not in cardio respiratory distressanicteric sclera

pale palpebral conjuctiva no tonsillopharyngeal congestion no cervicolymphadenopathy no nasoaural discharge clear breath sounds, symmetrical chest

expansion no retractions adynamic precordium normal rate regular rhythm no murmurs Flat, soft, nontender grossly normal extremities no cyanosis no edema full and equal pulses

G3P2 (1112) Incomplete Abortion 12 3/7weeks AOGby uterine size, Non septic non inducedCompletion curettage under GA-IV, Anemia secondary to Acute blood loss on going correction awaits histopath

Diet on NPO IVF: D5LR 1L x 8hours BT line: PNSS 1LxKVO CBCwith platelet and

Urinalysis HBSAg and Bloodtyping

done

Medications:

Ceftriaxone 1amp IV ()ANST Diphenhydramine 1 amp IV

prior to BT BT of 2units PRBC properly

typed and crossmatched

COURSE IN THE WARD

UPON ADMISSION

Internal Examination:OpenUterus slightly enlargedMinimal bleeding per osWith blood clotsNo adnexal mass

COURSE IN THE WARD

Intraoperative Findings:Obtained 1 tablespoon of

placental tissues admixed with blood

Non friable Non foul smelling Estimated blood loss

approximately 80cc

COURSE IN THE WARD

S O A P

Stable vital signsNot yet voiding

freelyPost BT of 2 ‘u’ PRBC

done

conscious, coherent, not in cardio respiratory distressanicteric sclera

pale palpebral conjuctiva no tonsillopharyngeal congestion no cervicolymphadenopathy no nasoaural discharge clear breath sounds, symmetrical chest

expansion no retractions adynamic precordium normal rate regular rhythm no murmurs Flat, soft, nontender grossly normal extremities no cyanosis no edema full and equal pulses

G3P2 (1112) Incomplete Abortion 12 3/7weeks AOGby uterine size, Non septic non inducedCompletion curettage under GA-IV, Anemia secondary to Acute blood loss on going correction awaits histopath

Post curettage medications:

Cefuroxime 500mg / tab 1 tab BID

Mefenamic Acid 500mg tab q12 x 7days

Patient placed on moderate high back rest

Oral fluid intake was increased

COURSE IN THE WARD

2 HOURS POST-CURETTAGE

S O A P

Stable vital signsvoiding freelyScanty vaginal

bleedingNo hypogastric

pain

conscious, coherent, not in cardio respiratory distressanicteric sclera

pale palpebral conjuctiva no tonsillopharyngeal congestion no cervicolymphadenopathy no nasoaural discharge clear breath sounds, symmetrical chest

expansion no retractions adynamic precordium normal rate regular rhythm no murmurs Flat, soft, nontender grossly normal extremities no cyanosis no edema full and equal pulses

G3P2 (1112) Incomplete Abortion 12 3/7weeks AOGby uterine size, Non septic non inducedCompletion curettage under GA-IV, Anemia secondary to Acute blood loss on going correction awaits histopath

Diet was Regular diet IVF: D5LR 1L x 8hours H&H repeated 10 hrs

post BT Vital signs monitored

every 4 hoursOral medications: Cefuroxime 500mg tab 1

tab BID Mefenamic acid 500mg

cap 1 cap TIDHOME MEDICATIONS:

COURSE IN THE WARD

1ST HOSPITAL DAY

FIRST HOSPITAL DAY• Results were normal and advised to go

home

• HOME MEDICATIONS: Cefuroxime500mg / tab 1 tab BID

Mefenamic Acid 500mg tab q12 x 7days

COURSE IN THE WARD

G3P2 (1112) Incomplete Abortion 12 3/7weeks AOG; Non-septic, Non- induced; Anemia secondary to Acute blood loss on going correction awaits histopathology results

FINAL DIAGNOSIS

ABORTION

Discussion

a·bort (-bôrt) To terminate (a pregnancy) To cause by expulsion (an embryo or fetus) To miscarry (an embryo or fetus)

Abortus- a fetus or embryo removed or expelled from the uterus during the first half of gestation—20 weeks or less—and weighing less than 500 g.

WHAT IS ABORTION?

Spontaneous Abortion• Abortion occurring without medical or

mechanical means to empty the uterus

Induced Abortion• the medical or surgical termination of

pregnancy before the time of fetal viability

TYPES OF ABORTION

• Increases with parity• Associated with paternal and

maternal age• Incidence of abortion increases if a

woman conceives within 3 months following a term birth

RISK FACTORS

• More than 80 percent of abortions occur in the first 12 weeks of pregnancy

• Half result from chromosomal anomalies• After the first trimester

both the abortion rate and the incidence of chromosomal anomalies decrease.

ETIOLOGY

Abnormal Zygotic DevelopmentAneuploid Abortion • Abnormal number of chromosomes50-60% of embryos and early fetusesthat are spontaneously aborted contain chromosomal abnormalities, accounting for most of early pregnancyEuploid Abortion• Abnormal development w/a normal

chromosomal complement• incidence increase dramatically after age of 35

FETAL FACTORS

InfectionsChronic Debilitating DiseasesNutritionDrug Use and Environmental FactorsImmunological FactorsInherited ThrombophiliaUterine DefectsIncompetent Cervix

MATERNAL FACTORS

Infections Uncommon causes of abortion in human:

Listeria monocytogenes Clamydia trachomatisMycoplasma hominis Ureaplasma urealyticumToxoplasma gondii

MATERNAL FACTORS

Chronic debilitating diseases• In early pregnancy, fetuses seldom abort

secondary to chronic wasting disease such as tuberculosis or carcinomatosis

• Celiac sprue

MATERNAL FACTORS

Endocrine abnormalitiesHypothyroidism • Iodine deficiency associated with excessive

miscarriages• Thyroid autoantibodies → incidence of abortion↑Diabetes mellitus• The rates of spontaneous abortion & major

congenital malformations• Poor glucose control → incidence of abortion↑Progesterone deficiency• Luteal phase defect• Insufficient progesterone secretion by the corpus

luteum or placenta• Poor glucose control → incidence of abortion↑

MATERNAL FACTORS

NutritionDietary deficiency of any one nutrients → not important cause

Drug use and environmental factorTobacco

↑ Risk for euploid abortion More than 14 cigarettes a day → the risk twofold greater ↑

AlcoholSpontaneous abortion & fetal anomalies → result from frequent alcohol use during the first 8 weeks of pregnancyDrinking twice a week → abortion rates doubled ↑Drinking daily → abortion rates tripled ↑

CaffeineAt least 5 cups of coffee per day → slightly increased risk of abortion

MATERNAL FACTORS

Drug use and environmental factorRadiation

In sufficient doses → abortifacientContraceptives

When intrauterine devices fail to prevent pregnancy → abortion↑

Environmental toxinsAnesthetic gases : exact fetal risk of chronic maternal exposure is unknownArsenic, lead, formaldehyde, benzene, ethylene oxide → abortifacientVideo display terminal & accompanying electromagnetic fields *short waves & ultrasound do not increase the risk of abortion

MATERNAL FACTORS

• abnormalities in sperm have been associated with abortion

PATERNAL FACTORS

• Hemorrhage into the decidua basalis, followed by necrosis of tissues adjacent to the bleeding

PATHOLOGY

Early Abortion• Ovum detaches , stimulating uterine

contractions that results in expulsion• When Gestational sac is opened, fluid is

commonly found surrounding a small macerated fetus, or alternatively no fetus is visible—the so-called blighted ovum.

PATHOLOGY

Late Abortion• The retained fetus may undergo

maceration, in which the skull bones collapse, the abdomen distends with blood-stained fluid, and the internal organs degenerate

• fetus compressus, fetus papyraceous

PATHOLOGY

Threatened Abortion Inevitable Abortion Complete and

Incomplete Abortion Missed Abortion

CATEGORIES OF ABORTION

Symptoms Usually bleeding begins firstCramping abdominal pain follows a few hours to several days laterPresence of bleeding & pain

→ Poor prognosis for pregnancy continuation

Treatment Bed rest & acetaminophen-based analgesia Progesterone (IM) or synthetic progestational agent (PO or IM)D-negative women with threatened abortion

Probably should receive anti-D immunoglobulin

Threatened Abortion

Treatment after death of conceptus

Uterus should be emptied → examination of all passed tissue whether the abortion is complete

Threatened Abortion

Gross rupture of membrane, evidenced by leaking amnionic fluid, in the presence of cervical dilatation, but no tissue passed during 1st half of pregnancy

Placenta (in whole or in part) is retained in the uterus → Uterine contractions begin promptly or infection develops

The gush of fluid is accompanied by bleeding, pain, or fever, abortion should be considered inevitable

Inevitable Abortion

Complete abortion Following complete detachment & expulsion of the conceptusThe internal cervical os closes

Incomplete abortionExpulsion of some but not all of the products of conception during 1st half of pregnancyThe internal cervical os remains open & allows passage of blood→ Remove retained tissue without delay

Complete & Incomplete Abortion

Definition: Three or more consecutive spontaneous abortionsClinical investigation of recurrent miscarriage

Parental cytogenetic analysisLupus anticoagulant & anticardiolipin antibodies assays

Postconceptional evaluationSerial monitoring of ß–hCG from missed mens period

ß–hCG>1500mIU/ml → USGMaternal serum α-fetoprotein assessment (GA16-18wks)Amniocentesis → fetal karyotype

Recurrent Abortion

• nonviable intrauterine pregnancy that has been retained within the uterus without spontaneous abortion

• Typically, no symptoms exist besides amenorrhea

• Patient finds out that the pregnancy stopped developing earlier when a fetal heartbeat is not observed or heard at the appropriate time

Missed Abortion

• Early pregnancy appears to be normal• After fetal death, there may or may not be

vaginal bleeding or other symptoms of threatened abortion

• Uterus becomes gradually smaller

Missed Abortion

• No increase in fundic height• Absence of FHT• Regression of changes in pregnancy• Loss of weight

Missed Abortion

• Many women have no symptoms except persistent amenorrhea

• Uterus remain stationary in size, but mammary changes usually regress → uterus become smaller

• Most terminates spontaneously• Serious coagulation defect occasionally

develop after prolonged retention of fetus

CLINICAL MANIFESTATIONS

• TRANSVAGINAL ULTRASOUND• Absence of any growth of the gestational

sac or fetal pole over a 5-day period of observation.

• Gestational sac larger than 12 mm mean diameter (around 5 weeks 5 days) without visual evidence of a yolk sac.

DIAGNOSTICS

• TRANSVAGINAL ULTRASOUND Absence of a visible fetal heartbeat when

the crown-rump length (CRL) is greater than 5 mm.

Yolk sac larger than 6 mm diameter Yolk sac that is abnormally shaped or

echogenic (sono dense rather than the normal sono lucent).

No fetal cardiac activity

DIAGNOSTICS

DIAGNOSTICS

• DILATATION ANG CURETTAGEDilatation and curettage

Hygroscopic dilators : swell slowly & dilate cervix → cervical trauma can be minimizedLaminaria tents : stem of brown seaweed ( Laminaria digitata or japonica)

→ drawing water from proteoglycan complexes of cervix → dissociation allow the cervix to soften & dilate

Insertion technique : tip rests just at the level of internal osUsually after 4-6hours, laminaria dilate the cervix sufficiently to allow easier mechanical dilation & curettageMay cause cramping pain → easily managed with 60 mg codeine every 3-4 hours

SURGICAL MANAGEMENT

• DILATATION ANG CURETTAGETechnique for dilatation & curettage

Remove laminaria → Uterus is sounded carefully to

Identify the status of the internal os

Confirm uterus size & position

Further dilation of cervix with Hegar dilator

SURGICAL MANAGEMENT

SURGICAL MANAGEMENT

• Pathology results from specimen sent from an early pregnancy should reveal chorionic villi.

HISTOLOGIC FINDINGS

Complications : uterine perforation2 important determinants

Skill of the physicianPosition of the uterus (retroverted)

• Small defects by uterine sound or narrow dilator→ often heal without complication

• Suction & sharp curettage → Considerable intra-abdominal damage risk↑→ Laparotomy to examine abdominal content (safest action)

• Other complications – cervical incompetence or uterine synechiae

SURGICAL MANAGEMENT

• MIFEPRISTONE- anti- progestin• METHOTREXATE- anti- metabolite• MISOPROSTOL- PG E1

• These agents increases uterine contractility• MOA: reversing the progesterone-induced

inhibition of contractions• stimulating the myometrium directly

MEDICAL MANAGEMENT

OxytocinSuccessful induction of 2nd trimester abortion is possible with high doses of oxytocin administered in small volumes of IV fluids

Satisfactory alternatives to PG E2 for midtrimester abortion

Laminaria tents inserted the night beforeChance of successful induction is greatly enhanced

MEDICAL MANAGEMENT

ProstaglandinsUsed extensively to terminate pregnancies, especially in the 2nd T

PG E1, E2, F2αTechnique: Can act effectively on the cervix & uterus (86~95% effectiveness)

Vaginal prostaglandin E2 suppository & prostaglandin E1 (misoprostol)As a gel through a catheter into the cervical canal & lowermost uterusInjection into the amnionic sac by amniocentesisParenteral injectionOral ingestion

MEDICAL MANAGEMENT

TypesUterine

contraction Bleeding Cervical dilatation

Uterine size vs.

gestation BOWOther

findings

Threatened +/- +/- Closed Compatible Intact (+)FHT

Imminent ++ + Open Compatible Intact (+)FHT

Inevitable +++ ++ Open Incompatible Ruptured (+)FHT

Incomplete +/- ++ Open Incompatible Ruptured or

Not appreciated

MEATY TISSUE

Complete - +/- Closed Incompatible Not appreciated

Abs signs of

preg.

Missed - Spotting Closed Incompatible Notappreciated

(-) FHT

Habitual +/- + + Compatible +/- (+) FHT

TYPES OF ABORTION

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