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| Abortion, spontaneous |
Abortion is the separation of products of conception from the uterus prior to the potential for fetal survival outside the uterus. Gestationally, the point at which potential fetal viability exists has been the subject of much legal and scientific debate, and definitions vary from state to state; however, a "potentially viable" fetus generally weighs at least 500 grams and/or has a gestational age over 20 weeks.
•Spontaneous abortion: refers to expulsion of all (complete abortion) or part (incomplete abortion) of the products of conception from the uterus prior to the 20th completed week of gestation. The placenta, either in whole or in part, can be retained and leads to continuing vaginal bleeding (sometimes profuse). Abortion is "threatened" when vaginal bleeding occurs early in pregnancy, with or without uterine contractions, but without dilatation of the cervix, rupture of the membranes, or expulsion of products of conception. Cervical dilation, rupture of membranes or expulsion of products in the presence of vaginal bleeding portends "inevitable abortion." Differentiation between threatened and inevitable abortion is desirable since management differs.
•Missed abortion: Failed first trimester pregnancy but without the usual signs and symptoms such as bleeding or cramping. Term blighted ovum replaced with anembryonic gestation. Ultrasound findings of "empty sac."
•Induced abortion: refers to the evacuation of uterine contents/products of conception by either medical or surgical methodology
•Infected abortion: infection involving the products of conception and the maternal reproductive organs
•Septic abortion: dissemination of bacteria (and/or their toxins) into the maternal circulatory and organ system
•Habitual spontaneous abortion: three or more consecutive spontaneous abortions. Risk of another spontaneous abortion is approximately 25-30% with 70% rate of successful pregnancy in subsequent pregnancy.
Approximately 2/3 of first trimester spontaneous abortions have significant chromosomal anomalies with 1/2 of these being autosomal trisomies and the remainder being triploidy, tetraploidy, or 45X monosomies
Approximately 10-15% of all clinically recognized pregnancies end in spontaneous abortion. Biochemical pregnancy manifests itself by the presence of β-HCG in the blood 7-10 days after conception. When both clinical and biochemical pregnancies are considered, more than 50% of conceptions are spontaneous aborted. Increases with advancing age, especially after 35 years of age. At age 40, the loss rate is 2 times that of age 20.
SIGNS AND SYMPTOMS:
•In a previously diagnosed intrauterine pregnancy
•Vaginal bleeding
•Uterine cramping
•Cervical dilation
•Ruptured membranes
•Passage of non-viable products of conception
RISK FACTORS:
•Chromosomal abnormalities
•Luteal phase defect
•Leiomyomas
•Incompetent cervix
•Infections
•Antifetal antibodies
•Autoimmune disease - phospholipid syndrome
•Alloimmune disease (shared paternal antigens)
•Drugs, chemicals, noxious agents (alcohol, smoking, caffeine)
•X-irradiation
•Contraceptive IUD
DIFFERENTIAL DIAGNOSIS:
•Ectopic pregnancy: a potentially life-threatening complication, difficult to distinguish from threatened abortion. Transvaginal ultrasonography can identify intrauterine gestational sacs at 32 days of gestation (at serum HCG levels of 1500-2000 IU). The absence of transvaginal ultrasound evidence of an intrauterine gestation with serum HCG over 2000 IU/L should be considered an ectopic pregnancy until proven otherwise.
•Cervical polyps, neoplasias, and/or inflammatory conditions can cause vaginal bleeding. This bleeding is not usually associated with pain/cramping and is apparent on speculum exam.
•Hydatidiform mole pregnancy usually ends in abortion prior to the 20th week of pregnancy. Bloody discharge prior to abortion is common. An intrauterine grape-like appearing mass on the ultrasound is diagnostic (a "snow storm" appearance). Human chorionic gonadotropin (HCG) is often high.
•Membranous dysmenorrhea: characterized by bleeding, cramps and passage of endometrial casts can mimic spontaneous abortion. HCG is negative.
•HCG secreting ovarian tumor
LABORATORY Pocedures:
Cultures - gonorrhea and chlamydia, CBC, Rh type, Human chorionic gonadotropin (HCG), Serial β-HCG measurements can assess viability of the pregnancy. Normal gestations have an approximate 67% increase over 2-day interval. Abnormal gestations do not rise appropriately, plateau, or decrease in level before the eighth week of gestation.
SPECIAL TESTS:
Progesterone levels > 25 ng/mL are consistent with normal intrauterine pregnancy and are rarely seen in ectopic and/or non-viable pregnancy. A progesterone of < 5 ng/mL is an indicator of a nonviable intrauterine gestation or an ectopic pregnancy.
IMAGING:
Ultrasound examination for fetal viability and to rule out ectopic pregnancy. Ultrasound imaging can be sensitive enough to confirm an intrauterine pregnancy in the fourth or fifth gestational week from last menstrual period
DIAGNOSTIC PROCEDURES:
Viable intrauterine pregnancy with fetal cardiac activity detected between 5-8 weeks from last menstrual period on transvaginal ultrasound. Transvaginal ultrasound criteria for nonviable intrauterine gestation include:
•5 mm fetal pole without cardiac activity, or
•16 mm gestational sac without a fetal pole
Fetal heart tones can be auscultated with doppler starting between 10-12 weeks gestation from last menstrual period for a viable pregnancy. Consider a diagnosis of spontaneous abortion in a woman, of childbearing age, presenting with abnormal vaginal bleeding
TREATMENT
APPROPRIATE HEALTH CARE:
Outpatient or inpatient, depending on severity of symptoms (bleeding or pain)
ACTIVITY:
If appropriate, bed rest; probably no effect on eventual outcome
PREVENTION/AVOIDANCE:
•Any vaginal bleeding in intrauterine pregnancy is abnormal and should be considered a "threatened" abortion. In reality, vaginal bleeding in early pregnancy is common (occurring in up to 1/3 of pregnancies) and often the bleeding source eludes diagnosis.
•In habitual abortion, the abortus should be sent for karyotyping. Explore other causes of habitual abortion with the couple to determine the best therapy.
•Special care and attention for the patient who has a subsequent pregnancy
POSSIBLE COMPLICATIONS:
•Complications of D&C include uterine perforation, infection and bleeding
•Possibly retained products of conception
•Depression and feelings of guilt (patient may need education and reassurance that she did not cause the miscarriage)
EXPECTED COURSE AND PROGNOSIS:
•If bleeding ceases, prognosis is excellent.
•Habitual abortion: prognosis is dependent on etiology. After a 2 consecutive abortions, most couples want some investigation of the problem. After 3 spontaneous abortions, evaluation is usually indicated. Prognosis is still excellent with up to 70% rate of success with subsequent pregnancy. |
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| 2 Comments: |
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Doesn't the spontaneous abortion rate rise with the age of the father too? http://www.genetics.uab.edu/Education/Graduate/Genomics09-06-06.pdf
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You are correct:-)
The frequency of chromosomal anomalies in spermatozoa appears to increase with male age. Because these anomalies play a role in the etiology of spontaneous abortion, an influence of paternal age on risk of spontaneous abortion is plausible but not established. The authors characterized this influence in a prospective study among 5,121 California women, who as members of a prepaid health plan were interviewed in 1990 or 1991 when they were less than 13 weeks' pregnant and who were followed until the end of pregnancy. The risk of spontaneous abortion between weeks 6 and 20 of pregnancy was studied using a Cox model adjusted for maternal age. The adjusted hazard ratio of spontaneous abortion associated with paternal age of 35 years or more, compared with less than 35 years, was 1.27 (95% confidence interval: 1.00, 1.61), with no modification by maternal age. Among women aged less than 30 years, the hazard ratio of spontaneous abortion associated with paternal age of 35 years or more was 1.56 for first trimester spontaneous abortion and 0.87 for early second trimester spontaneous abortion (test of interaction, p = 0.25).
Finally they concluded that the risk of spontaneous abortion increased with increasing paternal age, with a suggestion that the association is stronger for first trimester losses.
Reference:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15840613&query_hl=3&itool=pubmed_docsum
Dr. Rafael
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Doesn't the spontaneous abortion rate rise with the age of the father too? http://www.genetics.uab.edu/Education/Graduate/Genomics09-06-06.pdf