Pregnancy Loss

Duration 9:49


Duration 19:40


Duration 13:41

00:00
hi this is dr. Jane Lamar gonna be
00:02
talking about abortion the learning
00:07
objectives for this talk are as follows
00:09
to understand the difference between
00:11
their appearing and spontaneous abortion
00:13
to note the different types of
00:16
spontaneous abortions
00:17
trivita risk factors for spontaneous
00:20
abortion to understand how should
00:22
spontaneous abortions be managed and how
00:24
therapeutic abortions are performed and
00:26
to know the possible complications of
00:28
both types of abortion
00:32
the talk will proceed as follows we will
00:35
review the types etiology and management
00:38
of spontaneous abortion the types of
00:39
induced abortion and the complications
00:41
of both spontaneous abortion is more
00:46
commonly known as miscarriage it is
00:49
defined as pregnancy loss prior to 20
00:51
weeks gestation such pregnancy loss
00:54
occurs far more frequently than most
00:55
people think and it is estimated that 50
00:57
to 70 percent of all pregnancies end in
00:59
miscarriage the majority of these losses
01:02
occur before women even realize they are
01:04
pregnant approximately 20% of clinically
01:07
recognized pregnancies end in
01:09
spontaneous abortion it is estimated
01:11
that 80% of spontaneous abortions occur
01:14
in the first trimester of pregnancy
01:15
prior to 12 weeks gestation spontaneous
01:21
abortion is further categorized into
01:23
subtypes based on whether the cervix is
01:25
open or closed and whether or not the
01:27
fetus is alive moreover there are some
01:30
fertilization events that will lead to
01:31
growth of pregnancy tissue but never
01:33
develop a fetal pole known as an
01:36
embryonic gist stations or blighted ovum
01:38
‘z these pregnancies also fall under the
01:40
category of spontaneous abortion if a
01:44
woman experiences vaginal bleeding but
01:46
has a live fetus for potentially viable
01:48
early first trimester pregnancy the
01:50
speculum exam should be performed if the
01:53
cervix is closed the patient is having a
01:55
threatened abortion if the service is
01:58
open the abortion is considered
02:00
inevitable and the patient should be
02:01
offered some type of intervention to
02:03
complete the abortion we will discuss
02:05
this further later in the presentation
02:07
in comparison if a patient experiences
02:10
fetal demise the type of spontaneous
02:12
abortion depends on whether or not the
02:14
fetal tissue remains in the uterus if
02:16
all fetal and placental tissue remains
02:18
the patient has a missed abortion
02:23
some tissue has passed but still remains
02:25
the patient has an incomplete abortion
02:27
finally if the patient has had a fetal
02:30
demise and has passed all the pregnancy
02:31
tissue the abortion is categorized as
02:34
complete some patients will develop
02:37
intrauterine or even systemic infections
02:39
associated with a spontaneous abortion
02:41
often characterized by fevers and
02:43
abdominal pain
02:45
these patients are described as having
02:47
septic abortion finally women who
02:51
undergo three spontaneous abortions in a
02:53
row with no intervening normal pregnancy
02:56
are described as having recurrent
02:58
abortions these women should be worked
03:00
up for causes of recurrent miscarriage
03:04
although the etiology of many
03:06
spontaneous abortions is never known
03:08
there are certain conditions that
03:10
commonly end in pregnancy loss these
03:13
conditions may be specific to the fetus
03:15
or the mother or the mother’s
03:17
environment certain conditions are more
03:20
likely to cause pregnancy loss at
03:21
certain gestational ages for example
03:25
losses at less than 10 weeks gestation
03:27
are usually related to a chromosomal
03:29
anomaly in the fetus in contrast uterine
03:33
anomalies and cervical insufficiency
03:35
typically result in fetal loss in the
03:37
mid second trimester after 18 weeks
03:40
within chromosomal anomalies
03:41
specifically which caused the majority
03:43
of spontaneous pregnancy losses
03:45
autosomal trisomy or 3 copies of a
03:48
chromosome is the most common
03:50
abnormality trisomy 16 and trisomy 22
03:55
occur most frequently it is postulated
03:59
that single gene mutations may also be
04:01
responsible for the loss of chromosomal
04:03
a normal pregnancies several maternal
04:06
conditions place women at risk for
04:08
pregnancy loss first structural
04:12
anomalies in the uterus both congenital
04:14
and acquired can create an inhospitable
04:16
environment for fetal growth and
04:17
development for example septate uterus
04:20
is the most common uterine anomaly
04:22
associated with spontaneous abortion
04:25
other such anomalies include bicornuate
04:27
uterus uterine fibroids and intricate
04:30
arias Aniki eye or scar tissue from
04:32
prior surgeries cervical insufficiency
04:36
is painless cervical dilation leading to
04:39
delivery of a non-viable fetus in the
04:41
second trimester
04:43
in addition there are multiple medical
04:46
conditions such as hypothyroidism and
04:48
poorly controlled diabetes mellitus that
04:50
may predispose a woman to spontaneous
04:52
abortion it is important to note that
04:55
many women with these conditions carry
04:57
successful pregnancies maternal
05:00
thrombophilia is in which women have an
05:02
increased tendency to form blood clots
05:03
such as antiphospholipid antibody
05:06
syndrome can lead to pregnancy loss
05:08
likely by damaging the placental
05:10
vasculature
05:12
moreover certain infections in the
05:14
cervix uterus and or semen have been
05:16
associated with spontaneous abortion
05:18
these include chlamydia gonorrhea urea
05:20
plasma mycoplasma Staphylococcus and
05:23
streptococcus
05:24
in addition maternal infection with
05:27
Listeria toxoplasmosis parvovirus b19
05:32
varicella cytomegalovirus rubella and
05:36
primary herpes simplex can cause
05:38
pregnancy loss
05:41
there are also modifiable factors in the
05:43
maternal environment that may lead to an
05:45
increased risk of miscarriage
05:46
these include maternal tobacco and
05:49
alcohol use and radiation exposure
05:53
finally some women are carriers of
05:55
balanced translocations such that they
05:58
may have a normal number of chromosomes
05:59
but their offspring often will not
06:04
if a spontaneous abortion is not
06:07
complete at the time of diagnosis
06:08
sometimes intervention is required the
06:11
need for active management of a
06:13
pregnancy loss depends upon the presence
06:14
or absence of heavy bleeding the
06:16
presence or absence of infection the
06:18
gestational age of the pregnancy the
06:21
patient’s medical history and the
06:23
patient’s wishes in the setting of
06:26
infection and/or heavy vaginal bleeding
06:28
with hemodynamic instability surgical
06:31
intervention to empty the uterus is
06:32
always indicated this can be
06:35
accomplished with manual or surgical
06:37
vacuum aspiration pregnancies that later
06:40
than nine weeks gestation are more
06:42
likely to require surgical intervention
06:43
in order to complete the passage of all
06:45
pregnancy tissue simply because of the
06:47
amount of tissue present it is estimated
06:50
that a missed or incomplete abortion who
06:52
will pass between 52 to 84 percent of
06:54
the time with no intervention depending
06:56
on how long the patient waits for the
06:58
tissue to pass
07:00
if a patient elects for medical
07:02
management of pregnancy loss most
07:03
commonly misoprostol a prostaglandin e1
07:06
analog is prescribed
07:08
this causes both cervical softening and
07:11
dilation as well as uterine contractions
07:13
to expel the pregnancy tissue women with
07:16
pregnancies less than 12 weeks gestation
07:18
can complete a spontaneous abortion at
07:20
home using music rosto if they elect to
07:22
do so in contrast medical management of
07:25
a spontaneous abortion greater than 12
07:27
weeks should be performing or close
07:29
monitoring in the hospital due to an
07:31
increased risk of heavy bleeding
07:33
with all patients who undergo
07:35
spontaneous abortion it is crucial to
07:37
check a blood type and administer rhogam
07:39
if the mother is Rh negative in order to
07:41
prevent ISO immunization in future
07:43
pregnancies in contrast to spontaneous
07:48
abortion induced abortion is the medical
07:51
or surgical termination of a live
07:52
pregnancy induced abortions are
07:55
sometimes also referred to as
07:56
therapeutic abortions when they are
07:58
performed because of risk to a woman’s
08:00
health or lethal fetal anomalies when
08:03
asked why they are choosing to terminate
08:04
a pregnancy
08:05
the most common response that women give
08:07
is either responsibility to other family
08:09
members or economic constraints it is
08:13
estimated that 50% of pregnancies in the
08:15
United States are unplanned and four out
08:18
of ten of these pregnancies end in
08:20
abortion
08:21
it is important that women who have an
08:23
unplanned pregnancy are counseled on all
08:25
possible options which would include
08:27
continuing the pregnancy terminating the
08:29
pregnancy or giving the infant up for
08:31
adoption
08:34
methods for pregnancy termination are
08:36
similar to those for managing a
08:37
spontaneous abortion though there are
08:39
some key differences medication
08:42
terminations can be performed up to 63
08:44
days or nine weeks gestation depending
08:47
on the regimen that is used most
08:49
commonly these are performed with a
08:51
combination of mythic Prestone which is
08:53
given first and music crustle which is
08:55
taken at home 24 to 72 hours later with
08:59
a Chris stone a competitive progesterone
09:02
receptor antagonist interrupts the
09:04
endometrial lining that is supporting a
09:06
growing pregnancy and sensitizes the
09:08
myometrium to prostaglandins thereby
09:11
making these apostille more effective
09:14
pregnancies in the first trimester that
09:16
are past nine weeks gestation are
09:18
terminated by uterine evacuation either
09:20
manual or electrical uterine aspiration
09:22
or D&C in the second trimester pregnancy
09:27
terminations are completed either by
09:29
dilation and evacuation or labor
09:31
induction dilation and evacuation or D&E
09:35
is similar to D and C except that the
09:38
cervix is dilated further and forceps
09:40
are used to extract fetal tissue rather
09:42
than ice suction cannula cervical
09:45
dilation is often initiated the day
09:47
prior to the procedure using laminaria
09:49
laminaria are osmotic dilators that
09:52
mechanically open the cervix as they
09:53
absorb fluid and expand
09:56
second and third trimester abortions can
09:59
also be performed as labor inductions
10:01
prior to D&E or labor induction fetal
10:05
demise can be caused by injections of
10:07
intracardiac potassium chloride or intra
10:09
amniotic versus intra fetal digoxin or
10:13
by trans section of the umbilical cord
10:14
after membrane rupture there are
10:18
multiple options for carrying out
10:19
abortion as a labor induction first the
10:23
cervix can be dilated and ripened
10:24
mechanically with a Foley catheter
10:25
balloon placed through the cervix
10:28
alternatively even if oppressed own and
10:30
misoprostol can be used by the same
10:32
mechanism as previously discussed in
10:35
addition music rustle alone can be used
10:38
as can several prostaglandins including
10:40
Emma Frost and denna Pro stone
10:44
ethic right and lactate can be given as
10:46
an intramuscular extra amniotic or intra
10:49
amniotic injection urea can also be
10:53
given as an intra amniotic injection
10:56
finally high-dose oxytocin can be given
10:59
intravenously to cause uterine
11:00
contractions
11:02
intra amniotic injections are rarely
11:04
used anymore in the United States the
11:10
potential complications of abortion are
11:11
the same for both management of
11:13
spontaneous abortion and induced
11:14
abortion these include bleeding that may
11:17
require a blood transfusion infection
11:19
that may require antibiotics perforation
11:22
of the uterus that may lead to injury of
11:24
other intra-abdominal organs cervical
11:27
laceration from either tearing of a
11:29
tenaculum or excessively forceful
11:31
dilation retain products of conception
11:34
that may require another procedure in
11:37
formation of intrauterine scar tissue
11:39
that can cause infertility otherwise
11:41
known as a Sherman syndrome acute hamato
11:45
Mitra is also known as post abortive
11:47
syndrome in which women develop heavy
11:49
cramping and an enlarged tender uterus
11:51
but have minimal bleeding it is treated
11:54
by immediate uterine evacuation the
11:57
numbers listed on this slide for
11:58
complication rates are for suction
12:00
curettage abortions
12:02
according to tillens operative
12:03
gynecology complications are more likely
12:07
to occur at later gestational ages it is
12:10
important to note that induced abortion
12:12
is very safe less than 0.3 percent of
12:15
all patients who undergo abortion need
12:17
to be hospitalized for complication if
12:20
performed at less than 8 weeks gestation
12:22
the risk of death from induced abortion
12:24
is less than 1 in 1 million whereas the
12:27
risk of death is one in 29 thousand at
12:29
16 to 20 weeks gestation
12:32
risk are minimized when procedures are
12:34
performed by experienced providers it is
12:37
also important to note that abortion is
12:39
much safer than childbirth for women
12:41
finally multiple studies have
12:44
demonstrated that induced abortion
12:45
causes no harm to a woman’s mental or
12:47
emotional health and in fact may improve
12:49
her emotional well-being by providing a
12:51
sense of relief
12:53
in summary abortion is a term that
12:57
refers to loss of a pregnancy whether
12:59
spontaneous or induced there are many
13:02
types of spontaneous abortions as well
13:04
as multiple fetal and maternal
13:05
conditions that increase the risk of
13:07
spontaneous abortion the options for
13:10
managing a spontaneous abortion are
13:11
similar to the options for induced
13:13
abortion and these vary depending on the
13:15
gestational age of the pregnancy the
13:18
incidence of spontaneous abortion and
13:19
induced abortion is high and it is thus
13:22
important to know how to care for these
13:23
patients
13:32
you


Duration 6:00

Following a pregnancy loss prior to the 20th week, patients are naturally concerned for their future prognosis.

And we reassure these patients that early pregnancy loss occurs in about one out of every six pregnancies, it is usually caused by isolated chromosome abnormalities or placental malformations, it is not preventable, and that the next time the patient becomes pregnant, she will again have a one out of six chance of having a miscarriage.

While all of that is true, it is also true that with increasing numbers of consecutive miscarriages, the likelihood of another miscarriage does go up, and the causes of these miscarriages change. And that’s because while in general, the vast majority of early pregnancy losses are caused by isolated, non-recurring events, a few of them are related to ongoing problems. So if these women continue to have pregnancies and pregnancy losses, they ultimately will make up a much larger proportion of the miscarriage population.

Understand that I’m not talking about large numbers of women. Only 2 percent of pregnant women will experience two miscarriages in a row, and only 0.4% will experience three miscarriages in a row.

Independently, as women age, their risk of a miscarriage increases, from around 13% between age 20 to 30, up to 40% at age 40.

Recurrent pregnancy loss is usually defined as 3 or more consecutive pregnancy losses prior to the 20th week.

There are a number of identifiable causes for these recurrences, although for about 40% of patients, no cause can be determined with our current knowledge. But we can identify one or more causes in 60% of these patients, and the causes include:

Anatomic genital malformations
Endocrine abnormalities
Immunologic problems
Microbiologic causes
Genetic abnormalities

Because of the significant rise in risk of another miscarriage after three in a row, we usually initiate an evaluation to identify causes for recurrent pregnancy loss at that time, although some physicians in specific settings might begin the evaluation after two losses. The evaluation addresses each of the categories of causes for repetitive early pregnancy loss.

Chromosome evaluation

I obtain a blood karyotype from each partner, looking for such abnormalities as translocations, either balanced or Robertsonian, and mosaicism that might contribute to a lethal fetal defect. The yield on these tests is small, with about 4% of couples being positive for some significant structural abnormality. With some abnormalities, simply trying again for pregnancy may be the best option. With others, it may be wiser to pursue a course of donor insemination or donor eggs to avoid the chromosomal problem.

Anatomic Genital Malformations

Anything that distorts the normal uterine cavity shape and size can adversely affect conception and maintaining an early pregnancy. These abnormalities would include:

Uterine fibroids
Uterine didelphyc deformities such as a bicornuate or septate uterus
Endometrial polyps

The best way to evaluate the patient for these problems will vary with their history, physical exam, and available resources, but some commonly-used techniques include:

Sonohysterogram
Hysterosalpingogram
Transvaginal ultrasound
Hysteroscopy
Laparoscopy

Whenever a significant abnormality is identified, it usually can be surgically corrected.

Endocrine Abnormalities

Thyroid disorders, notably hypothyroidism, is associated with pregnancy loss, so a TSH and free T4 can rule out this problem. It may also prove useful to check the thyroid peroxidase antibody levels, since elevated TPO levels in euthyroid women have also been associated with pregnancy loss.

Diabetes, particularly poorly controlled diabetes has a significant association with early pregnancy loss, so it is valuable to rule out diabetes.

Polycystic ovary syndrome is associated with an increased risk of early loss. Screening for this may be helpful in identifying a cause for loss, but it is unclear whether such insulin-resistance modifiers as metformin will lead to improved outcome.

In contrast, hyperprolactinemia, also associated with early pregnancy loss, has been shown to be effectively reduced with bromcriptine, with an accompanying reduction in subsequent pregnancy loss rates.

Microbiologic Problems

Although infectious organisms can be associated with recurrent pregnancy loss in about 5% of cases, routine screening for Chlamydia, mycoplasma, bacterial vaginosis and toxoplasmosis has not been shown to be effective in lowering the recurrent loss rates.

For that reason, some physicians screen for these conditions while others do not. Whenever infectious agents are identified, specific antibiotics or antivirals can be prescribed. If no infectious organisms are identified, some physicians will provide a course of antibiotics to both partners empirically.

Immunologic issues

Both anticardiolipin antibodies and lupus anticoagulant are associated with recurring early pregnancy loss.

When identified, antiphospholipid syndrome can be treated with heparin or aspirin with an anticipated reduction in risk to future pregnancies.

Immunotherapy, in contrast, has not consistently demonstrated beneficial effects and its use in this setting would be considered experimental.

Progesterone Deficiency

For many years, patients with recurring early pregnancy loss were tested for the presence of a progesterone, or luteal phase deficiency. This was based on the observation that many miscarriages were preceded by a significant drop in serum progesterone. What is not clear is whether this drop is the cause of the miscarriage, or an effect of an abnormal pregnancy, destined to miscarry. Large, randomized, prospective studies are not available.

While some physicians continue to test for progesterone deficiency with luteal phase serum progesterones and endometrial biopsies and to prescribe progesterone to treat presumed deficiencies, others have abandoned this practice.


 

Introductory Women's HealthCare