{"id":378,"date":"2020-08-13T20:19:07","date_gmt":"2020-08-13T20:19:07","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=378"},"modified":"2020-08-13T20:19:07","modified_gmt":"2020-08-13T20:19:07","slug":"pregnancy-loss","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/advanced-training\/pregnancy-loss\/","title":{"rendered":"Pregnancy Loss"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/86543938?dnt=1&amp;app_id=122963\" width=\"474\" height=\"267\" frameborder=\"0\" allow=\"autoplay; fullscreen; picture-in-picture; clipboard-write\"><\/iframe><\/p>\n<p>Duration 9:49<\/p>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/83292055\" width=\"640\" height=\"360\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 19:40<\/p>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/e-SYEwE2-0w\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 13:41<\/p>\n<input type='hidden' bg_collapse_expand='69e9b57f25caf6040724833' value='69e9b57f25caf6040724833'><input type='hidden' id='bg-show-more-text-69e9b57f25caf6040724833' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b57f25caf6040724833' value='Hide Transcript'><button id='bg-showmore-action-69e9b57f25caf6040724833' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcfafa;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b57f25caf6040724833' ><\/p>\n<p>00:00<br \/>\nhi this is dr. Jane Lamar gonna be<br \/>\n00:02<br \/>\ntalking about abortion the learning<br \/>\n00:07<br \/>\nobjectives for this talk are as follows<br \/>\n00:09<br \/>\nto understand the difference between<br \/>\n00:11<br \/>\ntheir appearing and spontaneous abortion<br \/>\n00:13<br \/>\nto note the different types of<br \/>\n00:16<br \/>\nspontaneous abortions<br \/>\n00:17<br \/>\ntrivita risk factors for spontaneous<br \/>\n00:20<br \/>\nabortion to understand how should<br \/>\n00:22<br \/>\nspontaneous abortions be managed and how<br \/>\n00:24<br \/>\ntherapeutic abortions are performed and<br \/>\n00:26<br \/>\nto know the possible complications of<br \/>\n00:28<br \/>\nboth types of abortion<br \/>\n00:32<br \/>\nthe talk will proceed as follows we will<br \/>\n00:35<br \/>\nreview the types etiology and management<br \/>\n00:38<br \/>\nof spontaneous abortion the types of<br \/>\n00:39<br \/>\ninduced abortion and the complications<br \/>\n00:41<br \/>\nof both spontaneous abortion is more<br \/>\n00:46<br \/>\ncommonly known as miscarriage it is<br \/>\n00:49<br \/>\ndefined as pregnancy loss prior to 20<br \/>\n00:51<br \/>\nweeks gestation such pregnancy loss<br \/>\n00:54<br \/>\noccurs far more frequently than most<br \/>\n00:55<br \/>\npeople think and it is estimated that 50<br \/>\n00:57<br \/>\nto 70 percent of all pregnancies end in<br \/>\n00:59<br \/>\nmiscarriage the majority of these losses<br \/>\n01:02<br \/>\noccur before women even realize they are<br \/>\n01:04<br \/>\npregnant approximately 20% of clinically<br \/>\n01:07<br \/>\nrecognized pregnancies end in<br \/>\n01:09<br \/>\nspontaneous abortion it is estimated<br \/>\n01:11<br \/>\nthat 80% of spontaneous abortions occur<br \/>\n01:14<br \/>\nin the first trimester of pregnancy<br \/>\n01:15<br \/>\nprior to 12 weeks gestation spontaneous<br \/>\n01:21<br \/>\nabortion is further categorized into<br \/>\n01:23<br \/>\nsubtypes based on whether the cervix is<br \/>\n01:25<br \/>\nopen or closed and whether or not the<br \/>\n01:27<br \/>\nfetus is alive moreover there are some<br \/>\n01:30<br \/>\nfertilization events that will lead to<br \/>\n01:31<br \/>\ngrowth of pregnancy tissue but never<br \/>\n01:33<br \/>\ndevelop a fetal pole known as an<br \/>\n01:36<br \/>\nembryonic gist stations or blighted ovum<br \/>\n01:38<br \/>\n&#8216;z these pregnancies also fall under the<br \/>\n01:40<br \/>\ncategory of spontaneous abortion if a<br \/>\n01:44<br \/>\nwoman experiences vaginal bleeding but<br \/>\n01:46<br \/>\nhas a live fetus for potentially viable<br \/>\n01:48<br \/>\nearly first trimester pregnancy the<br \/>\n01:50<br \/>\nspeculum exam should be performed if the<br \/>\n01:53<br \/>\ncervix is closed the patient is having a<br \/>\n01:55<br \/>\nthreatened abortion if the service is<br \/>\n01:58<br \/>\nopen the abortion is considered<br \/>\n02:00<br \/>\ninevitable and the patient should be<br \/>\n02:01<br \/>\noffered some type of intervention to<br \/>\n02:03<br \/>\ncomplete the abortion we will discuss<br \/>\n02:05<br \/>\nthis further later in the presentation<br \/>\n02:07<br \/>\nin comparison if a patient experiences<br \/>\n02:10<br \/>\nfetal demise the type of spontaneous<br \/>\n02:12<br \/>\nabortion depends on whether or not the<br \/>\n02:14<br \/>\nfetal tissue remains in the uterus if<br \/>\n02:16<br \/>\nall fetal and placental tissue remains<br \/>\n02:18<br \/>\nthe patient has a missed abortion<br \/>\n02:23<br \/>\nsome tissue has passed but still remains<br \/>\n02:25<br \/>\nthe patient has an incomplete abortion<br \/>\n02:27<br \/>\nfinally if the patient has had a fetal<br \/>\n02:30<br \/>\ndemise and has passed all the pregnancy<br \/>\n02:31<br \/>\ntissue the abortion is categorized as<br \/>\n02:34<br \/>\ncomplete some patients will develop<br \/>\n02:37<br \/>\nintrauterine or even systemic infections<br \/>\n02:39<br \/>\nassociated with a spontaneous abortion<br \/>\n02:41<br \/>\noften characterized by fevers and<br \/>\n02:43<br \/>\nabdominal pain<br \/>\n02:45<br \/>\nthese patients are described as having<br \/>\n02:47<br \/>\nseptic abortion finally women who<br \/>\n02:51<br \/>\nundergo three spontaneous abortions in a<br \/>\n02:53<br \/>\nrow with no intervening normal pregnancy<br \/>\n02:56<br \/>\nare described as having recurrent<br \/>\n02:58<br \/>\nabortions these women should be worked<br \/>\n03:00<br \/>\nup for causes of recurrent miscarriage<br \/>\n03:04<br \/>\nalthough the etiology of many<br \/>\n03:06<br \/>\nspontaneous abortions is never known<br \/>\n03:08<br \/>\nthere are certain conditions that<br \/>\n03:10<br \/>\ncommonly end in pregnancy loss these<br \/>\n03:13<br \/>\nconditions may be specific to the fetus<br \/>\n03:15<br \/>\nor the mother or the mother&#8217;s<br \/>\n03:17<br \/>\nenvironment certain conditions are more<br \/>\n03:20<br \/>\nlikely to cause pregnancy loss at<br \/>\n03:21<br \/>\ncertain gestational ages for example<br \/>\n03:25<br \/>\nlosses at less than 10 weeks gestation<br \/>\n03:27<br \/>\nare usually related to a chromosomal<br \/>\n03:29<br \/>\nanomaly in the fetus in contrast uterine<br \/>\n03:33<br \/>\nanomalies and cervical insufficiency<br \/>\n03:35<br \/>\ntypically result in fetal loss in the<br \/>\n03:37<br \/>\nmid second trimester after 18 weeks<br \/>\n03:40<br \/>\nwithin chromosomal anomalies<br \/>\n03:41<br \/>\nspecifically which caused the majority<br \/>\n03:43<br \/>\nof spontaneous pregnancy losses<br \/>\n03:45<br \/>\nautosomal trisomy or 3 copies of a<br \/>\n03:48<br \/>\nchromosome is the most common<br \/>\n03:50<br \/>\nabnormality trisomy 16 and trisomy 22<br \/>\n03:55<br \/>\noccur most frequently it is postulated<br \/>\n03:59<br \/>\nthat single gene mutations may also be<br \/>\n04:01<br \/>\nresponsible for the loss of chromosomal<br \/>\n04:03<br \/>\na normal pregnancies several maternal<br \/>\n04:06<br \/>\nconditions place women at risk for<br \/>\n04:08<br \/>\npregnancy loss first structural<br \/>\n04:12<br \/>\nanomalies in the uterus both congenital<br \/>\n04:14<br \/>\nand acquired can create an inhospitable<br \/>\n04:16<br \/>\nenvironment for fetal growth and<br \/>\n04:17<br \/>\ndevelopment for example septate uterus<br \/>\n04:20<br \/>\nis the most common uterine anomaly<br \/>\n04:22<br \/>\nassociated with spontaneous abortion<br \/>\n04:25<br \/>\nother such anomalies include bicornuate<br \/>\n04:27<br \/>\nuterus uterine fibroids and intricate<br \/>\n04:30<br \/>\narias Aniki eye or scar tissue from<br \/>\n04:32<br \/>\nprior surgeries cervical insufficiency<br \/>\n04:36<br \/>\nis painless cervical dilation leading to<br \/>\n04:39<br \/>\ndelivery of a non-viable fetus in the<br \/>\n04:41<br \/>\nsecond trimester<br \/>\n04:43<br \/>\nin addition there are multiple medical<br \/>\n04:46<br \/>\nconditions such as hypothyroidism and<br \/>\n04:48<br \/>\npoorly controlled diabetes mellitus that<br \/>\n04:50<br \/>\nmay predispose a woman to spontaneous<br \/>\n04:52<br \/>\nabortion it is important to note that<br \/>\n04:55<br \/>\nmany women with these conditions carry<br \/>\n04:57<br \/>\nsuccessful pregnancies maternal<br \/>\n05:00<br \/>\nthrombophilia is in which women have an<br \/>\n05:02<br \/>\nincreased tendency to form blood clots<br \/>\n05:03<br \/>\nsuch as antiphospholipid antibody<br \/>\n05:06<br \/>\nsyndrome can lead to pregnancy loss<br \/>\n05:08<br \/>\nlikely by damaging the placental<br \/>\n05:10<br \/>\nvasculature<br \/>\n05:12<br \/>\nmoreover certain infections in the<br \/>\n05:14<br \/>\ncervix uterus and or semen have been<br \/>\n05:16<br \/>\nassociated with spontaneous abortion<br \/>\n05:18<br \/>\nthese include chlamydia gonorrhea urea<br \/>\n05:20<br \/>\nplasma mycoplasma Staphylococcus and<br \/>\n05:23<br \/>\nstreptococcus<br \/>\n05:24<br \/>\nin addition maternal infection with<br \/>\n05:27<br \/>\nListeria toxoplasmosis parvovirus b19<br \/>\n05:32<br \/>\nvaricella cytomegalovirus rubella and<br \/>\n05:36<br \/>\nprimary herpes simplex can cause<br \/>\n05:38<br \/>\npregnancy loss<br \/>\n05:41<br \/>\nthere are also modifiable factors in the<br \/>\n05:43<br \/>\nmaternal environment that may lead to an<br \/>\n05:45<br \/>\nincreased risk of miscarriage<br \/>\n05:46<br \/>\nthese include maternal tobacco and<br \/>\n05:49<br \/>\nalcohol use and radiation exposure<br \/>\n05:53<br \/>\nfinally some women are carriers of<br \/>\n05:55<br \/>\nbalanced translocations such that they<br \/>\n05:58<br \/>\nmay have a normal number of chromosomes<br \/>\n05:59<br \/>\nbut their offspring often will not<br \/>\n06:04<br \/>\nif a spontaneous abortion is not<br \/>\n06:07<br \/>\ncomplete at the time of diagnosis<br \/>\n06:08<br \/>\nsometimes intervention is required the<br \/>\n06:11<br \/>\nneed for active management of a<br \/>\n06:13<br \/>\npregnancy loss depends upon the presence<br \/>\n06:14<br \/>\nor absence of heavy bleeding the<br \/>\n06:16<br \/>\npresence or absence of infection the<br \/>\n06:18<br \/>\ngestational age of the pregnancy the<br \/>\n06:21<br \/>\npatient&#8217;s medical history and the<br \/>\n06:23<br \/>\npatient&#8217;s wishes in the setting of<br \/>\n06:26<br \/>\ninfection and\/or heavy vaginal bleeding<br \/>\n06:28<br \/>\nwith hemodynamic instability surgical<br \/>\n06:31<br \/>\nintervention to empty the uterus is<br \/>\n06:32<br \/>\nalways indicated this can be<br \/>\n06:35<br \/>\naccomplished with manual or surgical<br \/>\n06:37<br \/>\nvacuum aspiration pregnancies that later<br \/>\n06:40<br \/>\nthan nine weeks gestation are more<br \/>\n06:42<br \/>\nlikely to require surgical intervention<br \/>\n06:43<br \/>\nin order to complete the passage of all<br \/>\n06:45<br \/>\npregnancy tissue simply because of the<br \/>\n06:47<br \/>\namount of tissue present it is estimated<br \/>\n06:50<br \/>\nthat a missed or incomplete abortion who<br \/>\n06:52<br \/>\nwill pass between 52 to 84 percent of<br \/>\n06:54<br \/>\nthe time with no intervention depending<br \/>\n06:56<br \/>\non how long the patient waits for the<br \/>\n06:58<br \/>\ntissue to pass<br \/>\n07:00<br \/>\nif a patient elects for medical<br \/>\n07:02<br \/>\nmanagement of pregnancy loss most<br \/>\n07:03<br \/>\ncommonly misoprostol a prostaglandin e1<br \/>\n07:06<br \/>\nanalog is prescribed<br \/>\n07:08<br \/>\nthis causes both cervical softening and<br \/>\n07:11<br \/>\ndilation as well as uterine contractions<br \/>\n07:13<br \/>\nto expel the pregnancy tissue women with<br \/>\n07:16<br \/>\npregnancies less than 12 weeks gestation<br \/>\n07:18<br \/>\ncan complete a spontaneous abortion at<br \/>\n07:20<br \/>\nhome using music rosto if they elect to<br \/>\n07:22<br \/>\ndo so in contrast medical management of<br \/>\n07:25<br \/>\na spontaneous abortion greater than 12<br \/>\n07:27<br \/>\nweeks should be performing or close<br \/>\n07:29<br \/>\nmonitoring in the hospital due to an<br \/>\n07:31<br \/>\nincreased risk of heavy bleeding<br \/>\n07:33<br \/>\nwith all patients who undergo<br \/>\n07:35<br \/>\nspontaneous abortion it is crucial to<br \/>\n07:37<br \/>\ncheck a blood type and administer rhogam<br \/>\n07:39<br \/>\nif the mother is Rh negative in order to<br \/>\n07:41<br \/>\nprevent ISO immunization in future<br \/>\n07:43<br \/>\npregnancies in contrast to spontaneous<br \/>\n07:48<br \/>\nabortion induced abortion is the medical<br \/>\n07:51<br \/>\nor surgical termination of a live<br \/>\n07:52<br \/>\npregnancy induced abortions are<br \/>\n07:55<br \/>\nsometimes also referred to as<br \/>\n07:56<br \/>\ntherapeutic abortions when they are<br \/>\n07:58<br \/>\nperformed because of risk to a woman&#8217;s<br \/>\n08:00<br \/>\nhealth or lethal fetal anomalies when<br \/>\n08:03<br \/>\nasked why they are choosing to terminate<br \/>\n08:04<br \/>\na pregnancy<br \/>\n08:05<br \/>\nthe most common response that women give<br \/>\n08:07<br \/>\nis either responsibility to other family<br \/>\n08:09<br \/>\nmembers or economic constraints it is<br \/>\n08:13<br \/>\nestimated that 50% of pregnancies in the<br \/>\n08:15<br \/>\nUnited States are unplanned and four out<br \/>\n08:18<br \/>\nof ten of these pregnancies end in<br \/>\n08:20<br \/>\nabortion<br \/>\n08:21<br \/>\nit is important that women who have an<br \/>\n08:23<br \/>\nunplanned pregnancy are counseled on all<br \/>\n08:25<br \/>\npossible options which would include<br \/>\n08:27<br \/>\ncontinuing the pregnancy terminating the<br \/>\n08:29<br \/>\npregnancy or giving the infant up for<br \/>\n08:31<br \/>\nadoption<br \/>\n08:34<br \/>\nmethods for pregnancy termination are<br \/>\n08:36<br \/>\nsimilar to those for managing a<br \/>\n08:37<br \/>\nspontaneous abortion though there are<br \/>\n08:39<br \/>\nsome key differences medication<br \/>\n08:42<br \/>\nterminations can be performed up to 63<br \/>\n08:44<br \/>\ndays or nine weeks gestation depending<br \/>\n08:47<br \/>\non the regimen that is used most<br \/>\n08:49<br \/>\ncommonly these are performed with a<br \/>\n08:51<br \/>\ncombination of mythic Prestone which is<br \/>\n08:53<br \/>\ngiven first and music crustle which is<br \/>\n08:55<br \/>\ntaken at home 24 to 72 hours later with<br \/>\n08:59<br \/>\na Chris stone a competitive progesterone<br \/>\n09:02<br \/>\nreceptor antagonist interrupts the<br \/>\n09:04<br \/>\nendometrial lining that is supporting a<br \/>\n09:06<br \/>\ngrowing pregnancy and sensitizes the<br \/>\n09:08<br \/>\nmyometrium to prostaglandins thereby<br \/>\n09:11<br \/>\nmaking these apostille more effective<br \/>\n09:14<br \/>\npregnancies in the first trimester that<br \/>\n09:16<br \/>\nare past nine weeks gestation are<br \/>\n09:18<br \/>\nterminated by uterine evacuation either<br \/>\n09:20<br \/>\nmanual or electrical uterine aspiration<br \/>\n09:22<br \/>\nor D&amp;C in the second trimester pregnancy<br \/>\n09:27<br \/>\nterminations are completed either by<br \/>\n09:29<br \/>\ndilation and evacuation or labor<br \/>\n09:31<br \/>\ninduction dilation and evacuation or D&amp;E<br \/>\n09:35<br \/>\nis similar to D and C except that the<br \/>\n09:38<br \/>\ncervix is dilated further and forceps<br \/>\n09:40<br \/>\nare used to extract fetal tissue rather<br \/>\n09:42<br \/>\nthan ice suction cannula cervical<br \/>\n09:45<br \/>\ndilation is often initiated the day<br \/>\n09:47<br \/>\nprior to the procedure using laminaria<br \/>\n09:49<br \/>\nlaminaria are osmotic dilators that<br \/>\n09:52<br \/>\nmechanically open the cervix as they<br \/>\n09:53<br \/>\nabsorb fluid and expand<br \/>\n09:56<br \/>\nsecond and third trimester abortions can<br \/>\n09:59<br \/>\nalso be performed as labor inductions<br \/>\n10:01<br \/>\nprior to D&amp;E or labor induction fetal<br \/>\n10:05<br \/>\ndemise can be caused by injections of<br \/>\n10:07<br \/>\nintracardiac potassium chloride or intra<br \/>\n10:09<br \/>\namniotic versus intra fetal digoxin or<br \/>\n10:13<br \/>\nby trans section of the umbilical cord<br \/>\n10:14<br \/>\nafter membrane rupture there are<br \/>\n10:18<br \/>\nmultiple options for carrying out<br \/>\n10:19<br \/>\nabortion as a labor induction first the<br \/>\n10:23<br \/>\ncervix can be dilated and ripened<br \/>\n10:24<br \/>\nmechanically with a Foley catheter<br \/>\n10:25<br \/>\nballoon placed through the cervix<br \/>\n10:28<br \/>\nalternatively even if oppressed own and<br \/>\n10:30<br \/>\nmisoprostol can be used by the same<br \/>\n10:32<br \/>\nmechanism as previously discussed in<br \/>\n10:35<br \/>\naddition music rustle alone can be used<br \/>\n10:38<br \/>\nas can several prostaglandins including<br \/>\n10:40<br \/>\nEmma Frost and denna Pro stone<br \/>\n10:44<br \/>\nethic right and lactate can be given as<br \/>\n10:46<br \/>\nan intramuscular extra amniotic or intra<br \/>\n10:49<br \/>\namniotic injection urea can also be<br \/>\n10:53<br \/>\ngiven as an intra amniotic injection<br \/>\n10:56<br \/>\nfinally high-dose oxytocin can be given<br \/>\n10:59<br \/>\nintravenously to cause uterine<br \/>\n11:00<br \/>\ncontractions<br \/>\n11:02<br \/>\nintra amniotic injections are rarely<br \/>\n11:04<br \/>\nused anymore in the United States the<br \/>\n11:10<br \/>\npotential complications of abortion are<br \/>\n11:11<br \/>\nthe same for both management of<br \/>\n11:13<br \/>\nspontaneous abortion and induced<br \/>\n11:14<br \/>\nabortion these include bleeding that may<br \/>\n11:17<br \/>\nrequire a blood transfusion infection<br \/>\n11:19<br \/>\nthat may require antibiotics perforation<br \/>\n11:22<br \/>\nof the uterus that may lead to injury of<br \/>\n11:24<br \/>\nother intra-abdominal organs cervical<br \/>\n11:27<br \/>\nlaceration from either tearing of a<br \/>\n11:29<br \/>\ntenaculum or excessively forceful<br \/>\n11:31<br \/>\ndilation retain products of conception<br \/>\n11:34<br \/>\nthat may require another procedure in<br \/>\n11:37<br \/>\nformation of intrauterine scar tissue<br \/>\n11:39<br \/>\nthat can cause infertility otherwise<br \/>\n11:41<br \/>\nknown as a Sherman syndrome acute hamato<br \/>\n11:45<br \/>\nMitra is also known as post abortive<br \/>\n11:47<br \/>\nsyndrome in which women develop heavy<br \/>\n11:49<br \/>\ncramping and an enlarged tender uterus<br \/>\n11:51<br \/>\nbut have minimal bleeding it is treated<br \/>\n11:54<br \/>\nby immediate uterine evacuation the<br \/>\n11:57<br \/>\nnumbers listed on this slide for<br \/>\n11:58<br \/>\ncomplication rates are for suction<br \/>\n12:00<br \/>\ncurettage abortions<br \/>\n12:02<br \/>\naccording to tillens operative<br \/>\n12:03<br \/>\ngynecology complications are more likely<br \/>\n12:07<br \/>\nto occur at later gestational ages it is<br \/>\n12:10<br \/>\nimportant to note that induced abortion<br \/>\n12:12<br \/>\nis very safe less than 0.3 percent of<br \/>\n12:15<br \/>\nall patients who undergo abortion need<br \/>\n12:17<br \/>\nto be hospitalized for complication if<br \/>\n12:20<br \/>\nperformed at less than 8 weeks gestation<br \/>\n12:22<br \/>\nthe risk of death from induced abortion<br \/>\n12:24<br \/>\nis less than 1 in 1 million whereas the<br \/>\n12:27<br \/>\nrisk of death is one in 29 thousand at<br \/>\n12:29<br \/>\n16 to 20 weeks gestation<br \/>\n12:32<br \/>\nrisk are minimized when procedures are<br \/>\n12:34<br \/>\nperformed by experienced providers it is<br \/>\n12:37<br \/>\nalso important to note that abortion is<br \/>\n12:39<br \/>\nmuch safer than childbirth for women<br \/>\n12:41<br \/>\nfinally multiple studies have<br \/>\n12:44<br \/>\ndemonstrated that induced abortion<br \/>\n12:45<br \/>\ncauses no harm to a woman&#8217;s mental or<br \/>\n12:47<br \/>\nemotional health and in fact may improve<br \/>\n12:49<br \/>\nher emotional well-being by providing a<br \/>\n12:51<br \/>\nsense of relief<br \/>\n12:53<br \/>\nin summary abortion is a term that<br \/>\n12:57<br \/>\nrefers to loss of a pregnancy whether<br \/>\n12:59<br \/>\nspontaneous or induced there are many<br \/>\n13:02<br \/>\ntypes of spontaneous abortions as well<br \/>\n13:04<br \/>\nas multiple fetal and maternal<br \/>\n13:05<br \/>\nconditions that increase the risk of<br \/>\n13:07<br \/>\nspontaneous abortion the options for<br \/>\n13:10<br \/>\nmanaging a spontaneous abortion are<br \/>\n13:11<br \/>\nsimilar to the options for induced<br \/>\n13:13<br \/>\nabortion and these vary depending on the<br \/>\n13:15<br \/>\ngestational age of the pregnancy the<br \/>\n13:18<br \/>\nincidence of spontaneous abortion and<br \/>\n13:19<br \/>\ninduced abortion is high and it is thus<br \/>\n13:22<br \/>\nimportant to know how to care for these<br \/>\n13:23<br \/>\npatients<br \/>\n13:32<br \/>\nyou<\/p>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" title=\"vimeo-player\" src=\"https:\/\/player.vimeo.com\/video\/112305253\" width=\"640\" height=\"360\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 6:00<\/p>\n<input type='hidden' bg_collapse_expand='69e9b57f2772d0093506931' value='69e9b57f2772d0093506931'><input type='hidden' id='bg-show-more-text-69e9b57f2772d0093506931' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b57f2772d0093506931' value='Hide Transcript'><button id='bg-showmore-action-69e9b57f2772d0093506931' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b57f2772d0093506931' ><\/p>\n<p>Following a pregnancy loss prior to the 20th week, patients are naturally concerned for their future prognosis.<\/p>\n<p>And we reassure these patients that early pregnancy loss occurs in about one out of every six pregnancies, it is\u00a0usually caused by isolated chromosome abnormalities or placental malformations, it is not preventable, and that\u00a0the next time the patient becomes pregnant, she will again have a one out of six chance of having a miscarriage.<\/p>\n<p>While all of that is true, it is also true that with increasing numbers of consecutive miscarriages, the likelihood of\u00a0another miscarriage does go up, and the causes of these miscarriages change. And that\u2019s because while in\u00a0general, the vast majority of early pregnancy losses are caused by isolated, non-recurring events, a few of them\u00a0are related to ongoing problems. So if these women continue to have pregnancies and pregnancy losses, they\u00a0ultimately will make up a much larger proportion of the miscarriage population.<\/p>\n<p>Understand that I\u2019m not talking about large numbers of women. Only 2 percent of pregnant women will\u00a0experience two miscarriages in a row, and only 0.4% will experience three miscarriages in a row.<\/p>\n<p>Independently, as women age, their risk of a miscarriage increases, from around 13% between age 20 to 30, up\u00a0to 40% at age 40.<\/p>\n<p>Recurrent pregnancy loss is usually defined as 3 or more consecutive pregnancy losses prior to the 20th week.<\/p>\n<p>There are a number of identifiable causes for these recurrences, although for about 40% of patients, no cause\u00a0can be determined with our current knowledge. But we can identify one or more causes in 60% of these patients,\u00a0and the causes include:<\/p>\n<p>Anatomic genital malformations<br \/>\nEndocrine abnormalities<br \/>\nImmunologic problems<br \/>\nMicrobiologic causes<br \/>\nGenetic abnormalities<\/p>\n<p>Because of the significant rise in risk of another miscarriage after three in a row, we usually initiate an\u00a0evaluation to identify causes for recurrent pregnancy loss at that time, although some physicians in specific\u00a0settings might begin the evaluation after two losses. The evaluation addresses each of the categories of causes\u00a0for repetitive early pregnancy loss.<\/p>\n<p>Chromosome evaluation<\/p>\n<p>I obtain a blood karyotype from each partner, looking for such abnormalities as translocations, either balanced\u00a0or Robertsonian, and mosaicism that might contribute to a lethal fetal defect. The yield on these tests is small,\u00a0with about 4% of couples being positive for some significant structural abnormality. With some abnormalities,\u00a0simply trying again for pregnancy may be the best option. With others, it may be wiser to pursue a course of\u00a0donor insemination or donor eggs to avoid the chromosomal problem.<\/p>\n<p>Anatomic Genital Malformations<\/p>\n<p>Anything that distorts the normal uterine cavity shape and size can adversely affect conception and maintaining\u00a0an early pregnancy. These abnormalities would include:<\/p>\n<p>Uterine fibroids<br \/>\nUterine didelphyc deformities such as a bicornuate or septate uterus<br \/>\nEndometrial polyps<\/p>\n<p>The best way to evaluate the patient for these problems will vary with their history, physical exam, and available\u00a0resources, but some commonly-used techniques include:<\/p>\n<p>Sonohysterogram<br \/>\nHysterosalpingogram<br \/>\nTransvaginal ultrasound<br \/>\nHysteroscopy<br \/>\nLaparoscopy<\/p>\n<p>Whenever a significant abnormality is identified, it usually can be surgically corrected.<\/p>\n<p>Endocrine Abnormalities<\/p>\n<p>Thyroid disorders, notably hypothyroidism, is associated with pregnancy loss, so a TSH and free T4 can rule out\u00a0this problem. It may also prove useful to check the thyroid peroxidase antibody levels, since elevated TPO levels\u00a0in euthyroid women have also been associated with pregnancy loss.<\/p>\n<p>Diabetes, particularly poorly controlled diabetes has a significant association with early pregnancy loss, so it is\u00a0valuable to rule out diabetes.<\/p>\n<p>Polycystic ovary syndrome is associated with an increased risk of early loss. Screening for this may be helpful in\u00a0identifying a cause for loss, but it is unclear whether such insulin-resistance modifiers as metformin will lead to\u00a0improved outcome.<\/p>\n<p>In contrast, hyperprolactinemia, also associated with early pregnancy loss, has been shown to be effectively\u00a0reduced with bromcriptine, with an accompanying reduction in subsequent pregnancy loss rates.<\/p>\n<p>Microbiologic Problems<\/p>\n<p>Although infectious organisms can be associated with recurrent pregnancy loss in about 5% of cases, routine\u00a0screening for Chlamydia, mycoplasma, bacterial vaginosis and toxoplasmosis has not been shown to be effective\u00a0in lowering the recurrent loss rates.<\/p>\n<p>For that reason, some physicians screen for these conditions while others do not. Whenever infectious agents\u00a0are identified, specific antibiotics or antivirals can be prescribed. If no infectious organisms are identified, some\u00a0physicians will provide a course of antibiotics to both partners empirically.<\/p>\n<p>Immunologic issues<\/p>\n<p>Both anticardiolipin antibodies and lupus anticoagulant are associated with recurring early pregnancy loss.<\/p>\n<p>When identified, antiphospholipid syndrome can be treated with heparin or aspirin with an anticipated\u00a0reduction in risk to future pregnancies.<\/p>\n<p>Immunotherapy, in contrast, has not consistently demonstrated beneficial effects and its use in this setting\u00a0would be considered experimental.<\/p>\n<p>Progesterone Deficiency<\/p>\n<p>For many years, patients with recurring early pregnancy loss were tested for the presence of a progesterone, or\u00a0luteal phase deficiency. This was based on the observation that many miscarriages were preceded by a\u00a0significant drop in serum progesterone. What is not clear is whether this drop is the cause of the miscarriage, or\u00a0an effect of an abnormal pregnancy, destined to miscarry. Large, randomized, prospective studies are not\u00a0available.<\/p>\n<p>While some physicians continue to test for progesterone deficiency with luteal phase serum progesterones and\u00a0endometrial biopsies and to prescribe progesterone to treat presumed deficiencies, others have abandoned this\u00a0practice.<\/p>\n<p><\/div>\n<hr \/>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Duration 9:49 Duration 19:40 Duration 13:41 Duration 6:00 &nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":160,"menu_order":12,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-378","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/378","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=378"}],"version-history":[{"count":0,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/378\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/160"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=378"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}