1. Early Pregnancy Loss Abigail Wolf, MD Obstetrics and Gynecology
Thomas Jefferson Medical College

2. Early Pregnancy Loss Objectives: Review basics of preconception care
Review normal early pregnancy
Develop a differential diagnosis of early pregnancy loss including risk factors, presentation and management
Define ectopic pregnancy including risk factors, presentation and management

3. Definition of Pregnancy
American College of Obstetricians &Gynecologists
Talking Points
The National Institutes of Health / Food and Drug Administration defines pregnancy as “Encompassing the period of time from confirmation of implantation until expulsion or extraction of the fetus.”
The American College of Obstetricians and Gynecologists defines pregnancy as “The state of a female after conception and until termination of the gestation.”
ACOG further notes that “Conception is the implantation of the blastocyst. It is not synonymous with fertilization; synonym: implantation.”
References
OPRR Reports: Protection of Human Subjects. Code of Federal Regulations 45CFR 46, March 8, 1983.
Hughes EC (ed.). Committee on Terminology, The American College of Obstetricians and Gynecologists, Obstetric-Gynecologic Terminology. Philadelphia PA: F.A. Davis Company, 1972.
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Original content for this slide submitted by James Trussell, PhD, in May Original funding received from the Davie and Lucille Packard Foundation. Revised content for this slide submitted by James Trussell, PhD, in April Last reviewed/updated by Linda Dominguez, RN-C, NP, Don Downing, RPh, and James Trussell, PhD, in April This slide is available at
OPRR Reports
Hughes EC

4. Incidence of Early Pregnancy Loss
≤ 20 weeks’
gestation
12%–24% of
pregnancies
600,000
to 800,000
annually
Talking Points
Early pregnancy loss, or spontaneous abortion, is the loss of products of conception before the 20th week of pregnancy without surgical or medical intervention to terminate the pregnancy.
Approximately 12%–24% of pregnancies end in spontaneous abortion before 20 weeks’ gestation.
In the United States, this figure represents about 600,000 to 800,000 pregnancies per year.
References
Griebel CP, Halvorsen J, Golemon TB. Management of spontaneous abortion. Am Fam Physician. 2005;72:1243–50.
Everett C. Incidence and outcome of bleeding before the 20th week of pregnancy: prospective study from general practice. BMJ. 1997;315:32–4.
Smith NC. Epidemiology of spontaneous abortion. Contemp Rev Obstet Gynecol. 1988;1:43–9.
Stirrat GM. Recurrent miscarriage I: definition and epidemiology. Lancet ;336:673–5.
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Original content for this slide submitted by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in December Original funding received from Ipas and the John Merck Fund through an unrestricted educational grant. Last reviewed/updated by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in October This slide is available at
Griebel CP, et al. Am Fam Physician ; Everett C. BMJ
Smith NC. Contemp Rev Obstet Gynecol ; Stirrat GM. Lancet

5. Preconception Female Male Both
Assess gynecologic and obstetric history, family genetic history, medical history and medication use
Perform physical exam
Increase folic acid, exercise
Male
Assess obstetric history, family genetic history
Both
Review vaccinations
Screen for HIV, STD and domestic violence
Counsel to avoid smoking, alcohol, drugs and obesity

6. Fertilization to Implantation
Pronuclear Phase
Sperm and egg separate in egg cytoplasm
Morula
Solid ball of totipotential cells
Blastocyst
sphere of about 150 cells, with an outer layer (the trophoblast), a fluid-filled cavity (the blastocoel), and a cluster of cells on the interior (the inner cell mass).

8. morula

9. Blastocyst
blastocyst

10. Implantation through first trimester
Implantation occurs 6-9 days from conception
At implantation the blastocyst contains about 250 cells
At 12 weeks external genitalia are visible and the fetus begins to make urine
The fetus is about 2.5 inches

13. 29 year old G2P1001 with LMP 7 weeks ago presents complaining of vaginal bleeding.

14. Differential Diagnosis

15. Differential Diagnosis
ECTOPIC PREGNANCY
Threatened Abortion
Incomplete Abortion
Spontaneous Abortion
Inevitable abortion
Septic Abortion
Molar Pregnancy
Trauma
Infection
Malignancy

16. Epidemiology of Abortion
15-20% of known human pregnancies end in clinically recognized abortion
22% of pregnancies end before pregnancy is clinically recognized
Total pregnancy loss rate at least 31%
Approximately 50% of pregnancies are unintended and approximately 50% of those end in elective abortion

17. Spontaneous/Complete Abortion
Definition: spontaneous passage of all products of conception.
Approximately 50% of spontaneous abortions are due to chromosomal abnormalities
Other risk factors include:
Age
Infection
Toxic habits
Underlying medical illness
Uterine anomalies

18. Spontaneous/Complete Abortion
Diagnosis: history of bleeding and passing tissue, physical exam of closed cervix, ultrasound with no intra or extra-uterine pregnancy
Management: usually resolves spontaneously, no further management needed
Sequelae: none. After one SAB risk of second SAB is increased to 40%. Age also increases risk. 18

19. Threatened Abortion
Definition: uterine bleeding without cervical dilation or passage of tissue
Diagnosis: history (bleeding), physical exam (cervix closed), ultrasound (fetal heart rate seen)
Management: expectant management, serial Beta-hcg, ultrasound, pelvic rest
Sequelae: Occurs in up to 25% of pregnancies. About half of those go on to viability but are at higher risk for preterm delivery and low birth weight. 19

20. Missed Abortion Definition: fetus dies but remains in the uterus
Diagnosis: physical exam-closed cervix and ultrasound-intrauterine pregnancy with no fetal heart beat
Management: options include expectant management, medical induction of labor, surgical evacuation (EVA), manual vacuum evacuation (MVA)
Sequelae: risk of hemorrhage with expectant/medical management 20

21. Missed abortion synonyms
Embryonic Death: sonographically visualized embryo 4-15mm long without cardiac activity
Intrauterine Fetal Death: sonographically visualized fetus >15mm long without cardiac activity

22. Incomplete Abortion
Definition: uterine bleeding and cramping with passage of some, but not all products of conception
Diagnosis: history of bleeding and passing tissue, physical exam of open cervix, ultrasound with some intrauterine products
Management: expectant, medical or surgical
Sequelae: risk of uncontrolled bleeding 22

23. Elective Abortion Sequelae:
Definition: elective termination of pregnancy prior to viability
Management:
i. Medical
1. Mifepristone/misoprostol at less than 49 days from LMP
2. Misoprostol induction after intra-cardiac injection after 49 days
ii. Surgical
1. manual vacuum aspiration
2. electric vacuum aspiration
Sequelae: 23

24. Recurrent Abortion
Definition: loss of > or = 3 consecutive pregnancies before 20 weeks
Diagnosis: by history, chart review may be helpful for details
Management: Identify and treat underlying causes
uncontrolled diabetes mellitus
uterine cavity synechiae or other uterine defects
antiphospholipid antibody syndrome or other autoimmune disease
chromosomal abnormalities (parental) 24

25. Septic Abortion
Definition: any of the above accompanied by intra-uterine infection
Diagnosis: any abortion with fever, elevated white blood count, fundal tenderness
Management: requires uterine evacuation
Sequelae: uterine synechiae, systemic infection, uterine perforation 25

26. Molar Pregnancy Definition:
A placental abnormality involving swollen placental villi and trophoblastic hyperplasia
Complete mole is 46XX all paternal cells, usually no fetus forms
Incomplete mole is often 69XXY and presents with a chromosomally abnormal fetus

27. Molar Pregnancy Diagnosis:
Symptoms include vaginal bleeding, nausea and vomiting, elevated blood pressure
Signs include tachycardia, tachypnea, hypertension, disproportionately large uterus for dates, ultrasound with snowstorm pattern.

28. Figure 11. Molar pregnancy
Nalaboff, K. M. et al. Radiographics 2001;21:
Copyright ©Radiological Society of North America, 2001

29. Molar Pregnancy Management Surgical evacuation of uterus
Close follow up with serial HCG until negative 3 weeks in a row
Monthly HCG to verify negative for months
Risk is development of persistent gestational trophoblastic disease

30. Molar Pregnancy
Sequelae:
Risk of gestational trophoblastic disease 30

31. Ectopic Pregnancy Definition
Pregnancy that develops after implantation of the blastocyst anywhere other than the endometrium lining the uterine cavity

32. Ectopic Pregnancy

33. Types of Ectopic Pregnancies
Tubal (>95%)
Abdominal cavity
Cervical
Ovarian
Heterotopic
Bilateral Ectopic

34. Risk factors for Ectopic Pregnancy
High Risk
-previous ectopic pregnancy
-previous tubal surgery
-sterilization
-use of IUD
-documented tubal pathology
-In utero diethylstilbestrol exposure

35. Ectopic Pregnancy Diagnosis
Classic symptoms:
-abdominal/pelvic pain
-abnormal uterine bleeding/spotting
-amenorrhea
Pregnancy associated symptoms
Symptoms due to rupture: syncope, shock
~50% of women are asymptomatic before tubal ruputure

36. Ectopic Pregnancy Physical findings
Tenderness – abdominal, adnexal or cervical motion tenderness
Adnexal mass
Orthostatic changes if ruptured
Often unremarkable

37. Surgical Management Ectopic Pregnancy
Laparoscopy or laparotomy
Indications:
Clinically unstable
Unable to comply with medical management
Failure of medical treatment
Contraindications to methotrexate

38. Medical Management of Ectopic Pregnancy
Methotrexate
Indications:
Hemodynamically stable
Patient able to return for follow-up care
Patient has no contraindications to methotrexate
Unruptured mass ≤3.5 cm
No fetal cardiac activity
β-hCG less than 15,000

39. Management of Ectopic Pregnancy
Methotrexate
Contraindications
Breastfeeding
Immunodeficiency
Abnormal liver or kidney function
Known sensitivity to methotrexate
Gestational sac >3.5 cm
Cardiac activity

40. Clinical Case
29 year old G2P1001 with LMP 7 weeks ago presents complaining of vaginal bleeding.

41. Evaluation History HPI: LMP, pain, bleeding (volume, tissue), trauma
PGYN: menstrual history, Sexual history/STD’s
OB history: D&E’s, recurrant Ab’s
PMH/PSH: bleeding disorders, surgical risk
Meds/Soc Hx/Fam Hx
ROS: Symptoms of acute blood loss/anemia

42. Evaluation Physical Exam Vital signs Abdominal exam: peritoneal signs?
Pelvic
Speculum exam – trauma, lesions, products of conception, clot vs. active bleeding
Bimanual – size of uterus, cervical dilation, adnexal masses, CMT

44. Evaluation Labs quantitative HCG (human chorionic gonadotropin CBC
Type and screen
Coags? (if significant hemorrhage and risk of DIC)
LFT’s, SMA-7? (if considering methotrexate for treatment of ectopic)

45. Evaluation
Radiology
ultrasound

47. Management Expectant Management Medical Management Surgical Management
Await spontaneous passage of tissue
Medical Management
Misoprostol (E1 prostaglandin analog)
Surgical Management
Dilation and Currettage
Manual Vacuum Aspiration

50. Early Pregnancy Loss Review basics of preconception care
Review normal early pregnancy
Develop a differential diagnosis of early pregnancy loss including risk factors, presentation and management
Define ectopic pregnancy including risk factors, presentation and management