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Complications of Pregnancy

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Spontaneous Abortion

 

Abortion is defined as termination of pregnancy resulting in expulsion of an immature, nonviable fetus. A fetus of <20 weeks gestation or a fetus weighing <500 gm is considered an abortus. Spontaneous abortion occurs in 15% of all pregnancies.

Threatened abortion is defined as vaginal bleeding occurring in the first 20 weeks of pregnancy, without the passage of tissue or rupture of membranes.

Symptoms of pregnancy (nausea, vomiting, fatigue, breast tenderness, urinary frequency) are usually present.
Speculum exam reveals blood coming from the cervical os without amniotic fluid or tissue in the endocervical canal.
The internal cervical os is closed, and the uterus is soft and enlarged appropriate for gestational age.
Differential diagnosis

Benign and malignant lesions. The cervix often bleeds from an ectropion of friable tissue.
Hemostasis can be accomplished by applying pressure for several minutes with a large swab or by cautery with a silver nitrate stick. Atypical cervical lesions are evaluated with colposcopy and biopsy.

Disorders of pregnancy

Hydatidiform mole may present with early pregnancy bleeding, passage of grape-like vesicles, and a uterus that is enlarged in excess of that expected from dates. An absence of heart tones by Doppler after 12 weeks is characteristic. Hyperemesis, preeclampsia, or hyperthyroidism may be present. Ultrasonography confirms the diagnosis.

Ectopic pregnancy should be excluded when first trimester bleeding is associated with pelvic pain. Orthostatic light-headedness, syncope or shoulder pain (from diaphragmatic irritation) may occur.
Abdominal tenderness is noted, and pelvic examination reveals cervical motion tenderness.
Serum beta-HCG is positive.

Laboratory tests

Complete blood count. The CBC will not reflect acute blood loss.
Quantitative serum beta-HCG level may be positive in nonviable gestations since beta-HCG may persist in the serum for several weeks after fetal death.
Ultrasonography should detect fetal heart motion by 7 weeks gestation or older. Failure to detect fetal heart motion after 9 weeks gestation should prompt consideration of curettage.

Treatment of threatened abortion

Bed rest with sedation and abstinence from intercourse.
The patient should report increased bleeding (>normal menses), cramping, passage of tissue, or fever. Passed tissue should be saved for examination.

Inevitable abortion is defined as a threatened abortion with a dilated cervical os. Menstrual-like cramps usually occur.

Differential diagnosis

Incomplete abortion is diagnosed when tissue has passed. Tissue may be visible in the vagina or endocervical canal.
Threatened abortion is diagnosed when the internal os is closed and will not admit a fingertip.
Incompetent cervix is characterized by dilatation of the cervix without cramps.

Treatment of inevitable abortion :

Surgical evacuation of the uterus is necessary.
D immunoglobulin (RhoGAM) is administered to Rh-negative, unsensitized patients to prevent isoimmunization.

Incomplete abortion is characterized by cramping, bleeding, passage of tissue, and a dilated internal os with tissue present in the vagina or endocervical canal. Profuse bleeding, orthostatic dizziness, syncope, and postural pulse and blood pressure changes may occur.

Laboratory evaluation :
  • Complete blood count. CBC will not reflect acute blood loss.
  • Rh typing
  • Blood typing and cress-matching.
  • Karyotyping of products of conception is completed if loss is recurrent.
Treatment:

Stabilization. If the patient has signs and symptoms of heavy bleeding, at least 2 large-bore IV catheters (<16 gauge) are placed. Lactate Ringerís or normal saline with 40 U oxytocin/L is given IV at 200 mL/hour or greater. Products of conception are removed from the endocervical canal and uterus with a ring forceps. Immediate removal decreases bleeding. Curettage is performed after vital signs have stabilized. Suction dilation and curettage The patient is placed in the dorsal lithotomy position in stirrups, prepared, draped, and sedated. A weighted speculum is placed intravaginally, the vagina and cervix are cleansed, and a paracervical block is placed. Bimanual examination confirms uterine position and size, and uterine sounding confirms the direction of the endocervical canal. Mechanical dilatation is completed with dilators if necessary. Curettage is performed with an 8 mm suction curette, with a singletooth tenaculum on the anterior lip of the cervix.

Post-curettage.
After curettage, a blood count is ordered. If the vital signs are stable for several hours, the patient is discharged with instructions to avoid coitus, douching, or the use of tampons for 2 weeks.
Rh-negative, unsensitized patients are given IM RhoGAM.

Complete abortion
A complete abortion is diagnosed when complete passage of products of conception has occurred. The uterus is well contracted, and the cervical os may be closed.


Differential diagnosis

Incomplete abortion

Ectopic pregnancy.
Products of conception should be examined grossly and submitted for pathologic examination. If no fetal tissue or villi are observed grossly, ectopic pregnancy must be excluded by ultrasound.

Management of complete abortion
Between 8 and 14 weeks, curettage is necessary because of the high probability that the abortion was incomplete. D immunoglobulin (RhoGAM) is administered to Rh-negative, unsensitized patients. Beta-HCG levels are obtained weekly until zero.Incomplete abortion is suspected if beta-HCG levels plateau or fail to reach zero within 4 weeks.

Missed abortion
is diagnosed when products of conception are retained after the fetus has expired. If products are retained, a severe coagulopathy with bleeding often occurs. Missed abortion should be suspected when the pregnant uterus fails to grow as expected or when fetal heart tones disappear. Amenorrhea may persist, or intermittent vaginal bleeding, spotting, or brown discharge may be noted.

Ultrasonography confirms the diagnosis.

Management of missed abortion
CBC with platelet count, fibrinogen level, partial thromboplastin time, and ABO blood typing and antibody screen are obtained.

Evacuation of the uterus is completed after fetal death has been confirmed. Dilation and evacuation by suction curettage is appropriate when the uterus is less than 12-14 weeks gestational size.

D immunoglobulin (RhoGAM) is administered to Rh-negative, unsensitized patients.

 

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