ABORTION AND ECTOPIC PREGNANCY PPTX.pptx

a 63 slide powerpoint about ectopic pregnancy and abortion

1. Abortion and Ectopic Pregnancy TARIMAN, ROGELIO RR M. CLINICAL CLERK

2. Abortion is defined as pregnancy termination or loss before 20 weeks gestation or with a fetus delivered weighing <500 grams (WHO, CDC, NCHS) ABORTION

3. ABORTION Nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus without fetal activity within the first 12 6/7 weeks AOG (American College of Obstetricians and Gynecologists)

4. SPONTANEOUS ABORTION

5. Termination of pregnancy without deliberate measures before 20 weeks gestation SPONTANEOUS ABORTION Abortion Intoduction >80% occur within the first 12 weeks of gestation 1.5- 3% occur during the early second trimester 1% after 16 weeks’ gestation Threatened Incomplete Inev i table Complete Missed Septic

6. Abortion Intoduction Threatened Incomplete Inev i table Complete Missed Infections Medical Disorders Cancer Surgical Procedure Nutrition Social and behavioral EUPLOID Abortion Chromosomal Abnormality or Aneuploidy FETAL FACTORS MATERNAL FACTORS SPONTANEOUS ABORTION ETIOLOGY Septic

7. Abortion Intoduction Threatened Inev i table Incomplete Complete Missed General Overview MATERNAL FACTORS Occupational & Environmental Uterine defects Autoimmune factors Trauma Substance Maternal Age EUPLOID Abortion Chromosomal Abnormality or Aneuploidy FETAL FACTORS SPONTANEOUS ABORTION ETIOLOGY Septic

8. Abortion Intoduction Threatened Incomplete Inev i table Complete Missed Septic SPONTANEOUS ABORTION THREATENED ABORTION Bleeding through a cervical os in the first 20 weeks of pregnancy and with a live embryo or fetus Characteristics: Vital signs within normal limits Uterine enlargement in the first half of pregnancy with or without hypogastric pain Presence of bloody discharge Abdomen is soft and non-tender uterine size = AOG Internal exam: CLOSED CERVIX and intact BOW UTZ: viable fetus with good FHT

9. Abortion Intoduction Threatened Incomplete Inev i table Complete Missed SPONTANEOUS ABORTION THREATENED ABORTION Bleeding through a cervical os in the first 20 weeks of pregnancy and with a live embryo or fetus Management: Avoid strenuous activities (e.g. sexual intercourse) Bed rest Analgesia Watch out for bleeding Monitor fetal status (b- hCG and progesterone) Hb and Hct monitoring Septic

10. Abortion Intoduction Threatened Incomplete Inev i table Complete Missed SPONTANEOUS ABORTION INEV I TABLE ABORTION The sudden discharge of fluid is accompanied or followed by vaginal bleeding Characteristics: Sudden discharge of fluid Vaginal bleeding that is more severe than with threatened abortion Lower abdominal pain (crampy) similar to dysmenorrhea which persist s or worsen s Internal exam: DILATED CERVIX, RBOW Septic

11. Abortion Intoduction Threatened Incomplete Inev i table Complete Missed SPONTANEOUS ABORTION INEV I TABLE ABORTION The sudden discharge of fluid is accompanied or followed by vaginal bleeding Management: Await for spontaneous expulsion If >16 weeks AOG, fetal parts are well formed, await spontaneous expulsion then evacuate remaining contents Evacuation of retained products Do ultrasound to check for remnants ⚬ Perform completion curettage Septic

12. Abortion Intoduction Threatened Incomplete Inev i table Complete Missed SPONTANEOUS ABORTION INCOMPLETE ABORTION Tissue may remain entirely within the uterus or partially extrude through the cervix. Characteristics Products of conception may be partially present in the uterus, may protrude from the external os, or may be present in the vagina If with intense vaginal bleeding, the patient may be shocky Septic

13. Abortion Intoduction Threatened Incomplete Inev i table Complete Missed SPONTANEOUS ABORTION INCOMPLETE ABORTION Tissue may remain entirely within the uterus or partially extrude through the cervix. Characteristics Internal exam: cervix may either be dilated, closed or effaced Suprapubic tenderness UTZ: presence of remnant of conception in the uterus Septic

14. Abortion Intoduction Threatened Incomplete Inevetable Complete Missed SPONTANEOUS ABORTION INCOMPLETE ABORTION Tissue may remain entirely within the uterus or partially extrude through the cervix. Management Treatment of shock Give oxytocin Completion curettage Hysterotomy Septic

15. Characteristics History of abdominal pain and vaginal bleeding as well as passage of clots and tissues Bleeding and pain have subsided Uterus is contracted Uterus size is smaller than expected for gestational age UTZ: empty uterus Pregnancy test: negative 2 weeks after abortion Abortion Intoduction Threatened Incomplete Inev i table Complete Missed Septic SPONTANEOUS ABORTION COMPLETE ABORTION The entire pregnancy is expelled.

16. Management The patient is usually well and fit to go home Evacuation of the uterus is NOT necessary Ensure follow- up for probable missed abortion or retention of products Potential complication with retained products: trophoblastic diseases and choriocarcinoma Request UTZ 2 weeks after miscarriage Abortion Intoduction Threatened Incomplete Inev i table Complete Missed Septic SPONTANEOUS ABORTION COMPLETE ABORTION The entire pregnancy is expelled.

17. Abortion Intoduction Threatened Incomplete Inev i table Complete Missed SPONTANEOUS ABORTION MISSED ABORTION Dead products of conception may be retained for prolonged periods of time without expulsion with a closed cervical os Characteristics Embryo dies and the uterus did not expel its contents Retention can be 8 weeks or more Loss of pregnancy symptoms: breast non- tender, loss of cravings, disappearance of vomiting Septic

18. Abortion Intoduction Threatened Incomplete Inev i table Complete Missed SPONTANEOUS ABORTION MISSED ABORTION Dead products of conception may be retained for prolonged periods of time without expulsion with a closed cervical os Characteristics Uterine size is smaller than expected Closed cervix UTZ: no FHB, embryo/fetal size is smaller than expected for gestational age Septic

19. Abortion Intoduction Threatened Incomplete Inev i table Complete Missed SPONTANEOUS ABORTION MISSED ABORTION Dead products of conception may be retained for prolonged periods of time without expulsion with a closed cervical os Management Cervical preparation (decreases the length of the uterine evacuation process) Misoprostol 800 micrograms dose vaginally repeated in 1 to 2 days Mifepristone 200 mg OD 24 hours prior to misoprostol Septic

20. Abortion Intoduction Threatened Incomplete Inev i table Complete Missed SPONTANEOUS ABORTION SEPTIC ABORTION Any abortion, spontaneous or induced, that is complicated by uterine infection, including endometritis Characteristics Associated with infection Associated with incomplete induced abortion History/experiencing abdominal pain, fever/chills, vaginal bleeding, and foul vaginal discharge Severe endothelial injury, capillary leakage, hypotension, profound leukocytosis Septic

21. Abortion Intoduction Threatened Incomplete Inevetable Complete Missed SPONTANEOUS ABORTION SEPTIC ABORTION Any abortion, spontaneous or induced, that is complicated by uterine infection, including endometritis Management Management of infection Empiric therapy: Clindamycin 900mg IV q8h + Gentamicin 5mg/lg IV OD, with or without Ampicillin 2g IV q4h Antitetanus for instrumentation abortion Evacuate uterus (preferably suction evacuation) • Do hysterectomy in severe, unresponsive case Septic

22. RECURRENT PREGNANCY LOSS

23. RECURRENT PREGNANCY LOSS Three or more consecutive pregnancy losses before 20 weeks from the last normal period or with fetal weights less than 500 grams (Philippine Obstetrical and Gynecological Society) Two or more failed pregnancies confirmed by sonographic or histopathological examination (American Society for Reproductive Medicine)

24. RECURRENT PREGNANCY LOSS P ARENTERAL CHROMOSOMAL ABNORMALITIES ENDOCRINOPATHIES ANTIPHOSPHOLIPID ANTIBODY SYNDROME ANATOMICAL FACTORS -> Uterine abnormalities

25. RECURRENT PREGNANCY LOSS PARENTERAL CHROMOSOMAL ABNORMALITIES Most common: reciprocal translocation or Robertsonian translocation ANTIPHOSPHOLIPID ANTIBODY SYNDROME ANATOMICAL FACTORS

26. PARENTERAL CHROMOSOMAL ABNORMALITIES ANTIPHOSPHOLIPID ANTIBODY SYNDROME Family of autoantibodies that bind to phospholipid- binding plasma proteins Associated with thrombosis, thrombocytopenia, recurrent abortions and fetal loss Management: LMWH and Aspirin ANATOMICAL FACTORS RECURRENT PREGNANCY LOSS

27. P ARENTERAL CHROMOSOMAL ABNORMALITIES ANTIPHOSPHOLIPID ANTIBODY SYNDROME ANATOMICAL FACTORS Uterine synechiae (Asherman Syndrome) is a destruction of large areas of endometrium that can follow uterine curettage, surgeries, or uterine compression sutures Sonography: multiple filling defects Treatment: hysteroscopic adhesiolysis RECURRENT PREGNANCY LOSS

28. INDUCED ABORTION

29. THERAPEUTIC Most frequent indication: prevent birth of a fetus with significant anatomical, metabolic or mental deformity ELECTIVE/VOLUNTARY Interruption of pregnancy before viability at the request of the woman, but not for medical reasons INDUCED ABORTION Medical or surgical termination of pregnancy before the time of fetal viability

30. THERAPEUTIC Most frequent indication: prevent birth of a fetus with significant anatomical, metabolic or mental deformity Interrup of at the r viability not for ELECTIVE/VOLUNTARY tion pregnancy before equest of the but medical woman, reasons INDUCED ABORTION Medical or surgical termination of pregnancy before the time of fetal viability

31. MIDTRIMESTER ABORTION

32. MIDTRIMESTER ABORTION Extends from the end of first trimester until the fetus weighs <500 grams or gestational age reaches 20 weeks Unlike earlier miscarriages that frequently are caused by chromosomal aneuploidies, these later fetal losses are due to a multitude of causes Many second- trimester abortions are medically induced because of fetal abnormalities detected by prenatal screening programs for chromosome aneuploidy and structural defects

33. CERVICAL INSUFFICIENCY Incompetent cervix Painless vaginal bleeding and cervical dilatation in the second trimester Ultrasound Cervical length of less than 25 mm Funneling (Ballooning of membranes into dilated internal os but with closed external os) Management: cerclage

34. Surgical reinforcement of the weak cervix by an encircling suture If the cervical length measures <25 mm, cerclage is offered to this group of women Contraindications: bleeding, contractions or ruptured membrane CERVICAL INSUFFICIENCY

35. ECTOPIC PREGNANCY

36. ECTOPIC PREGNANCY

37. Ectopic pregnancy refers to those pregnancies that implant outside the uterine cavity ECTOPIC PREGNANCY This disorder is a leading cause of maternal death in the first trimester of pregnancy Ectopic pregnancies generally result from abnormalities in the structure or function of the fallopian tube

38. ECTOPIC PREGNANCY The most common cause of tubal abnormality associated with ectopic pregnancy is internal inflammation (salpingitis), such as gonococcal salpingitis, chlamydial salpingitis, and salpingitis isthmica nodos Other causes include external tubal scarring secondary to endometriosis, ruptured appendicitis, or previous surgery 30% of all pregnancies that follow tubal ligation are ectopic One of the greatest risk factors is a history of a previous ectopic pregnancy

39. ECTOPIC PREGNANCY Tubal peristalsis is slowed by progestins, such as those released by hormonal contraceptive IUDs, contraceptive implants, injections, and oral contraceptives Higher levels of progesterone induced by ovarian hyperstimulation during use of assisted reproductive technologies can also slow tubal motility Other risk factors include a history of infertility and smoking

40. ECTOPIC PREGNANCY

41. Delayed Menstruation Abdominal/ pelvic pain Vaginal Spotting

42. DECIDUAL CAST Entire sloughed endometrium that takes the form of the endometrial cavity May also occur with uterine abortion No gestational sac or villi

43. ECTOPIC PREGNANCY DIAGNOSIS Serial quantitative hCG levels in serum Sequential ultrasonic imaging

44. ECTOPIC PREGNANCY DEFINITION ETIOLOGY S/SX PATHOPHYSIO DIAGNOSIS MANAGEMENT OTHER TYPPES Serial quantitative hCG levels in serum 20 to 25 mIU/mL for urine and less than or equal to 5 mIU/mL for serum DISCRIMINATORY ZONE Range of hCG values in which an ultrasonic image can first detect the signs of an intrauterine pregnancy 1500 to 2000 mIU/mL of hCG ECTOPIC PREGNANCY DIAGNOSIS

45. Serial quantitative hCG levels in serum 20 to 25 mIU/mL for urine and less than or equal to 5 mIU/mL for serum ABOVE THE DISCRIMINATORY ZONE: When the hCG level exceeds the upper limit of the DZ and no signs of an intrauterine pregnancy are seen on ultrasound: ectopic pregnancy ECTOPIC PREGNANCY DIAGNOSIS

46. Gestational Sac 4.5 to 5 weeks Yolk sac 5 to 6 weeks Fetal pole with cardiac motion 5.5 to 6 weeks Sequential Ultrasonic Imaging ECTOPIC PREGNANCY DIAGNOSIS

47. True gestational sac With 2 hyperechoic ring (double ring sign) Eccentric location Steady, usually round shape Pseudosac Single layer border Centrally located Shape may change during scan • High vascular glow • Avascular flow

48. TRANSVAGINAL ULTRASOUND

49. TRANSVAGINAL ULTRASOUND Visualization of an adnexal mass separate from the ovary If fallopian tubes and ovaries are visualized and an extrauterine yolk sac, embryo, or fetus is identified, then an ectopic pregnancy is confirmed Hyperechoic halo or tubal ring surrounding an anechoic sac Ring of fire: placental blood flow within the periphery if the complex adnexal mass

50. DIAGNOSIS ENDOMETRIAL CURRETAGE Low rate of increase in hCG titers <35% in 48 hours Decrease in hCG titers that is too slow to represent a complete abortion (<30% in 48 hours) The absence of chorionic villi on examination of the biopsy specimen makes the diagnosis of ectopic pregnancy more likely

51. SERUM PROGESTERONE suggests either a IUP or an ectopic <5 ng/mL nonliving pregnancy In most ectopic pregnancies, progesterone levels range between 10 and 25 ng/ML >25 ng/mL excludes ectopic pregnancy

52. SERUM PROGESTERONE Significantly lower at 4,5,6 weeks compared to intrauterine gestations 4 weeks AOG: 5 ng/mL 5 weeks AOG: 10 ng/mL 6 weeks AOG: 20 ng/mL

53. OTHER TESTS MRI LAPAROSCOPY CULDOCENTESIS

54. METHOTREXATE Folic acid antagonist Tightly binds to dihydrofolate reductase, blocking the reduction of dihydrofolate to tetrahydrofolate De novo purine and pyramidine synthesis is halted Arrested DNA, RNA, and protein synthesis MEDICAL MANAGEMENT

55. Hemodynamically stable Beta- hCG <5,000 mIU/mL No fetal cardiac rate Ectopic mass <3.5 cm Willing and able to comply with post- treatment follow- up No cardiac activity Abnormal baseline laboratories Immunodeficiency Active pulmonary disease Peptic Ulcer Disease Hypersensitivity Heterotropic pregnancy Breastfeeding Active bleeding Optimal Candidates Contraindications MEDICAL MANAGEMENT

56. Fetal cardiac activity Size and volume of gestational mass (>4cm) High initial hCG concentration (>5000 mIU/mL Hemoperitoneum Rapidly increasing hCG concentrations (>50% over 48h before MTX treatment) Continued rapid rise in hCG concentrations during MTX Predictors of MTX Treatment Failure

57. SURGICAL MANAGEMENT

58. Thank You ! By : Rogelio Rr M. Tariman