Spontaneous and Legal Abortion

• Causes of bleeding during pregnancy during the first trimester can include abortion

Abortion

• Delivery of a fetus before it can survive

Legal Abortion

• Less than 20 weeks gestation, or less than 500 grams

Spontaneous Abortion

• Occurs in 10-20% of all pregnancies
• 60% are due to chromosomal defects
• Fetus typically dies 2-4 weeks before bleeding or abortion
• Other causes include viruses, chemicals, infections, and radiation
• If a fetal heartbeat is heard between 8-12 weeks via ultrasound, the pregnancy usually continues

Threatened Abortion

• Characterized by bleeding and cramping with an intact membrane and closed cervix
• Treatment includes rest, vaginal rest, and saving any passed tissue

Inevitable Abortion

• Involves bleeding/cramping with cervical dilation, possibly with ruptured membranes, but without tissue passage

Complete Abortion

• All products of conception are expelled
• May involve a blighted ovum (intact ball without a fetus)

Incomplete Abortion

• Only part of the tissue is expelled

Missed Abortion

• The conceptus is retained for 8 weeks after fetal death

Habitual Abortion

• Occurs in 3 consecutive pregnancies

Induced Abortion

• Deliberate interruption of pregnancy before viability

Therapeutic Abortion

• Performed when the pregnancy threatens the patient's life or health
• Can occur in cases of rape or incest, or when the fetus is defective
• Rhogam is administered to Rh-negative mothers

Ectopic Pregnancy

• Occurs in approximately 1 in 100 to 1 in 200 pregnancies
• About 40% are associated with a previous inflammatory process (PID) in tubal pregnancies
• Other causes transmigration of ovum, previous ectopic pregnancy, tubal ligation

Classic Triad of Symptoms

• Pain
• Amenorrhea
• Vaginal bleeding
• Usually occurs 6-8 weeks after the last menstrual period (LMP)
• 50% report pregnancy symptoms
• 50% have a palpable pelvic mass
• Pregnancy test is usually, but not always, positive
• Can rupture and bleed into the abdomen, potentially causing hypovolemic shock

Diagnosis Dilemma

• Fever Absent:
• Ruptured corpus luteum cyst
• Torsion of the tube or ovary
• Threatened/incomplete abortion
• Fever Present:
• PID
• Appendicitis
• Septic abortion
• Tubo-ovarian abscess

Diagnosis

• Ultrasound (transvaginal)
• Culdocentesis: aspirate non-clotting blood
• Serosanguinous fluid indicates a corpus luteum cyst without need for surgery

Treatment

• Laparoscopy/surgery

Placental Abruption (Abruptio Placentae)

• Occurs in the third trimester
• Separation of a normally implanted placenta before delivery
• Can be overt or occult
• Results in hemorrhage and maternal/fetal death
• Etiology is often unknown, but may include trauma, short umbilical cord, pregnancy-induced hypertension (PIH), chronic hypertension, history of placental abruption, smoking, and cocaine use

Clinical Findings

• Severe abruption involves vaginal bleeding, tense uterus, absent fetal heart tones (FHT), and shock
• Moderate abruption includes mild-moderate uterine bleeding, increased uterine tone and irritability, lower abdominal discomfort, and mild fetal distress
• Mild abruption may resemble bloody show and early labor contractions
• Presence of uterine tenderness and increased uterine resting tone are suspicious

Management

• Referral
• Assessment of maternal blood loss and replacement with IV fluids
• Electronic fetal monitoring (EFM) to note fetal distress; a dead fetus may show maternal pulse
• Ultrasound evaluation of placenta
• If fetal distress or maternal blood loss is unmanageable, a C-section may be necessary

Placenta Previa

• Presents as painless, bright red, vaginal bleeding
• Pelvic exams are contraindicated

Diagnosis

• Ultrasound

May Be

• Complete: implanted across the os
• Partial: covers part of the internal os
• Marginal: placenta just reaches the edge of the internal os
• Risks include maternal hemorrhage and fetal distress

Hydatidiform Mole

• Related to first trimester bleeding

Trophoblastic Disease (Hydatidiform Mole)

• Occurs when the trophoblast degenerates to form edematous, grapelike vesicles
• Presence of a fetus is rare
• Mostly benign, but can invade locally (chorioadenoma destruens) or metastasize (choriocarcinoma)
• Vaginal bleeding (usually after the first trimester) may lead to hemorrhage
• Uterus may be larger or smaller than expected
• Hyperemesis is common
• Unusually high levels of HCG

Diagnosis

• Ultrasound

Hypertension in Pregnancy

• Involves diagnosis, treatment, outcome, and consequences

Pregnancy-Induced Hypertension (PIH)

• Commonly referred to as toxemia of pregnancy
• Occurs on at least two occasions, 6 hours apart, while the patient is at rest
• Blood pressure is greater than 140/90 or an increase of 30 mm Hg systolic or 15 mm Hg diastolic

Preeclampsia

• Defined as hypertension, edema, and/or proteinuria after 20 weeks of gestation (except with hydatidiform mole earlier)
• Edema may only be detectable as increased weight gain: more than 2.5 lb./week or 4 lb./2 weeks

Severe Preeclampsia

• Blood pressure greater than 160/110
• Proteinuria greater than 2+
• Oliguria less than 400 ml/24 hours
• Cerebral or visual disturbances
• Pulmonary edema or cyanosis
• Epigastric pain
• Intrauterine growth retardation (IUGR)

HELLP Syndrome

• Hemolysis (microangiopathic hemolytic anemia)
• Elevated Liver function tests
• Low Platelet counts

Risks Associated with Preeclampsia

• Fetal: IUGR, uteroplacental insufficiency, oligohydramnios, placental abruption, prematurity
• Maternal: CNS seizures and stroke, Disseminated intravascular coagulation (DIC), renal/hepatic failure, increased C-section risk

Eclampsia

• Defined as preeclampsia with convulsions

Chronic Hypertension

• Sustained elevated blood pressure before 20 weeks of gestation

Superimposed Toxemia

• Preeclampsia/eclampsia in the latter part of pregnancy in conjunction with chronic hypertension

Current System of Classification

• Hypertension without proteinuria or edema
• Hypertension with proteinuria or edema (preeclampsia), either mild or severe
• Hypertension with proteinuria/edema and convulsions (eclampsia)

Gestational Diabetes

• Focus on diagnosis, testing, treatment goals, and outcomes

Diagnosis History

• Diabetic parent or sibling
• Previous infant weighing more than 9 lb./4000 grams
• Persistent/significant glycosuria
• Previous unexplained stillbirth or neonatal death
• Previous congenital abnormality
• Obesity (weight greater than 200 lb.)

Additional Red Flags

• Polyhydramnios
• Excessive thirst
• Recurrent UTIs
• Age over 30
• Persistent candida vulvovaginitis

Glucose Screening Test

• 1-hour post 50 gm glucose load at 24-28 weeks gestation (non-fasting)
• Normal is less than 140 mg/dl (plasma)
• If greater than 140 mg/dl, do a full 3-hour GTT after a 100 gm glucose load

Glucose Screening Test cont

• 150 gm carbs for 3 days before test
• FBS less than 105
• 1-hour less than 190
• 2-hour less than 165
• 3-hour less than 145
• Positive for GDM if any two levels are elevated