POTD: OB/Miscarriage

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Abortion Types

Fetal Heart Tones Open Closed
Present Inevitable Threatened
Absent Incomplete Missed

-If Threatened Abortion, get quantitative beta-hCG and/or progesterone levels to establish viability and risk of ectopy.

>20 weeks=still birth (intrauterine fetal demise)

First Trimester=usually due to chromosomal abnormalities (~70%); also possible:  infection, maternal anatomic defect, immunologic or endocrine factors.  OFTEN DON’T KNOW.

Second Trimester (up to 20 wks)=multiple things, including infection, uterine/anatomic defect, exposure to fetotoxic agent, trauma, maternal systemic disease.   Type I diabetes and Thyroid antibodies may be culprits!  Usually NOT chromosomal abnormality.

Late second trimester/Periviable deliveries=preterm labor (contractions lead to cervical dilation) or incompetent cervix (painless cervical dilation due to cone biopsy, previous dilation, cervical lac during previous vag deliver, or DES exposure).  Uterus unable to maintain a pregnancy.

Mgmt:  Check vitals, get CBC, quantitative beta-HCG, blood type, antibody screen, coags and ultrasound.


If complete (everything came out), just follow for recurrent bleed/signs of infxn

If incomplete, inevitable, or miss, ob may do D&C or administer prostaglandins (misoprostol)

If threatened, pelvic rest w/ nothing per vagina.  At increased risk for preterm labor and PPROM.  Should receive RhoGAM if Rh negative.

If second trimester, D&E or high doses of oxytocin or prostaglandins.  D&E is not inducing labor.  Required to use laminaria to force open cervix which can have several complications (uterine perforation, cervical laceration).   Could also induce labor which takes longer but has fewer complications because no instrumentation is involved.

If trying to save (this is OB, not EM):  cervical cerclage until 36-37 weeks if incompetent cervix OR tocolysis if preterm labor.  If a Transabdominal cerclage/TAC, must do C-section.

Difference between Dilation and Cutterage vs. Dilation and Evaculation is time/procedure.  D&C during first trimester, D&E during second trimester because more difficult/involved.

Recurrent pregnancy loss (3+ losses consecutively), check for:

1.  Antiphospholipid Antibody (APA)- low dose aspirin

2.  Luteal phase defect- give progesterone in future pregnancies

3.  TSH for hypothyroidism

4.  A1C for diabetes

5.  Hypercoagulability;  Factor V Leiden deficiency, Russel Viper Venom, Antithrombin III/prothrombin mutation, Protein S and Protein C- tx w/ Enoxaparin or unfractionated heparin, subQ

6.  SLE (lupus anticoagulant, ANA, dsDNA, anticardiolipin Ab which is also see in Syphillis, Behcet's)

Ob-gyn may do a karyotype, hysterosalpingogram or possibly a hysteroscopic or laparotic exploration.  Still send cultures for infection (vaginal, cervix, endometrium)