Abortion resident survival guide: Difference between revisions
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{{SK}} Miscarriage; pregnancy termination | {{SK}} Miscarriage; pregnancy termination | ||
==Overview== | ==Overview== | ||
Abortion refers to pregnancy loss occurring before 20 weeks of gestation. Without external intervention is known as Spontaneous abortion. An example of a life-threatening cause that may result in death or permanent disability within 24 hours if left untreated is a ruptured | [[Abortion]] refers to [[pregnancy]] loss occurring before 20 weeks of [[gestation]]. Without external intervention is known as [[Spontaneous abortion]]. An example of a life-threatening cause that may result in death or permanent disability within 24 hours if left untreated is a ruptured [[Ectopic pregnancy]]. Other causes include [[chromosomal abnormalities]], [[infections]], [[cervical]] anomalies, etc. [[Ultrasound]], β-HCG, and [[progesterone]] levels are helpful in confirming [[diagnosis]] and [[treatment]] could be conservative, [[medical]], or [[surgical]] depending on the cause, presentation, and/or patient's preference. Administer Rhogam to [[Rh (D) disease|Rh (D)]] negative mothers, and [[counsel]], accordingly if pregnancy is subsequently desired. Medical management is [[contraindicated]] in conditions like severe [[anemia]], [[bleeding disorders]], etc while surgical intervention is not indicated with an unconfirmed [[diagnosis]] of [[spontaneous abortion]]. | ||
==Causes== | ==Causes== | ||
===Life Threatening Causes=== | ===Life Threatening Causes=== | ||
* Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. | |||
** Ruptured ectopic pregnancy | *Life-threatening causes include conditions that may result in death or permanent [[disability]] within 24 hours if left untreated. | ||
** Blunt abdominal trauma with hemodynamic instability | **Ruptured [[ectopic pregnancy]] | ||
**Blunt [[abdominal trauma]] with [[hemodynamic instability]] | |||
===Common Causes=== | ===Common Causes=== | ||
* Unknown | |||
* Chromosomal abnormalities such as: | *Unknown | ||
**Trisomies | *[[Chromosomal abnormalities]] such as: | ||
**Molar | **[[Trisomies]] | ||
**Blighted ovum | **[[Molar pregnancy]] | ||
* Congenital anomalies | **[[Blighted ovum]] | ||
* Infections | *[[Congenital anomalies]] | ||
* Cervical insufficiency | *[[Infections]] | ||
* Abnormalities of the reproductive system e.g. uterine malformations, fibroids especially submucosal. | *Cervical insufficiency | ||
* Behavioural/lifestyle causes such as illicit drug and alcohol use, smoking | *Abnormalities of the [[reproductive system]] e.g. [[uterine]] [[malformations]], [[fibroids]] especially [[submucosal]]. | ||
* Environmental such as exposure to radiation | *[[Behavioural]]/[[lifestyle]] causes such as illicit drug and [[Alcohol, Drug Abuse, and Mental Health Services Block Grant|alcohol]] use, [[smoking]] | ||
* Uncontrolled chronic diseases (Diabetes, Hypertension, Hypo/Hyperthyroidism, Antiphospholipid syndrome, etc) | *[[Environmental Health Perspectives|Environmental]] such as exposure to [[radiation]] | ||
* Iatrogenic such as amniocentesis, chorionic villus sampling | *Uncontrolled [[chronic diseases]] ([[Diabetes]], [[Hypertension]], Hypo/[[Hyperthyroidism]], [[Antiphospholipid syndrome]], etc) | ||
*[[Iatrogenic]] such as [[amniocentesis]], [[chorionic villus sampling]] | |||
==Diagnosis== | ==Diagnosis== | ||
*Shown below is an algorithm summarizing the diagnosis of Abortion.<ref>https://www.aafp.org/afp/2005/1001/p1243.html</ref> <ref>https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/pediatrics/spontaneous-abortion/</ref> | *Shown below is an algorithm summarizing the diagnosis of Abortion.<ref>https://www.aafp.org/afp/2005/1001/p1243.html</ref> <ref>https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/pediatrics/spontaneous-abortion/</ref> | ||
{{familytree/start}} | {{familytree/start}} | ||
| Line 79: | Line 82: | ||
==Treatment== | ==Treatment== | ||
* Shown below is an algorithm summarising the treatment of abortion.<ref>https://www.aafp.org/afp/2005/1001/p1243.html</ref> | |||
*Shown below is an algorithm summarising the treatment of abortion.<ref>https://www.aafp.org/afp/2005/1001/p1243.html</ref> | |||
{{Family tree/start}} | {{Family tree/start}} | ||
{{Family tree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |A01=Viable pregnancy?}} | {{Family tree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |A01=Viable pregnancy?}} | ||
| Line 102: | Line 106: | ||
==Do's== | ==Do's== | ||
* Administer Rhogam to Rh (D) negative mothers and counsel accordingly if pregnancy is subsequently desired. | |||
* Counsel/Reassure patients and their partners when they are available on how to deal with guilt, the grieving process, and handling friends and family.<ref name="pmid16225027">{{cite journal| author=Griebel CP, Halvorsen J, Golemon TB, Day AA| title=Management of spontaneous abortion. | journal=Am Fam Physician | year= 2005 | volume= 72 | issue= 7 | pages= 1243-50 | pmid=16225027 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16225027 }} </ref> | *Administer Rhogam to Rh (D) negative mothers and counsel accordingly if pregnancy is subsequently desired. | ||
* Reversible risk factors can be addressed professionally. | *Counsel/Reassure patients and their partners when they are available on how to deal with guilt, the grieving process, and handling friends and family.<ref name="pmid16225027">{{cite journal| author=Griebel CP, Halvorsen J, Golemon TB, Day AA| title=Management of spontaneous abortion. | journal=Am Fam Physician | year= 2005 | volume= 72 | issue= 7 | pages= 1243-50 | pmid=16225027 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16225027 }} </ref> | ||
* Reassure when the cause is unknown. | *Reversible risk factors can be addressed professionally. | ||
*Reassure when the cause is unknown. | |||
==Don'ts== | ==Don'ts== | ||
* Contraindications to conservative management/use of uterotonic drugs are: | |||
** Severe blood loss leading to anemia | *Contraindications to conservative management/use of uterotonic drugs are: | ||
** Septicemia or pelvic infections | **Severe blood loss leading to anemia | ||
** Shock | **Septicemia or pelvic infections | ||
** Equivocal diagnosis of abortion/desired pregnancy | **Shock | ||
** Presence of bleeding disorder | **Equivocal diagnosis of abortion/desired pregnancy | ||
** Ectopic pregnancy | **Presence of bleeding disorder | ||
** Molar pregnancy | **Ectopic pregnancy | ||
** Adverse reaction to uterotonic agents | **Molar pregnancy | ||
** >12 weeks uterine volume | **Adverse reaction to uterotonic agents | ||
* Surgical management is contraindicated in the following settings: | **>12 weeks uterine volume | ||
** Presence of bleeding disorder that has not been corrected | *Surgical management is contraindicated in the following settings: | ||
** Unconfirmed diagnosis of abortion | **Presence of bleeding disorder that has not been corrected | ||
**Unconfirmed diagnosis of abortion | |||
==References== | ==References== | ||
Revision as of 03:00, 24 October 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifeoma Anaya, M.D.[2]
Synonyms and keywords: Miscarriage; pregnancy termination
Overview
Abortion refers to pregnancy loss occurring before 20 weeks of gestation. Without external intervention is known as Spontaneous abortion. An example of a life-threatening cause that may result in death or permanent disability within 24 hours if left untreated is a ruptured Ectopic pregnancy. Other causes include chromosomal abnormalities, infections, cervical anomalies, etc. Ultrasound, β-HCG, and progesterone levels are helpful in confirming diagnosis and treatment could be conservative, medical, or surgical depending on the cause, presentation, and/or patient's preference. Administer Rhogam to Rh (D) negative mothers, and counsel, accordingly if pregnancy is subsequently desired. Medical management is contraindicated in conditions like severe anemia, bleeding disorders, etc while surgical intervention is not indicated with an unconfirmed diagnosis of spontaneous abortion.
Causes
Life Threatening Causes
- Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
- Ruptured ectopic pregnancy
- Blunt abdominal trauma with hemodynamic instability
Common Causes
- Unknown
- Chromosomal abnormalities such as:
- Congenital anomalies
- Infections
- Cervical insufficiency
- Abnormalities of the reproductive system e.g. uterine malformations, fibroids especially submucosal.
- Behavioural/lifestyle causes such as illicit drug and alcohol use, smoking
- Environmental such as exposure to radiation
- Uncontrolled chronic diseases (Diabetes, Hypertension, Hypo/Hyperthyroidism, Antiphospholipid syndrome, etc)
- Iatrogenic such as amniocentesis, chorionic villus sampling
Diagnosis
| Female of reproductive age, gestation <20weeks, bleeding per vagina, +/-pelvic pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Targeted history and examination, β-HCG,CBC, type and screen | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Hemodynamically stable? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| IV access and fluid resuscitation, move to the ED and send consult to OBGYN | Signs of peritonitis? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Pelvic ultrasound | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Intrauterine | Extrauterine, confirmed ectopic? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Surgery. Stabilise if need be | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Threatened abortion; viable preganancy+closed cervix | Missed abortion; non-viable pregnancy+closed cervix | Inevitable abortion; viable pregnancy+open cervix | Incomplete abortion; Retained Products of Conception+closed cervix | Complete abortion; empty uterus+closed cervix | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Uncertain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Serial prpogesterone, β-HCG, ultrasound | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Ectopic Pregnancy | ↑β-HCG >66% in 48hrs,normal ultrasound, progesterone >25ng/ml | Progesterone <5ng/ml, β-HCG ↓ or ↔, non-viability on ultrasound | β-HCG equivocal, ultrasound not diagnostic, progesterone 5-25ng/ml | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Treat accordingly | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Surgery | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Uncertain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| β-HCG every 2-3 days, repeat ultrasound weekly till viability is ascertained | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Treatment
- Shown below is an algorithm summarising the treatment of abortion.[3]
| Viable pregnancy? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Threatened abortion | Missed, incomplete or inevitable abortion | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Weekly check ups till bleeding ceases, administer Rhogam[Rhο(D)] immunoglobulin if indicated, watch out for oligohydramnios, IUGR and preterm labor | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Any complications? E.g.pain, hemorrhage, sepsis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Counsel on expectant management | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Consent | Decline | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Follow-up with serial β-HCG | Uterine evacuation or medical treatment | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Uterine evacuation and stabilise patient | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do's
- Administer Rhogam to Rh (D) negative mothers and counsel accordingly if pregnancy is subsequently desired.
- Counsel/Reassure patients and their partners when they are available on how to deal with guilt, the grieving process, and handling friends and family.[4]
- Reversible risk factors can be addressed professionally.
- Reassure when the cause is unknown.
Don'ts
- Contraindications to conservative management/use of uterotonic drugs are:
- Severe blood loss leading to anemia
- Septicemia or pelvic infections
- Shock
- Equivocal diagnosis of abortion/desired pregnancy
- Presence of bleeding disorder
- Ectopic pregnancy
- Molar pregnancy
- Adverse reaction to uterotonic agents
- >12 weeks uterine volume
- Surgical management is contraindicated in the following settings:
- Presence of bleeding disorder that has not been corrected
- Unconfirmed diagnosis of abortion
References
- ↑ https://www.aafp.org/afp/2005/1001/p1243.html
- ↑ https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/pediatrics/spontaneous-abortion/
- ↑ https://www.aafp.org/afp/2005/1001/p1243.html
- ↑ Griebel CP, Halvorsen J, Golemon TB, Day AA (2005). "Management of spontaneous abortion". Am Fam Physician. 72 (7): 1243–50. PMID 16225027.