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What defines 1st trimester loss?

Termination of pregnancy before 20 weeks, loss before viability outside of the womb


When do the majority of spontaneous miscarriages happen (SAB)?


What are the causes of 1st trimester loss?

Infectious, immune, environmental, endocrine, structural


What is a major endocrine cause of 1st trim loss?

Uncontrolled glucose from type I DM


When is SAB most commonly caused by ETOH?

High doses in the first 8 weeks


What might be some concerning hx symptoms that could indicate 1st trimester loss?

Cramps, backache, vaginal blood or discharge, and uterine contractions


What diagnostics should be run to confirm a viable pregnancy?

Serum B-hCG should double q 48 hrs up to 60-80 days post last menstrual cycle
US: should have gestational sac 4-5 weeks and fetal pole at 5-6 weeks


Spotting or a light bleed around the time of expected pregnancy is normal or abnormal?

Normal if light flow, if heavy like an actual period more likely SAB
Always work them up regardless


What are some benign reasons for spotting?

 Corpus luteum dissolution, implantation


What are the types of spontaneous miscarriages?

 Threatened, inevitable, missed


What are emergent conditions associated with spotting?

Ectopic or molar


What might your pt present with if threatened abortion?

Hx of spotting and absence of ab/pelvic issues
All the PE is normal


What should you check for if mom is past 12 weeks and threatened abortion?

Check for FHT with doppler


What should you be checking if pt has threatened?

B-hCG, US,


How is a threatened abortion managed?

Reassurance and precautions


What does a threatened abortion mean?

May or may not abort… body is deciding
Have them call if bleeding intensifies or ab and pelvic pain…. No sex no tampons maybe stay off her feet (that probs wont help in real life)


If threatened progresses to inevitable, what s/s might mom present with?

Dilated or open cervix dilted, bleeding, and uterine contractions , low back ache


what is incomplete?

Partially expelled POC, cervix is dilated and there is bleeding and abdominal pain


What is complete?

Os closed, canal clear, uterus has expelled all of the POC, +/- adnexal mass, uterus smaller than GA


How is an incomplete AB managed?

In office… ring forceps to remove visible POC and send to path….monitor B-hCG levels until 0-5.. weekly for about 5 weeks to make sure tissue is gone
KEY: if there is any chorionic villi in sample confirms that POC is out
Hospital: suction curettage to remove POC- monitor B-hCG, will drop quickly


What is a missed AB?

Embryo fails to develop but POC is retained… no pain or symptoms really
May have brown discharge


What do you check in missed AB?

US and Doppler…. Verify no heart beats or nothing in sac


How is missed AB tx?

Need to do hospital outpt suction curettage to remove the POC


What are other managements for missed AB?

-Monitor bleeding/pain symptoms until B-hCG levels 0-5; analgesia PRN
-Minimize infection risk: monitor temp, pelvic rest
-Rh immunoglobulin (Rh negative mothers)
-Emotional support….. these pts will be angry because they were pregnant and had viable pregnancy past 6-8wks


What are the types of induced abortions?

1- Maternal choice: elective termination
2- therapeutic termination


How long do you have to induce abortions with medical option?

Depends on state…. 63 days


What are the medications used in medical abortion?

1st, Oral mifepristone: reverses UC inhibition & causes uterine lining to thin & prevents embryo from remaining implanted
next give misoprostol combo: causes contraction and expulsion, 24-48hrs after mife


when should women be rechecked to make sure there has been complete expulsion?

With in 2 weeks


What is the surgical procedure for abortion?

Vacuum aspiration 13 wks


What are post surgical complications you should have your women come back in for?

 Severe abdominal or back pain
 Heavy bleeding (soaking 2 maxipads per hour x 2 consecutive hours)
 Foul-smelling discharge; Temp > 100.4°F
 Rh immunoglobulin (Rh negative mothers)
 Emotional support