Chpt 60 Miscarriage, Recurrent Miscarriage and Pregancy Termination

What is the incidence of two or more consecutive SABs?

0.4% to 2%.

When is the appropriate time to do such a workup?

After three SABs or in women above 35 after two SABs.

What is the occurrence of uterine anomalies in those with repeated abortion?

10% to 15%.

What percentage of pregnancies end in SAB?

12% to 20% of clinically recognized pregnancies end in SAB, whereas 13% to 26% of unrecognized pregnancies end in SAB.

What percentage of stillbirths?

3%.

What is the risk of subsequent SAB in a patient with three consecutive miscarriages and with at least one liveborn?

30%.

What percentage of second trimester?

30%.

What is the approximate incidence of SAB associated with the unicornuate uterus?

34%.

What is the most common single chromosomal abnormality?

45,X.

How many weeks after fetal death with retained products of conception may consumptive coagulopathy with hypofibrinogenemia occur?

5 weeks.

What percentage of first-trimester SABs have karyotypic abnormalities?

50%.

What is the miscarriage rate if embryonic cardiac activity is seen sonograpically at 6 weeks' gestation and at 8 weeks' gestation?

6% to 8% and 2% to 3%.

What percentage of recurrent aborters have abnormal placentation?

6%. Most are of the circumvallate type.

What is the risk of surgical perforation in the first-trimester patient?

9.4/100,000 induced abortions

Suction curettage accounts for what percentage of all abortion procedures?

90%.

What percentage of abortions are performed within the first 12 weeks of pregnancy?

90%.

Surgical methods are used to terminate pregnancies at which gestational ages?

<7 to 23 weeks typically; however, the upper gestational limit varies according to each state.

Nonsurgical methods can be used to terminate pregnancies at which gestational ages?

<7 to 9 weeks.

What is the risk of ectopic pregnancy in those experiencing repetitive SAB?

A fourfold increased risk.

What is the SAB rate for those with a septate uterus?

21% to 44%.

What percentage of abortions are obtained by married

25%.

What is the risk of subsequent SAB in a patient with three consecutive miscarriages?

30% to 45%.

What is the risk of death from abortion?

0.6/100,000 for elective abortions.

What percentage of SABs become infected?

1% to 2%.

Patients experiencing spontaneous, recurrent abortion would benefit from what established testing?

1) Genetic testing - Karyotype of both parents 2) Anatomic testing - HSG/Sonohysterogram or hysteroscopy (MRI if needed) 3) Immunologic - Lupus anticoagulant/Anticardiolipin antibody 4) Thrombophilias - Factor V Leiden, prothrombin gene mutation, Activated protein C resistance, Homocysteine, MTHFR, Protein C, Protein S, Antithrombin III 5) Endocrine - TSH, Prolactin, Blood sugar, HbA1c 6) infectious - Gonorrhea/Chlamydia 7) History

What is the risk of abortion in those women who have more than two drinks/day of alcohol?

A twofold greater abortion risk.

Are prophylactic antibiotics recommended for pregnancy termination?

ACOG recommends use of 100 mg doxycycline prior to procedure followed by 200 mg post-op.

Why is local anesthesia preferable to general anesthesia with pregnancy termination?

General anesthesia is associated with greater risk of perforation, visceral injury, hemorrhage, and death.

What is the prevalence of major chromosomal abnormalities being present in either partner of a couple with two or more pregnancy losses?

Four to eight percent of couples with recurrent pregnancy loss one or the other partner may have a chromosomal abnormality, usually a balanced translocation.

What androgens have been associated with miscarriage rates?

Androstenedione and testosterone.

What is the most common single type of karyotypic abnormality present in SAB?

Aneuploidy especially trisomies.

What percentage of habitual aborters conceive post-myomectomy?

Approximately 50%.

What effect does laminaria japonicum have on the morbidity associated with forcible dilation during D&E?

Fivefold reduction in cervical laceration.

Name FIVE organisms associated with SAB.

Chlamydia, Toxoplasma gondii, herpes, Listeria, and cytomegalovirus.

What morbid events can occur with the use of local anesthetics?

Convulsions, syncope, and fever have been associated with the use of local anesthetics.

What is the predominate method of abortion beyond the first trimester?

Dilatation and evacuation.

Under what conditions is hysterotomy indicated?

Failed abortion when uterine anomaly is suspected.

What are causes of recurrent SAB?

Genetic, anatomic, immunologic, inherited thrombophilias, infectious, endocrine, and environmental.

What are two important determinants of abortion complication?

Gestational age and method of abortion chosen.

What percentage of pregnancy terminations are done in the first trimester?

In 1990, approximately 88% were done in the first trimester, 11% between 13 and 20 weeks, and 1% were done at 21 weeks or greater.

Name three independent risk factors for SAB.

Increasing parity, maternal age, and paternal age.

What agent is commonly used for multifetal, selective reduction to prevent cases of extreme prematurity?

Intracardiac KCl (0.05 to 3 mL).

What effect will 5 rads have on the abortion rate?

Irradiation of <5 rads will have no effect.

What is the SAB rate following surgical correction of septate uteri?

It decreases to 15%.

What effect does DES exposure have on patients who are able to conceive?

It may have an increased SAB rate, preterm labor and delivery, as well as an increase in the ectopic pregnancy rate.

What are the most common complications of surgical abortions?

Less than 1% of cases will develop hemorrhage, fever, infection, and retained products of conception.

Name tests for evaluation of fetal loss caused by antiphospholipid syndrome

Lupus anticoagulant and anticardiolipin antibody.

What is the etiology of uterine anomalies?

M ducts fusion defects that occur between 6 and 10 weeks in fetal development

What percentage of intrauterine adhesions are caused by spontaneous and induced abortions?

More than two thirds.

How effective is RU 486 when used with misoprostol in first-trimester medical pregnancy termination?

Ninety-seven percent had successful pregnancy termination if given by 49 days from the last menstrual cycle.

How effective is methotrexate when used with misoprostol in first-trimester medical pregnancy termination?

Ninety-six percent had successful pregnancy termination if given by 63 days from the last menstrual cycle.

RU 486 is an analogue of which steroid used frequently in oral contraceptive pill formulations?

Norethindrone.

Is the prevalence of urinary tract anomalies increased in patients with all uterine malformations?

Only for those with unicornuate/bicornuate uterus or uterus didelphys, NOT in those with septate uterus.

What is the SAB rate for those with a bicornuate uterus?

Only slightly higher than the normal population

What is the optimal management for postabortal pain, bleeding, and fever?

Oral antibiotics and ergot medications followed by repeat uterine evacuation performed under local anesthesia in an ambulatory center, if retained products are suspected.

What is the definition of miscarriage?

Pregnancy loss before 20 weeks gestational age.

Which groups of medical agents have been found extremely useful for pregnancy termination?

Prostaglandin E2 (dinoprostone) and prostaglandin E1 (misoprostol) as well as the antiprogestin RU 486 (mifepristone) and the antimetabolite methotrexate have been very useful for this purpose.

Name another method used to induce contractions to perform abortion in the second trimester.

Prostaglandin induction.

What is the most common uterine anomaly?

Septate uterus.

Which country has the highest abortion rate among all Western nations?

The United States of America.

Does caffeine influence fertility or SAB rates?

There is little evidence to support a clear detrimental effect of moderate to high amounts of caffeine intake on fertility or spontaneous miscarriage rates.

What is the effect of smoking on the abortion rate?

Those who smoke >10 cigarettes daily have a greater chance of SAB. Relative risk 1.2 to 3.4.

What is the occurrence of threatened miscarriage and what percentage results in abortion?

Threatened miscarriage occurs in 30% to 40% of human gestations leading to abortion in half of these.

What is "habitual aborter" or recurrent pregnancy loss?

Three or more consecutive spontaneous abortion (SAB).

Name three endocrinologic abnormalities associated with SAB?

Thyroid diseases (both hyper and hypo), uncontrolled diabetes mellitus, and hyperprolactinemia.

What are the most common types of abnormal karyotypes found?

Trisomy (50%), monosomy 45,X (20%), triploidy (10%), and structural abnormalities (5%).

What are the associated causes of hemorrhage after pregnancy termination?

Uterine atony, a low-lying implantation site, a pregnancy of more advanced gestational age, or perforation.

Does high hyperglycemia affect miscarriage rates?

Yes. Studies suggest that achieving euglycemia may lower the miscarriage rate.