Excitationpain
U/S
3. Differential Diagnosis
Implantation of embryo into endometrium (normal)
Spontaneous abortion
Ectopic pregnancy
Gestational trophoblastic disease
Abnormal placentation (ie. placenta previa) usually does not cause
bleeding until later in pregnancy
4. Spontaneous Abortion
5. Spontaneous Abortion
Definition: Passing of a pregnancy prior to 20 weeks gestation
(aka: miscarriage)
Half of pregnancies complicated by 1st trimester bleeding end in
spontaneous abortion
Causes separated into genetic and environmental (maternal)
Genetic abnormalities in 50-70% of SAs
Trisomy most common anomaly
Other causes include maternal systemic disease (ie. diabetes,
hypothyroidism, autoimmune dx), infection, maternal anatomic
defects (ie. bicornuate uterus)
Often, exact cause is unknown
6. Classification of Spontaneous Abortion
Threatened: Vaginal bleeding without cervical dilation
Incomplete: Vaginal bleeding with partial expulsion of products of
conception (POC) + cervical dilation
Missed: Embryonic demise prior to 20 wks without expulsion of POC
+/- vaginal bleeding
Complete: Vaginal bleeding + expulsion of all POC
Inevitable: Vaginal bleeding + cervical dilation
Septic: Any of the above + uterine infection
7. First-trimester Milestones
5 weeks: Gestational sac (~5mm) seen with TVUS
6 wks: Embryo (1-2mm) visible on TVUS
Yolk sac: Seen with TVUS when GS>10mm (>20 w/ TAUS)
Cardiac activity: Seen with TVUS when GS >18mm (>25mm on
TAUS)
Cardiac activity should always be seen when embryo >5mm
Normal gestational sac at arrow, endometrial cavity at curved
arrow
8. Double decidual sac sign
GS=gestational sac, DP=decidua parietalis, * = endometrial cavity,
arrow=decidua capsularis
9. Normal US Findings
Yolk sac (at arrow) within gestational sac
Yolk sac (at curved arrow) with embryo (between Xs)
10. Normal US Findings
Embryo (black arrow); amnion (small arrow) does not fuse with
chorion (large arrow) until 12-16wks gestation.
11. Spontaneous Abortion
Presentation: Varies greatly depending on type of abortion, but
often presents with vaginal bleeding and uterine cramps or back
pain.
-hCG: Falling or rising abnormally slow
US findings vary depending on classification andcause of
abortion
Anembryonic pregnancy: large (>18mm) gestational sac without
embryo
12. Abnormal US Findings: Spontaneous Abortion
Missed abortion: embryo (at arrow) is relatively small compared to
large gestational sac. No cardiac activity was present.
Abortion in progress: low-lying gestational sac (thick arrow),
decidual reaction and hemorrhage (mixed hyper- and hypo-echoic
material between arrowheads)
13. Threatened Abortion
14. Threatened Abortion
Threatened abortion is defined as vaginal bleeding before 20 weeks
of gestation
30-40% of all pregnant women
25-50% will progress to spontaneous abortion
15. History
( )
16. Symptoms
Usually bleeding begins first
Cramping abdominal pain follows a few hours to several days
later
Presence of bleeding & pain
-> Poor prognosis for pregnancy continuation
17. Physical examination
Vital signs : normal
Abdomen usually is not tender
Cervix is closed
Bleeding can be seen coming from the os, and usually there is no
cervical motion or adnexaltenderness
18. Investigation
CBC :
Blood group : ABO Rh
UA : UTI
Wet smear : gonorrhea chlamydia
19. Investigation
Urine pregnancy test
Serial measurements of hCG
Ultrasonography :
TAS :
TVS : TAS 1
20. ultrasound 3
:
: ultrasound 1
:
21. Treatment
There are no effective therapies for threatened abortion.
Bedrest, although often prescribed, does not alter its
course.
Progesterone or sedatives should not be used
Acetaminophen-based analgesia may be given to help relieve
discomfort
All patients should be counseled and reassured so that they
understand the situation
22. Inevitable abortion
23. Inevitable / Imminent abortion
