Jefelson Eu P.

Nahid Group IX May 7, 2020

Abortion and Ectopic Pregnancy

A. Abortion is defined as the spontaneous or induced termination of pregnancy before

fetal viability which is before 20 weeks gestation, or with weight of less than 500g.

More than 80 percent of spontaneous abortions occur within the first 12 weeks of gestation.
Maternal factors include: (1) Infections that may infect, (2) Medical Disorders, (3) Cancer, (4) Surgical
procedures, (5) Nutrition, (6) Social and behavior factors, most
often related to chronic and especially heavy use of legal substances. The most
commonly used is alcohol, with its potent teratogenic effects. Excessive caffeine consumption has been
associated with a higher abortion risk. Paternal factors include increasing age.

Definition of terms:
1. Threatened abortion - presumed when bloody vaginal discharge or bleeding appears
through a closed cervical os during the first 20 weeks. accompanied by suprapubic discomfort, mild
cramps, pelvic pressure, or persistent low backache.
2. Incomplete abortion - bleeding follows partial or complete placental separation and dilation of the
cervical os. Before 10 weeks’ gestation, the fetus and the placenta are frequently expelled together, but
later, they deliver separately. Products lying loosely within the cervical canal can be easily extracted with
ring forceps. In contrast, with incomplete expulsion, three management options include curettage,
expectant management, or misoprostol (Cytotec), which is prostaglandin E1 (PGE1).
3. Complete abortion - complete expulsion of the entire pregnancy may ensue, and the cervical
os subsequently closes. A history of heavy bleeding, cramping, and passage of tissue is typical. Patients
are encouraged to bring in passed tissue, in which a complete gestation should be discerned from blood
clots or a decidual cast. The latter is a layer of endometrium in the shape of the uterine cavity that when
sloughed can appear as a collapsed sac.
4. Missed abortion - This describes dead products of conception that have been retained for days or
weeks in the uterus with a closed cervical os. Diagnosis is imperative prior to intervention and avoids
interruption of a potentially live IUP. Transvaginal sonography is the primary tool.
5. Inevitable Abortion - Preterm premature rupture of membranes (PPROM) at a previable gestational
age. Rupture may be spontaneous or may follow an invasive procedure such as amniocentesis or fetal
surgery. A gush of vaginal fluid that is seen pooling during sterile speculum examination confirms the
diagnosis.
6. Induced Abortion - medical or surgical termination of pregnancy before the time of fetal viability.
7. Therapeutic abortion - termination of pregnancy for medical indications. Most frequent
indication currently is to prevent birth of a fetus with a significant anatomical, metabolic, or mental
deformity.

Recurrent Miscarriage - Affecting approximately 1 percent of fertile couples, recurrent pregnancy loss
(RPL) is classically defined as three or more consecutive pregnancy losses <20 weeks’ gestation or with a
fetal weight <500 g. Three widely accepted causes of recurrent pregnancy loss include: (1) parental
chromosomal abnormalities, (2) antiphospholipid antibody syndrome, (3) structural uterine
abnormalities.
Midtrimester abortion – fetal loss extends from the end of the first trimester until the fetus weighs
<500g or gestational age reaches 20 weeks. Unlike earlier miscarriages that frequently are caused by
chromosomal aneuploidies, these later fetal losses are due to a multitude of causes which includes:
(1) Fetal Anomalies (Chromosomal, Structural); (2) Uterine Defects (Congenital, Leiomyomas,
Incompetent cervix); (3) Placental Causes (Abruption, previa; Defective spiral artery transformation;
Chorioamnionitis); (4) Maternal Disorders (Autoimmune, Infections, Metabolic). Management include
cervical cerclage, which may be employed for cervical insufficiency.

B. Ectopic Pregnancy - Following fertilization and fallopian tube transit, the blastocyst normally implants
in the endometrial lining of the uterine cavity. Implantation elsewhere is considered ectopic.

Tubal Pregnancy – 95 percent of ectopic pregnancies are implanted in the various segments of the
fallopian tube. (70% - Ampulla, most common site), (12% - Isthmic), (11% - fimbrial), and (2% -
interstitial tubal pregnancies). Risks includes a. abnormal fallopian tube anatomy, b. prior surgeries, c.
prior sexually transmitted disease or other tubal infection. Clinical manifestation includes delayed
menstruation, pain, and vaginal bleeding or spotting. With tubal rupture, lower abdominal and pelvic
pain is usually severe and frequently described as sharp, stabbing, or tearing. Abdominal
palpation elicits tenderness. Bimanual pelvic examination, especially cervical motion, causes exquisite
pain. The posterior vaginal fornix may bulge from blood in the rectouterine cul-de-sac, or a tender,
boggy mass may be felt beside the uterus. The uterus can also be slightly enlarged due to hormonal
stimulation. Symptoms of diaphragmatic irritation, characterized by neck or shoulder pain, especially on
inspiration, develop in perhaps half of women with sizable hemoperitoneum.
Diagnosis:
1. Laboratory Test –
B-HCG – (+) pregnancy test at 10 – 20 mIU/ml
Discriminatory level of b-HCG is 1,500 mIU/ml
Serum progesterone
>25 ng/mL excludes ectopic pregnancy
<5 ng/mL FDU/ectopic
10-25 ng/mL is the usual level in ectopic pregnancy
2. Sonography – to assess the location and size
a. transvaginal ultrasound will reveal
Gestational sac at 4.5 – 5 weeks
Yolk sac at 5-6 weeks
Fetal pole with heartbeat at 5.5-6 weeks
b. transabdominal ultrasound – can only recognize uterine pregnancy at 28 days after timed
ovulation (5-6 menstrual weeks)
3. Culdocentesis – aspirate on the posterior fornix, if the fluid does not clot, consider ectopic pregnancy
4. Multimodality diagnosis –
a. transvaginal ultrasound
b. serum b-HCG
c. Serum progesterone
d. uterine curettage
e. laparoscopic/laparotomy

Management:
Surgical management
 1. Salphigostomy – linear incision at the antimesenteric border, left unsutured to heal by second
intention.
2. salphingotomy – same as salphigostomy but sutured.
3. salphingectomy – tubal resection

Medical management
1. Methotrexate – folic acid antagonist, contraindicated in patients with abdominal hemorrhage,
intrauterine pregnancy, breastfeeding, immunodeficiency, chronic renal disease, chronic hepatic
disease, chronic pulmonary disease, blood dyscrasia, peptic ulcer disease. Predictor of success include b-
HCG monitoring with level of <1000mIU/mL as the lowest and <10,000 mIU/mL as the highest.

Different criteria for ectopic pregnancies:

Rubin’s criteria for cervical pregnancy

1. placenta intimately attached to the cervix
2. positive endocervical glands opposite the placental attachment
3. placenta attached below the insertion of uterine arteries and anterior deflection of the
bladder to the peritoneum.

Spiegelburg’s criteria for ovarian pregnancy

1. tubes and fimbriae are normal
2. gestational sac is connected to the uterus via the ovarian ligament
3. gestational sac occupy the location of the ovary
4. positive ovarian tissue on the wall of the gestational sac

Studdiford’s criteria for abdominal pregnancy

1. tubes and ovaries are normal without signs of past or present pregnancy
2. no retroperitoneal fistula
3. pregnancy related to peritoneal surface and early enough to eliminate secondary
implantation

Criteria for heterotrophic pregnancy

1. fundus enlarged to AOG
2. positive symptoms of pregnancy despite excision of ectopic
3. positive hemoperitoneum despite termination in intrauterine pregnancy
4. abdominal pain, adnexal mass, and tenderness, peritoneal irritation and evidence of
Intrauterine pregnancy in more than 8 weeks.