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    Case Presentation: Prepared By: Kevin Marcial I. Aralar, MD 1St Year Resident

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    Kevin Aralar
    This case presentation describes a 23-year-old pregnant woman who presented with an incidental finding of embryonic demise at 11 weeks and 3 days gestation. Her medical, surgical, family, and social histories were otherwise unremarkable. A transvaginal ultrasound confirmed the embryonic demise. She underwent an uncomplicated dilatation and curettage procedure. The final diagnosis was a completed abortion at 9 weeks and 6 days gestation. Spontaneous abortion is common in the first trimester, often due to fetal or maternal factors. Different classifications and management options for abortion were discussed.

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    Case Presentation: Prepared By: Kevin Marcial I. Aralar, MD 1St Year Resident

    Uploaded by

    Kevin Aralar
    40 views47 pages
    This case presentation describes a 23-year-old pregnant woman who presented with an incidental finding of embryonic demise at 11 weeks and 3 days gestation. Her medical, surgical, family, and social histories were otherwise unremarkable. A transvaginal ultrasound confirmed the embryonic demise. She underwent an uncomplicated dilatation and curettage procedure. The final diagnosis was a completed abortion at 9 weeks and 6 days gestation. Spontaneous abortion is common in the first trimester, often due to fetal or maternal factors. Different classifications and management options for abortion were discussed.

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    This case presentation describes a 23-year-old pregnant woman who presented with an incidental finding of embryonic demise at 11 weeks and 3 days gestation. Her medical, surgical, family, and social histories were otherwise unremarkable. A transvaginal ultrasound confirmed the embryonic demise. She underwent an uncomplicated dilatation and curettage procedure. The final diagnosis was a completed abortion at 9 weeks and 6 days gestation. Spontaneous abortion is common in the first trimester, often due to fetal or maternal factors. Different classifications and management options for abortion were discussed.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    40 views47 pages

    Case Presentation: Prepared By: Kevin Marcial I. Aralar, MD 1St Year Resident

    Uploaded by

    Kevin Aralar
    This case presentation describes a 23-year-old pregnant woman who presented with an incidental finding of embryonic demise at 11 weeks and 3 days gestation. Her medical, surgical, family, and social histories were otherwise unremarkable. A transvaginal ultrasound confirmed the embryonic demise. She underwent an uncomplicated dilatation and curettage procedure. The final diagnosis was a completed abortion at 9 weeks and 6 days gestation. Spontaneous abortion is common in the first trimester, often due to fetal or maternal factors. Different classifications and management options for abortion were discussed.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 47

    CASE PRESENTATION

    PREPARED BY:
    KEVIN MARCIAL I. ARALAR, MD
    1ST YEAR RESIDENT
    GENERAL DATA

    • G.Y.
    • 23 years old
    • Married
    • Pasay City
    CHIEF COMPLAINT

    • Incidental finding of embryonic demise


    HISTORY OF PRESENT PREGNANCY

     Suspected pregnancy
    8 weeks amenorrhea
     Home pregnancy test kit (+)

     (-) symptoms
     No consult done. No meds taken
    HISTORY OF PRESENT PREGNANCY

     First prenatal check up


    At 7 1/7 weeks AOG
     Laboratories done
     Transvaginal ultrasound - Single, live,
    intrauterine pregnancy, 6 weeks and 1 day AOG
    by crown rump length – FHB 100bpms
     Given prenatal medications
     Advised for follow up
    HISTORY OF PRESENT PREGNANCY

    • Follow up check up
    At 11 3/7 weeks AOG
    • (-) symptoms
    • Repeat ultrasound - Embryonic demise, 9
    weeks and 6 days AOG by crown rump
    length
    • Advised for curettage
    LABORATORIES

    • RT PCR 11/2/2021 • Complete blood count 11/3/2021


    • Not detected • Hgb 116
    • Hct 34
    • WBC 6.6
    • Plt 204
    • HBS Antigen 11/3/2021 • S66
    • Non-reactive • L22
    • M9
    PAST FAMILY PERSONAL AND
    MEDICAL HISTORY SOCIAL HISTORY
    HISTORY
    • No Hypertension • (+) Hypertension – • College graduate
    • No Diabetes Mellitus maternal side
    • Married
    • No Bronchial Asthma • (+) Heart disease –
    • Works as an IT support
    maternal side
    • No Thyroid disease
    • No Diabetes Mellitus • Non smoker
    • No known allergies to food
    or medications • No Bronchial Asthma • Occasional alcoholic
    • No previous beverage drinker
    • No Thyroid Disease
    hospitalizations or surgeries • Denies illicit drug use
    MENSTRUAL HISTORY

    • Menarche: 12 y/o
    • Interval: Regular at 28-30 days
    • Duration: 3-5 days
    • Amount: 2 pads per day, moderately soaked
    • Symptoms: no dysmenorrhea

    • Last menstrual period: August 11, 2021


    • Prior menstrual period: July 13, 2021
    SEXUAL HISTORY

    • Coitarche: 15 y/o
    • Number of sexual partners – 4
    • (-) OCP
    • (-) dyspareunia or post-coital bleeding
    • (-) STD
    OBSTETRICAL HISTORY

    • Gravida 4 Para 0 (0-0-3-0)

    Gravida Year Sex Outcome Mode of delivery Place FMC


    1 2014 Abortion –
    Induced
    2 2016 Abortion –
    induced
    3 2018 Abortion -
    induced
    4 2021 Present pregnancy
    REVIEW OF SYSTEMS

    • General Survey: (-) pain, (-) fever, (-) weight loss, (-) chills, (-) change in appetite
    • Cutaneous: (-) hair loss, (-) rashes
    • HEENT: (-) blurring of vision, (-) excessive lacrimation, (-) decreased hearing, (-)
    ear pain, (-) colds, (-) epistaxis, (-) oral ulcers, (-) sore throat, (-) nasal discharge,
    (-) excessive salivation
    • Respiratory: (-) dyspnea, (-) shortness of breath, (-) cyanosis, (-) cough
    REVIEW OF SYSTEMS

    • Cardiovascular: (-) chest pain, (-) palpitations (-) orthopnea, (-) PND, (-) edema
    • Gastrointestinal: (-) nausea, (-) vomiting, (-) diarrhea, (-) melena, (-)
    hematemesis,
    • Endocrine: (-) thyroid enlargement, (-) heat or cold intolerance (-) polyuria, (-)
    polyphagia, (-) polydipsia
    REVIEW OF SYSTEMS

    • Nervous/Behavioral: (-) headache, (-) change of behavior, (-) seizures, (-)


    paralysis
    • Musculoskeletal: (-) joint stiffness/pain, (-) muscle atrophy, (-) restriction of
    movement, (-) deformity
    • Hematologic: (-) pallor, (-) petechiae, (-) gum bleeding, (-) easy bruisability
    PHYSICAL EXAMINATION

    • General: conscious, coherent, ambulatory


    • Vital Signs:
    • BP: 115/76 HR: 80 RR: 19 T: 36.5°C
    • Ht: 160cm Wt: 42kg BMI: 16.4kg/m2
    • Skin: warm moist skin, no rashes
    • HEENT: Anicteric sclera, pink palpebral conjunctiva
    • Lungs: symmetric chest wall, no deformities, no retractions, symmetrical chest expansion, clear
    breath sounds
    • Heart: adynamic precordium, normal rate, regular rhythm
    • Abdomen: flat, normoactive bowel sounds, soft, nontender
    • Extremities: pulses full and equal on all extremities, no clubbing, no cyanosis,
    PELVIC EXAMINATION

    • Inspection: grossly normal looking external genitalia


    • Speculum exam: cervix is violaceous, smooth, no gross lesion, with minimal brownish
    discharge, non foul smelling, no active vaginal bleeding
    • Internal exam
    • Cervix soft, close, no cervical motion tenderness, uterus slightly enlarged, no adnexal
    mass/tenderness
    ASSESSMENT

    • Gravida 4 Para 0 (0-0-3-0) Pregnancy uterine, 9 weeks, missed


    abortion
    PLAN

    • Dilatation & curettage


    ON ADMISSION

    • NPO
    • IVF: D5LR 1L + 10 u oxytocin x 8hrs
    • Evening primrose 4 softgels per vagina
    • Anesthesia: IV sedation
    INTRAOPERATIVE FINDINGS

    • Uterine cavity sounded at 9.0cm, anteverted


    • Curetted about 5cc of placental like tissues
    POST OPERATIVE ORDERS

    • S/P completion curettage under IV sedation


    • To recovery room
    • NPO temporarily
    • IVF: D5LR 1L + 10 u oxytocin x 8hrs
    • Medications:
    1. Co-Amoxiclav 625mg/tab every 8hrs for 7 days
    2. Mefenamic acid 500mg/cap, 1 cap every 8hrs for pain
    • Patient was discharged stable
    FINAL DIAGNOSIS

    • Gravida 4 Para 0 (0-0-4-0) Abortion completed


    • s/p Dilatation and curettage (Nov. 2021)
    SALIENT FEATURES

    • 23 years old
    • Gravida 4 Para 0 (0-0-3-0)
    • Cessation of menses
    • Pregnancy test positive
    • (-) hypogastric pain, vaginal bleeding, watery vaginal discharge
    • Internal examination: Cervix soft, close, uterus slightly enlarged
    • TVS: Embryonic demise, 9 weeks and 6 days AOG by crown rump length
    DISCUSSION
    ABORTION

    • Spontaneous or induced termination of pregnancy before fetal viability


    • prior to 20 weeks of gestation or
    • With a fetus weighing less than 500g
    FIRST-TRIMESTER SPONTANEOUS ABORTION

    • Pathogenesis:
    • More than 80 % of spontaneous abortions are in the first 12 weeks
    • Demise of the embryo always precedes spontaneous expulsion
    PATHOGENESIS

    Hemorrhage into decidua basalis

    Tissue necrosis

    Products of conception detaches and acts as foreign body

    Stimulates uterine contractions

    Cervical dilatation

    Complete or partial expulsion of products of conception


    INCIDENCE

    • In 5 to 20 weeks’ gestation
    • 11 – 22 percent
    FETAL FACTORS

    1. Euploid abortion
    • 50% of abortions

    2. Aneuploid abortion
    • 75% abort before 8 weeks gestation
    • 95% are due to maternal gametogenesis errors
    MATERNAL FACTORS

    • Infections • Nutrition
    • Medical disorders • Social and Behavioral Factors
    • Diabetes Mellitus • Alcohol
    • Thyroid Disorders • Smoking
    • Obesity

    • Cancer
    PATERNAL FACTORS

    • Increasing paternal age


    • Chromosomal abnormalities in spermatozoa
    CLASSIFICATION OF SPONTANEOUS ABORTION

    1. Threatened abortion
    2. Inevitable abortion
    3. Incomplete abortion
    4. Complete abortion
    5. Missed abortion
    6. Septic abortion
    Threatened Inevitable Incomplete Complete Missed
    Contractions +/- +++ +/- - -
    Bleeding + ++ ++ + with passage -/spotting
    of meaty
    materials
    Cervical Closed Open Open Closed Closed
    dilatation
    BOW Intact Ruptured Ruptured or Unappreciable Unappreciable
    unappreciable
    MISSED ABORTION

    • Death of the embryo or fetus before 20


    weeks with complete retention of all
    products of conception
    • Diagnosis: Transvaginal ultrasound –
    primary tool
    • With rapid confirmation of embryonic or
    fetal death, surgical or medical evacuation
    or expectant observation is an option
    SEPTIC ABORTION

    • Miscarriage and elective abortion complicated by severe infections


    • Endomyometritis – most common manifestation
    • Management:
    • Intravenous broad-spectrum antibiotics and uterine evacuation
    RECURRENT ABORTION

    • 2 or more failed pregnancies confirmed by sonographic or histopathological examination.


    • Primary recurrent pregnancy loss
    • Secondary recurrent pregnancy loss

    • >50% chances for a successful pregnancy even after five losses


    • Etiology: parental chromosomal abnormalities, antiphospholipid antibody syndrome,
    structural uterine abnormalities
    INDUCED ABORTION

    • Medical or surgical termination of pregnancy before the time of fetal viability

    1. Therapeutic abortion – termination for medical indications


    2. Elective abortion – interruption of pregnancy before viability at the request of the
    woman
    ABORTION METHODS

    • Medical or surgical
    SURGICAL ABORTION

    • Preoperative preparation
    • Preoperative cervical ripening
    • Hygroscopic dilators
    • Misoprostol
    HYGROSCOPIC DILATOR

    • Laminaria, Dilapan S
    • They absorb endocervical and local tissue fluids, causing the device to expand within the
    endocervix and provide mechanical pressure
    • Advantages: Outpatient placement, no need for fetal monitoring
    • Risks: Fetal and/or maternal infection
    MISOPROSTOL

    • Often used for cervical ripening


    • 400ug – sublingually, buccally or placed into the poster vaginal fornix 3-4 hrs prior to
    surgery

    Mifepristone
    • 200mg orally 24 to 48hrs before surgery
    SURGICAL ABORTION

    Vacuum aspiration
    • Suction dilation and curettage / suction curettage
    • Rigid cannula is attached either to an electric-powered vacuum source or to a handheld 60-ml
    syringe

    Sharp dilatation and curettage


    • First dilating the cervix and then evacuating the pregnancy by mechanically scraping out the
    contents
    ABORTION COMPLICATIONS

    • Uterine perforations
    • Lower genital tract laceration
    • hemorrhage
    • Incomplete removal of products
    • Postoperative infections
    MEDICAL ABORTION

    • 3 medications are used alone or in combination


    1. Mifepristone - antiprogestin
    2. Methotrexate
    3. Misoprostol - PGE1

    Mifepristone/misoprostol combinations are favored because of its greater efficacy


    • Mifepristone 200mg orally followed 24-48hrs by Misoprostol 800ug
    THANK YOU!

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