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!