Download - Intrauterine demise- 1st trimester
1ST TRIMESTER INTRAUTERINE FETAL DEMISE
DR. Archana Rathore
DEFINATIONFirst-trimester fetal death: Death of
the fetus in the first 12 weeks of gestation Many prefer miscarriage to refer to
spontaneous fetal loss before viability. Use of sonography and measurement of
serum human chorionic gonadotropin levels allow identification of extremely early pregnancies whose failure to be termed as early pregnancy loss or early pregnancy failure.
incidenceOf all pregnancies diagnosed from β-
HCG measurements 31% are lost. Preclinical or silent-22% (2/3rd) Clinical-12% (1/3rd)
About 80% of spontaneous pregnancy losses occur in the first trimester; the incidence decreases with each gestational week.
Most of these occur <8 weeks.
classificationCan be classified as
Anembryonic gestation Preclinical (2/3rd)
Biochemical pregnancy loss Clinical(1/3rd)
Natural course of 1st trimester IUD Missed abortion Incomplete abortion Complete abortion Inevitable abortion Septic abortion
Missed abortion Presence of definitive
embryo without cardiac activity
Expelled spontaneously in about 4 weeks
Now readily diagnosed by USGCRL ≤ 6 mm: viability
uncertain, rescan in 7-10 days
CRL > 10 mm: delayed miscarriage
50% due to chromosomal abnormality
Anembryonic gestation (blighted ovum)
An intrauterine sac without fetal tissue present at more than 7.5 weeks of gestation
USG criteriaMSD ≤20 mm: viability
uncertain, rescan in 7-10 days
MSD >20 mm: blighted ovum
Accounts for ½ of pregnancy loss
causes Chromosomal abnormalities Luteal phase defects Thyroid disorders Diabetes mellitus Asherman syndrome Infections Others
Contraceptives Smoking Alcohol Radiation Trauma Drugs
Chromosomal abnormalityAutosomal trisomy
50% of all chromosomal anomalies M.C. is trisomy 16
Polyploidy Normosaic triploid/ tetraploidy
Results in partial moleTetraploidy non viable
Diploid/triploid mosaicismSex chromosome polysomy
Frequency increased in ICSI
Monosomy X Single most common
chromosomal cause (15-20%)
Maternal age not contributory
80% of Monosomy X abort rest are live born with turner’s syndrome.
Autosomal MonosomyTranslocationsInversionsMendelian or polygenic factors
30-50% of 1st trimester pregnancy loss showing no chromosomal abnormalities
Abortus have isolated structural defects Confined placental mosaicism-
mosaicism restricted to placenta Uniparental disomy- due to trisomic
rescue
Luteal phase defectsDefn.- Lag of >2 days in histologic
development of Endometrium to day of menstrual cycle.
Mechanism Inadequate progesterone secretion due to
deficient action of corpus luteum Endometrium not responsive to
progesterone Estrogen primed endometrium unfavorable
for implantation Early & recurrent pregnancy loss
Causes Hypothalamo-pituitary-ovarian axis
Decreased FSHAbnormal pattern of LH secretionDecreased LH & FSH surge at ovulation
Hyperprolactenemia Hypothyroidism Ovarian
PCOSRuptured corpus luteum
UterineFibroidUterine septaEndometriosis
Diabetes mellitusRisk increases with loss of metabolic
control measured by HbA1cAlso with increased insulin resistance or
serum insulin levelsIf diabetes is controlled in 1st 21 days of
conception & maintained throughout pregnancy, abortion risk become equivalent to non diabetic controls but risk of congenital malformation remains unchanged.
Influence of hyperglycemia Implantation-inhibits trophoectoderm
differentiation Embryogenesis- increases oxidative
stress affecting expression of critical genes essential for embryogenesis
Miscarriage- increases premature programmed cell death of key progenitor cells of blastocyst
Organogenesis- activates the diacylglycerol-protein kinase C cascade increasing congenital defects
Thyroid disordersHypothyroidism
Thyroid peroxidase negativeHyperthyroidism
TSH 2.5-4 mIU/ml (3.6%) <2.5 mIU/ml (6.1%)
Autoimmune thyroidits: Thyroid antibodies
Antibody to thyroid peroxidaseAntibody to thyroglobulin
Asherman syndromeIntrauterine adhesions- loss of endometrial
surface area resulting in either failure of implantation or expulsion of products of conception on further growth
Causes Uterine curettage Intrauterine surgery, e.g. myomectomy Endometriosis PID- tuberculosis, schistosomiasis Infections related to intrauterine devices
Clinical presentation hypo or amenorrhea infertility repeated miscarriages
Diagnosis Hysteroscopy Hysterosalpingography (HSG) Sonosalpingography
Treatment: hysteroscopic resection
infections
Viral Parvovirus B19 Cytomegalovirus Variola Varicella
Bacterial Ureaplasma Chlamydia
Parasitic Toxoplasma Malaria
Infections causing fever Salmonella Shigella E.coli
diagnosisPresenting complaints
Amenorrhea Bleeding PV Passage of clots Passage of tissues Pain in abdomen Discharge PV Fever, chills, rigors
Past history Previous pregnancy
loss & their timing Uterine surgery Any febrile illness Stillbirths Malformed babies Big size baby Infertility
Menstrual history Regularity of cycles Any shortening of
cycles
Personal history Age Hypertension, diabetes mellitus, thyroid
disorders Contraceptive use Drug intake Alcohol & smoking Exposure to radiation
Family history Diabetes mellitus Genetic disease
Examination Pallor Temperature Pulse Blood pressure Tachypnea /dyspnea Body mass index Neck swelling Galactorrhea P/A
Abdominal distensionAbdominal
tendernessEnlarged irregular
shaped uterus
P/S Status of os Bleeding Discharge POC’s in vagina
P/V Uterine size Status of os Bleeding POC’s in cervical canal Adnexal mass Adnexal tenderness Uterine tenderness
Investigations Hemoglobin Blood group & Rh typing Peripheral smear for TLC, DLC Platelet count BT, CT, CRT Sickling Coagulation profile
PTaPTTFibrinogen level
Blood culture Intrauterine products culture
Confirmation USG- normal findings
5 wks- empty GS- MSD 10mm5.5 wks- GS with yolk sac6 wks- heart beat- embryo 3 mm- MSD 16 mm6.5 wks-CRL 6mm7 wks-CRL 10 mm8 wks- CRL 16 mm- amniotic sac- fetal body
movements β-HCG
1500(3000) U/ml- TVS(TAS) shows GS2X in 48 hrs- normal intrauterine pregnancyFall- miscarriageLow value or <2X rise- extrauterine pregnancyHigh value- twin pregnancy or H. mole
Criteria for predicting non viability Sac size (Nyberg criteria)
>20(8-TVS) mm without yolk sac>25(16-TVS) mm without embryo
Failure of sac/embryo to grow at expected rate (1.1 mm/day)
Embryo of 10 mm without cardiac activity
Loss of cardiac activity previously present
Failure of rise in β-HCG levels at expected rate (2X in 48 hrs)
Yolk sac >6 mm with abnormal morphology
Specific InvestigationsThyroid
Sr. TSH levels Sr. fT4 levels
Diabetes Blood sugar levels HbA1c levels Sr. insulin levels
Infections IgM, IgG antibodies HRP-2
Chromosomal abnormalities Products of conception
HistopathologyCultureKaryotyping- FISH, array CGH, 24 chromosome
SNP Placenta- karyotyping Parents- karyotyping
managementHemodynamic
ally stable•Patient’s choice•Expectant•Medical•Surgical
Hemodynamically unstable
•Stabilize vitals•Arrange for blood•surgical
Septic abortion
•Broad spectrum i.v. antibiotics•surgical
expectant
• Wait and watch• Up to 7 days• No intervention
medical
• Misoprost induction
surgical
• Manual vacuum aspiration
• Electric vacuum aspiration
• Dilatation & evacuation
Prenatal counseling Early registration Repeat abortion Congenital malformation Diet control Regular follow up Assisted reproductive techniques Folic acid administration 3 month before
conception Investigations and management accordingly
Prenatal investigations HbA1c TSH Chorionic villous biopsy Trophoectoderm biopsy Preimplantation genomic diagnosis (PGD) Luteal phase defects
Basal body temperature (BBT) chartFollicular size USGSr. Progesterone level
• At D21 <10 ng/ml• 3 measurements within D5-D9 after ovulation-
total <30 ng/ml, pooled concn. <9 ng/ml Luteal phase endometrial biopsySr. prolactin level
Management Control of diabetes Control of thyroid disorders LPD
GnRH agonistsClomiphene citrateProgesterone support
• Oral• Intramuscular• Vaginal suppositories• Vaginal gel
Bromocriptine