Spontaneous Abortion
1. Spontaneous Abortion or Miscarriage
According to RCOG, Miscarriage or Spontaneous Abortion is defined as the spontaneous loss of pregnancy before the fetus reaches viability.The term therefore includes all pregnancy losses from the time of conception until —– of gestation.
a) 18 weeks
b) 20 weeks
c) 22 weeks
d) 24 weeks
e) 28 weeks
Correct Answer: d) 24 weeks.
According to RCOG, Miscarriage is defined as the spontaneous loss of pregnancy before the fetus reaches viability. The term therefore includes all pregnancy losses from the time of conception until 24 weeks of gestation. It is 20 weeks according to ACOG. It is 23 weeks according to NHS.
Miscarriage is defined by the World Health Organization (WHO) as the premature loss of a fetus up to 23 weeks of pregnancy and weighing up to 500 g.
2. Cause of Spontaneous Abortion
Most common cause of First Trimester Spontaneous Abortion
a) Chromosomal abnormalities
b) Syphilis
c) Rhesus isoimmunization
d) Cervical incompetence
e) Bicornuate uterus
Correct Answer: a) Chromosomal abnormalities.
The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities (Aneuploidy) of the embryo or fetus, accounting for at least 50% of sampled early pregnancy losses. Trisomy, monosomy triploidy or tetraploidy are all examlpes of aneuploidy. In these aneuploid abortions most common is Trisomy (31%) and monosomy (10%).
3. First Trimester Abortion
Of the following which is the commonest cause of first trimester Spontaneous Abortion ?
a) Monosomy
b) Trisomy
c) Triploidy
d) Aneuploidy
e) Tetraploidy
Correct Answer: Poorly framed question. d) and then b).
The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities (Aneuploidy) of the embryo or fetus, accounting for at least 50% of sampled early pregnancy losses. Trisomy, monosomy triploidy or tetraploidy are all examlpes of aneuploidy. In these aneuploid abortions most common is Trisomy (31%) and monosomy (10%).
4. Pregnancy of uncertain viability
Early ultrasound during pregnancy that shows a mean gestational sac of 22mm and CRL 5 mm with no visible fetal heart. What is the likely diagnosis ?
a) Inevitable miscarriage
b) Missed miscarriage
c) Pregnancy of uncertain viability
d) Pregnancy of unknown location
e) Threatened miscarriage
Correct Answer: c) Pregnancy of uncertain viability.
This woman should be reassessed in 7 to 10 days time to assess viability. If the gestational sac is larger than 25 mm with no fetal pole, it is suggestive of silent miscarriage. If the CRL is
5. Gestational Sac Diameter
If the mean gestational sac diameter is 23.0 mm with a transvaginal ultrasound scan and there is no visible fetal pole,
a) Perform a second scan a minimum of 7 days
b) Blighted Ovum, terminate
c) Missed Abortion, terminate
Correct Answer: a) Perform a second scan a minimum of 7 days.
Early pregnancy Scan- If the mean G sac diameter is
6. Threatened abortion
A 25-year-0ldprimigravida with 8 weeks threatened abortion. The USG would most likely reveal :
a) Thickened endometrium with no gestational sac.
b) Fetal heart motion in the adnexia.
c) Empty gestational sac.
d) An intact gestational sac with fetal heart motion.
e) Collapsed gestational sac.
Correct Answer: d) An intact gestational sac with fetal heart motion.
7. Inevitable abortion
8 weeks pregnant woman presents with bleeding PV since 1 day. Os is open and bleeding present (minimal). Scan revealed 8 weeks live intrauterine pregnancy. Diagnosis ?
a) Threatened abortion
b) Missed abortion
c) Incomplete abortion
d) Inevitable abortion
e) Pregnancy of uncertain viability
f) Failing pregnancy
Correct Answers: d) Inevitable abortion.
An inevitable miscarriage describes a condition in which the cervix has already dilated open, but the fetus has yet to be expelled. This usually will progress to a complete miscarriage. Threatened miscarriage is when os is closed with normal intrauterine pregnancy.
8. Incomplete Abortion
9 weeks pregnancy scan was normal. Now at 11 weeks she presents with heavy bleeding PV. Os is open and bleeding present. Pallor present (~ 6 gm% clinically) and pulse is 110/min. What would be most appropriate action ?
a) First do USG, then transfuse 2 blood and then D&E.
b) First do USG, then transfuse 1 blood and then D&E.
c) Transfuse 1 blood and then D&E.
d) D&E directly under anaesthesia
e) D&E as soon as you see the patient
Correct Answer: e or even d.
She had already suffered from massive blood loss. Deferring the procedure for USG or blood transfusion will result in more blood loss. In this case USG is not required at all as os is open and we already have documented usg report which rules out vesicular mole and ectopic pregnancy. Bottom line is if the os is open (Inevitable or incomplete miscarriage), pregnancy cannot be salvaged. Procedure can be performed with GA or local anaesthesia or even without LA. If I have to handle this case, I would immediately insert ovum and remove retained products to stop further blood loss. Definitely we need to transfuse blood as soon as possible.
9. Anembryonic pregnancy
18-year-old, 10 weeks of amenorrhea with light vaginal bleeding after Pregnancy test 4 weeks ago had tested positive. TVS showed an irregular gestation sac with no fetal pole. What is the likely diagnosis?
a) Anembryonic pregnancy
b) Complete miscarriage
c) Hydatidiform mole
d) Incomplete miscarriage
e) Threatened miscarriage
Correct Answer: a) Anembryonic pregnancy.
Threatened miscarriage refers to vaginal bleeding in the presence of a viable pregnancy; however, this pregnancy is not viable. There are products of conception (gestation sac) that are visible on the scan so this is an incomplete miscarriage, which is usually associated with heavy vaginal bleeding. In this case, the patient is considered to be pregnant, although no embryonic tissue is present. Therefore, the most likely diagnosis is anembryonic pregnancy.
10. Non-viable pregnancy
Asymptomatic patient with early pregnancy. USG is negative for pregnancy. βhCG levels over 48 hours are 550 and 350, and serum progesterone levels are 17 nmol. What is the most likely diagnosis?
a) Ectopic pregnancy
b) Failing pregnancy
c) High risk of ectopic pregnancy needing intervention for treatment
d) Non-viable pregnancy with the possibility of spontaneous resolution
e) Viable pregnancy
Correct Answer: d) Non-viable pregnancy with the possibility of spontaneous resolution.
Serum progesterone levels are useful adjuncts in the diagnosis of pregnancy of unknown location. Levels below 15-25 are indicative of non viable pregnancy. Results below 20nmol/l are associated with spontaneous resolution with sensitivity of 93% and specificity of 94%. Levels above 60 strongly indicate development into normal pregnancy in the future. Serum hCG levels are useful in localising pregnancy while serum progesterone helps with the prognosis.
11. Missed Abortion
Regarding missed abortion, all of the followings are correct EXCEPT :
a) The patient may present with loss of pregnancy symptoms.
b) Per vaginal bleeding may be one of the presenting symptoms.
c) Immediate evacuation should be done once the diagnosis is made.
d) DIC may occur as a sequel.
e) Ultrasound should be done to confirm the diagnosis.
Correct Answer: d) DIC may occur as a sequel, but it is very rare. Expectant management can be offered for 7–14 days as the first-line management strategy for women with a confirmed diagnosis of miscarriage. (NICE 2012)
12. Missed Miscarriage
If the crown–rump length is 8 mm with a transvaginal ultrasound scan and there is no visible heartbeat
a) Blighted ovum
b) Missed abortion
c) Threatened abortion
d) Normal
Correct Answer: b) Missed abortion.
If the crown–rump length is 7.0 mm or more with a transvaginal ultrasound scan and there is no visible heartbeat: seek a second opinion on the viability of the pregnancy and/or perform a second scan a minimum of 7 days after the first before making a diagnosis before labeling it as missed abortion. (Ref: NICE 2012)
13. Serum Progesterone
A serum progesterone value less than 5ng/ml can exclude the diagnosis of viable pregnancy with a certainty of
a) 20%
b) 40%
c) 60%
d) 80%
e) 100%
Correct Answer: e) 100%.
The measurement of serum progesterone is a valuable test in the diagnosis of early pregnancy failure. No viable pregnancy can present with a progesterone level of less than 5ng/ml.
14. Treatment of Spontaneous Abortion
According to RCOG/NICE what should be offered as the first-line management strategy for women with a confirmed diagnosis of miscarriage of 9 weeks ?
a) Expectant Management
b) Use a single dose of 800 micrograms of misoprostol
c) Manual vacuum aspiration under local anaesthetic
d) Surgical management in a theatre under general anaesthetic
Correct Answer: a) Expectant Management.
Ref: NICE Guidelines 2012. Use expectant management for 7–14 days as the first-line management strategy for women with a confirmed diagnosis of miscarriage. Medical management if expectant management is not acceptable to the woman. If the resolution of bleeding and pain indicate that the miscarriage has completed during 7–14 days of expectant management, advise the woman to take a urine pregnancy test after 3 weeks, and to return for individualised care if it is positive.
15. Karyotype in Spontaneous Abortion
Karyotype should be performed on products of conception of the second spontaneous abortion.
a) True
b) False
Parental peripheral blood karyotyping of both partners should be performed in all couples with recurrent spontaneous abortion.
a) True
b) False
Correct Answer: b) False.
Karyotype analysis should be performed on products of conception of the third and subsequent consecutive spontaneous abortion.
Parental peripheral blood karyotyping of both partners should be performed in couples with recurrent miscarriage where testing of products of conception reports an unbalanced structural chromosomal abnormality. (Ref: RCOG)