CHAPTER I INTRODUCTION Threatened abortion is associated with bleeding and or uterine cramping while the cervix is closed.

This stage of abortion may progress to spontaneous incomplete or complete abortion. While this event may be considered a part of the quality control process in human reproduction, it is important to know the possible etiologies and when therapy might prevent pregnancy loss. The World Health Organization estimated that 15% of all clinically recognizable pregnancies and in spontaneous abortion, 50-60% of which are due to chromosomal abnormalities. Apart from the fetal factors, several maternal and probably paternal factors contribute to the causes of spontaneous abortion.1 Spontaneous abortion, which is the loss of a pregnancy without outside intervention before 20 weeks gestation, affects up to 20 percent of recognized pregnancies. Spontaneous abortion can be subdivided into threatened abortion, inevitable abortion, incomplete abortion, missed abortion, septic abortion, complete abortion, and recurrent spontaneous abortion. Ultrasonography is helpful in the diagnosis of spontaneous abortion, but other testing may be needed if an ectopic pregnancy cannot be ruled out. Chromosomal abnormalities are causative in approximately 50 percent of spontaneous abortions; multiple other factors also may play a role. Traditional treatment consisting of surgical evacuation of the uterus remains the treatment of choice in unstable patients. Recent studies suggest that expectant or medical management is appropriate in selected patients. Patients with a completed spontaneous abortion rarely require medical or surgical intervention. For women with incomplete spontaneous abortion, expectant management for up to two weeks usually is successful, and medical therapy provides little additional benefit. When patients are allowed to choose between treatment options, a large percentage will choose expectant management. Expectant management of missed spontaneous abortion has variable success rates, but medical therapy with intravaginal misoprostol has an 80 percent success rate. Physicians should be aware of psychologic issues that patients and 1

their partners face after completing a spontaneous abortion. Women are at increased risk for significant depression and anxiety for up to one year after spontaneous abortion. Counseling to address feelings of guilt, the grief process, and how to cope with friends and family should be provided. Ultrasound diagnosis at presentation was compared with final clinical diagnosis in consecutive pregnant women who presented to an emergency department with vaginal bleeding or abdominal pain. The sensitivity, specificity, predictive value, and overall diagnostic accuracy of ultrasound were calculated.2 The aim of this study was to define the clinical and sonographic criteria which best determined the likelihood of successful expectant management. Additional data concerning the severity and duration of symptoms following expectantmanagement of early pregnancy loss were also collated.3

CHAPTER II ULTRASOUND AND ABORTION

2.1 Ultrasound Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" (audible) sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is approximately 20 kilohertz (20,000 hertz) in healthy, young adults. The production of ultrasound is used in many different fields, typically to penetrate a medium and measure the reflection signature or supply focused energy. The reflection signature can reveal details about the inner structure of the medium, a property also used by animals such as bats for hunting. The most well known application of ultrasound is its use in sonography to produce pictures of fetuses in the human womb. There are a vast number of other applications as well. 4

2.1.1 Ultrasound in Pregnancy This is particularly valuable for intrauterine assessments in the fetal period. Charts are available from 12 weeks to birth indicating the normal ranges of developing bone lengths for each of humerus, radius, ulna, femur, tibia and fibula. The ultrasound studies document length from one metaphyseal end of the bone to the other.4 These lengths can serve as an early (16th week on) indicator of a syndrome with short bones. A fetal ultrasound may also identify major angular

deformity. Ultrasound is particularly valuable in diagnosing lethal perinatal dysplasias in the second trimester owing to the severity of the rib and long bone abnormalities in this group.4 Obstetric ultrasound can be used to identify many conditions that would be harmful to the mother and the baby. Many health care professionals consider the risk of leaving these conditions undiagnosed to be much greater than the very small risk, if any, associated with undergoing an ultrasound scan.6 Routine ultrasound in early pregnancy (less than 24 weeks) appears to enable better gestational age assessment, earlier detection of multiple pregnancies and earlier detection of clinically unsuspected fetal malformation at a time when termination of pregnancy is possible. Sonography is used routinely in obstetric appointments during pregnancy, but the FDA discourages its use for non-medical purposes such as fetal keepsake videos and photos, even though it is the same technology used in hospitals.5 Obstetric ultrasound is primarily used to:

Date the pregnancy (gestational age) Confirm fetal viability Determine location of fetus, intrauterine vs ectopic Check the location of the placenta in relation to the cervix Check for the number of fetuses (multiple pregnancy) Check for major physical abnormalities. Assess fetal growth (for evidence of intrauterine growth restriction (IUGR))

Check for fetal movement and heartbeat. Determine the sex of the baby

Unfortunately, results are occasionally wrong, producing a false positive (the Cochrane Collaboration is a relevant effort to improve the reliability of health care trials). False detection may result in patients being warned of birth defects when

no such defect exists. Sex determination is only accurate after 12 weeks gestation. When balancing risk and reward, there are recommendations to avoid the use of routine ultrasound for low risk pregnancies. In many countries ultrasound is used routinely in the management of all pregnancies.7 According to the European Committee of Medical Ultrasound Safety (ECMUS) "Ultrasonic examinations should only be performed by competent personnel who are trained and updated in safety matters. Ultrasound produces heating, pressure changes and mechanical disturbances in tissue. Diagnostic levels of ultrasound can produce temperature rises that are hazardous to sensitive organs and the embryo/fetus. Biological effects of non-thermal origin have been reported in animals but, to date, no such effects have been demonstrated in humans, except when a microbubble contrast agent is present. Nonetheless, care should be taken to use low power settings and avoid pulsed wave scanning of the fetal brain unless specifically indicated in high risk pregnancies.8 Obstetric Ultrasound is the use of ultrasound scans in pregnancy. Since its introduction in the late 1950s ultrasonography has become a very useful diagnostic tool in Obstetrics. Currently used equipments are known as real-time scanners, with which a continous picture of the moving fetus can be depicted on a monitor screen. Very high frequency sound waves of between 3.5 to 7.0 megahertz (i.e. 3.5 to 7 million cycles per second) are generally used for this purpose. They are emitted from a transducer which is placed in contact with the maternal abdomen, and is moved to "look at" (likened to a light shined from a torch) any particular content of the uterus. Repetitive arrays of ultrasound beams scan the fetus in thin slices and are reflected back onto the same transducer. 4 The information obtained from different reflections are recomposed back into a picture on the monitor screen (a sonogram, or ultrasonogram). Movements such as fetal heart beat and malformations in the feus can be assessed and measurements can be made accurately on the images displayed on the screen.

Such measurements form the cornerstone in the assessment of gestational age, size and growth in the fetus. 6 A full bladder is often required for the procedure when abdominal scanning is done in early pregnency. There may be some discomfort from pressure on the full bladder. The conducting gel is non-staining but may feel slightly cold and wet. There is no sensation at all from the ultrasound waves. 1 Ultrasound scan is currently considered to be a safe, non-invasive, accurate and cost-effective investigation in the fetus. It has progressively become an indispensible obstetric tool and plays an important role in the care of every pregnant woman.5 The main use of ultrasonography are in the following areas:

1. Diagnosis and confirmation of early pregnancy. The gestational sac can be visualized as early as four and a half weeks of gestation and the yolk sac at about five weeks. The embryo can be observed and measured by about five and a half weeks. Ultrasound can also very importantly confirm the site of the pregnancy is within the cavity of the uterus. 2. Vaginal bleeding in early pregnancy. The viability of the fetus can be documented in the presence of vaginal bleeding in early pregnancy. A visible heartbeat could be seen and detectable by pulsed doppler ultrasound by about 6 weeks and is usually clearly depictable by 7 weeks. If this is observed, the probability of a continued pregnancy is better than 95 percent. Missed abortions and blighted ovum will usually give typical pictures of a deformed gestational sac and absence of fetal poles or heart beat. Fetal heart rate tends to vary with gestational age in the very early parts of pregnancy. Normal heart rate at 6 weeks is around 90-110 beats per minute (bpm)

and at 9 weeks is 140-170 bpm. At 5-8 weeks a bradycardia (less than 90 bpm) is associated with a high risk of miscarriage.4 Many women do not ovulate at around day 14, so findings after a single scan should always be interpreted with caution. The diagnosis of missed abortion is usually made by serial ultrasound scans demonstrating lack of gestational development. For example, if ultrasound scan demonstrates a 7mm embryo but cannot demonstrable a clearcut heartbeat, a missed abortion may be diagnosed. In such cases, it is reasonable to repeat the ultrasound scan in 7-10 days to avoid any error.6 The timing of a positive pregnancy test may also be helpful in this regard to assess the possible dates of conception. A positive pregnancy test 3 weeks previously for example, would indicate a gestational age of at least 7 weeks.1 Such information would be useful against the interpretation of the scans. In the presence of first trimester bleeding, ultrasonography is also indispensible in the early diagnosis of ectopic pregnancies and molar pregnancies.9 3. Determination of gestational age and assessment of fetal size. Fetal body measurements reflect the gestational age of the fetus. This is particularly true in early gestation. In patients with uncertain last menstrual periods, such measurements must be made as early as possible in pregnancy to arrive at a correct dating for the patient. In the latter part of pregnancy measuring body parameters will allow assessment of the size and growth of the fetus and will greatly assist in the diagnosis and management of intrauterine growth retardation (IUGR). The weight of the fetus at any gestation can also be estimated with great accuracy using polynomial equations containing the BPD, FL, and AC. computer softwares and lookup charts are readily available. For example, a BPD of 9.0 cm and an AC of 30.0 cm will give a weight estimate of 2.85 kg.5

2.1.2 A Types of ultrasound Transvaginal Scans With specially designed probes, ultrasound scanning can be done with the probe placed in the vagina of the patient. This method usually provides better images (and therefore more information) in patients who are obese and/ or in the early stages of pregnancy. The better images are the result of the scanhead's closer proximity to the uterus and the higher frequency used in the transducer array resulting in higher resolving power. Fetal cardiac pulsation can be clearly observed as early as 6 weeks of gestation. Vaginal scans are also becoming indispensible in the early diagnosis of ectopic pregnancies. An increasing number of fetal abnormalities are also being diagnosed in the first trimester using the vaginal scan. Transvaginal scans are also useful in the second trimester in the diagnosis of congenital anomalies.

Doppler Ultrasound The doppler shift principle has been used for a long time in fetal heart rate detectors. Further developments in doppler ultrasound technology in recent years have enabled a great expansion in its application in Obstetrics, particularly in the area of assessing and monitoring the well-being of the fetus, its progression in the face of intrauterine growth restriction, and the diagnosis of cardiac malformations. Doppler ultrasound is presently most widely employed in the detection of fetal cardiac pulsations and pulsations in the various fetal blood vessels. The

"Doptone" fetal pulse detector is a commonly used handheld device to detect fetal heartbeat using the same doppler principle.

Blood flow characteristics in the fetal blood vessels can be assessed with Doppler 'flow velocity waveforms'. Diminished flow, particularly in the diastolic phase of a pulse cycle is associated with compromise in the fetus. Various ratios of the systolic to diastolic flow are used as a measure of this compromise. The blood vessels commonly interrogated include the umbilical artery, the aorta, the middle cerebral arteries, the uterine arcuate arteries, and the inferior vena cava. The use of color flow mapping can clearly depict the flow of blood in fetal blood vessels in a realtime scan, the direction of the flow being represented by different colors. Color doppler is particularly indispensible in the diagnosis of fetal cardiac and blood vessel defects, and in the assessment of the hemodynamic responses to fetal hypoxia and anemia. A more recent development is the Power Doppler (Doppler angiography). It uses amplitude information from doppler signals rather than flow velocity information to visualize slow flow in smaller blood vessels. A color perfusion-like display of a particular organ such as the placenta overlapping on the 2-D image can be very nicely depicted. Doppler examinations can be performed abdominally and via the transvaginal route. The power emitted by a doppler device is greater than that used in a conventional 2-D scan. Its use in early pregnancy is therefore cautioned. Doppler facilities are generally an integral part of modern ultrasound scanners. They merely would need to be switched on to function. One does not need to 'go' to another machine for the doppler investigations.

3-D and 4-D Ultrasound 3-D ultrasound can furnish us with a 3 dimensional image of what we are scanning. The transducer takes a series of images, thin slices, of the subject, and the computer processes these images and presents them as a 3 dimensional image. Using computer controls, the operator can obtain views that might not be available using ordinary 2-D ultrasound scan. 3-dimensional ultrasound is quickly moving out of the research and development stages and is now widely employed in a clinical setting. It too, is very much in the News. Faster and more advanced commercial models are coming into the market. The scans requires special probes and software to accumulate and render the images, and the rendering time has been reduced from minutes to fractions of a seconds. A good 3-D image is often very impressive to the parents. Further 2-D scans may be extracted from 3-D blocks of scanned information. Volumetric measurements are more accurate and both doctors and parents can better appreciate a certain abnormality or the absence of a certain abnormality in a 3-D scan than a 2-D one and there is the possibility of increasing psychological bonding between the parents and the baby.

An increasing volume of literature is accumulating on the usefulness of 3D scans and the diagnosis of congenital anomalies could receive revived attention. Present evidence has already suggested that smaller defects such as spina bifida, cleft lips/palate, and polydactyl may be more lucidly demonstrated. Other more

10

subtle features such as low-set ears, facial dysmorphia or clubbing of feet can be better assessed, leading to more effective diagnosis of chromosomal abnormalities. The study of fetal cardiac malformations is also receiving attention. The ability to obtain a good 3-D picture is nevertheless still very much dependent on operator skill, the amount of liquor (amniotic fluid) around the fetus, its position and the degree of maternal obesity, so that a good image is not always readily obtainable. More recently, 4-D or dynamic 3-D scanners are in the market and the attraction of being able to look at the face and movements of your baby before birth was also enthusiastically reported in parenting and health magazines. This is thought to have an important catalytic effect for mothers to bond to their babies before birth. What are known as 're-assurance scans' and the rather misnamed 'entertainment scans' have quickly become popular. Most experts do not consider that 3-D and 4-D ultrasound will be a mandatory evolution of our conventional 2-D scans, rather it is an additional piece of tool like doppler ultrasound. Most diagnosis will still be made with the 2-D scans. 3-D ultrasound appears to have great potential in research and in the study of fetal embryology. Whether 3-D ultrasound will provide unique information or merely supplemental information to the conventional 2-D scans will remain to be seen. 2.2 Abortion Abortion is the termination of pregnancy, either spontaneously or intentionally, before the fetus develops sufficiently to survive. By convention, abortion is usually defined as pregnancy termination prior to 20 weeks' gestation or less than 500-g birthweight. Definitions vary, however, according to state laws for reporting abortions, fetal deaths, and neonatal deaths.

11

Spontaneous Abortion Abortion occurring without medical or mechanical means to empty the uterus is referred to as spontaneous. Another widely used term is miscarriage. Pathology Hemorrhage into the decidua basalis, followed by necrosis of tissues adjacent to the bleeding, usually accompanies abortion. If early, the ovum detaches, stimulating uterine contractions that result in its expulsion. When a gestational sac is opened, fluid is commonly found surrounding a small macerated fetus, or alternatively no fetus is visiblethe so-called blighted ovum. In later abortions, several outcomes are possible. The retained fetus may undergo maceration, in which the skull bones collapse, the abdomen distends with bloodstained fluid, and the internal organs degenerate. The skin softens and peels off in utero or at the slightest touch. Alternatively, when amnionic fluid is absorbed, the fetus may become compressed and desiccated, forming a fetus compressus. Occasionally, the fetus may become so dry and compressed that it resembles parchmenta fetus papyraceous. Etiology More than 80 percent of abortions occur in the first 12 weeks of pregnancy, and at least half result from chromosomal anomalies. After the first trimester, both the abortion rate and the incidence of chromosomal anomalies decrease.

The risk of spontaneous abortion increases with parity as well as with maternal and paternal age. The frequency of clinically recognized abortion increases from 12 percent in women younger than 20 years to 26 percent in those older than 40 years. For the same paternal ages, the frequency increases from 12 to 20 percent.

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Finally, the incidence of abortion increases if a woman conceives within 3 months following a term birth. 2.2.1 Categories of Spontaneous Abortion The clinical aspects of spontaneous abortion separate into five subgroups: threatened, inevitable, complete or incomplete, missed, and recurrent abortion. Threatened Abortion The clinical diagnosis of threatened abortion is presumed when a bloody vaginal discharge or bleeding appears through a closed cervical os during the first half of pregnancy. Occurring commonly, vaginal spotting or heavier bleeding during early gestation may persist for days or weeks and may affect one out of four or five pregnant women. Overall, approximately half of these pregnancies will abort, although the risk is substantially lower if fetal cardiac activity can be documented (Tongsong and colleagues, 1995). Even without abortion, these fetuses are at increased risk for preterm delivery, low birthweight, and perinatal death (Batzofin, 1984; Funderburk, 1980; Weiss, 2004, and their colleagues). Importantly, the risk of a malformed infant does not appear to be increased. Some bleeding near the time of expected menses may be physiological. Cervical lesions commonly bleed in early pregnancy, especially after intercourse. Polyps presenting at the external cervical os and decidual reaction in the cervix also tend to bleed in early gestation. Lower abdominal pain and persistent low backache do not accompany bleeding from these benign causes. Bleeding usually begins first, and cramping abdominal pain follows a few hours to several days later. The pain of abortion may manifest as anterior and clearly rhythmic cramps; as a persistent low backache, associated with a feeling of pelvic pressure; or as a dull, midline, suprapubic discomfort. Whichever form the pain takes, the combination of bleeding and pain predicts a poor prognosis for

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pregnancy continuation. 10 Because ectopic pregnancy, ovarian torsion, and the other types of abortion may mimic threatened abortion, the threshold to examine women with vaginal bleeding and pain should be low. If the bleeding is persistent or heavy, a hematocrit should be obtained. If blood loss is sufficient to cause significant anemia or hypovolemia, uterine evacuation is done. There are no effective therapies for threatened abortion. Bed rest, although often prescribed, does not alter the course of threatened abortion. Acetaminophen-based analgesia may be given to help relieve the pain. As discussed in Chapter 10 (see Laboratory Tests), vaginal sonography, serial serum quantitative human chorionic gonadotropin (hCG) levels, and serum progesterone values, used alone or in various combinations, can help ascertain if the fetus is alive and its location. None of these tests, however, especially early in gestation, is 100 percent accurate to confirm fetal death; thus, repeat evaluations over 1 or 2 weeks may be necessary. Ectopic pregnancy should always be considered in the differential diagnosis of threatened abortion. 10 Inevitable Abortion Gross rupture of the membranes, evidenced by leaking amnionic fluid, in the presence of cervical dilatation signals almost certain abortion. Commonly, either uterine contractions begin promptly, resulting in abortion, or infection develops. Rarely, a gush of fluid from the uterus during the first half of pregnancy is without serious consequence. The fluid may have collected previously between the amnion and chorion. Thus, if a sudden discharge of fluid in early pregnancy occurs before any pain, fever, or bleeding, the woman may be put to bed and observed. If after 48 hours no additional amnionic fluid has escaped, and there is no bleeding, pain, or fever, she may resume her usual activities except for any form of vaginal penetration. If, however, the gush of fluid is accompanied or followed by bleeding, pain, or fever, abortion should be considered inevitable and

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the uterus emptied. Complete and Incomplete Abortion When the placenta, in whole or in part, detaches from the uterus, bleeding ensues. Following complete detachment and expulsion of the conceptus, termed complete abortion, the internal cervical os closes. During incomplete abortion, however, the internal cervical os remains open and allows passage of blood. The fetus and placenta may remain entirely in utero or may partially extrude through the dilated os. Incomplete abortion may or may not require additional cervical dilatation before curettage. In many cases, retained placental tissue simply lies loosely in the cervical canal, allowing easy extraction from an exposed external os with ring forceps. Suction curettage, as described later, effectively evacuates the uterus. In clinically stable women, expectant management also can be a reasonable option Hemorrhage from the incomplete abortion of a more advanced pregnancy, though rarely fatal, is occasionally severe. Therefore, in women with more advanced pregnancies or with heavy bleeding, evacuation should proceed promptly. Fever should not prohibit curettage once appropriate antimicrobials have been administered. 10 Missed Abortion In this case, the uterus retains dead products of conception behind a closed cervical os for days or even weeks. In the typical instance, early pregnancy appears to be normal, with amenorrhea, nausea and vomiting, breast changes, and growth of the uterus. After fetal death, there may or may not be vaginal bleeding or other symptoms of threatened abortion. For days or weeks, the uterus remains stationary in size, but then gradually becomes smaller. Mammary changes usually regress, and women often lose a few pounds. Many women have no symptoms during this period except persistent amenorrhea. If the missed abortion terminates spontaneously, and most do, the process of expulsion is the same as in any

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abortion. After death of the conceptus, management can be individualized, depending on individual circumstances. Expectant, medical, and surgical approaches can all be reasonable options, each with its own merits and disadvantages. Surgery is generally definitive and predictable but is invasive and is not necessary for all women. Expectant and medical management spare some women from curettage, but are associated with unpredictable bleeding and, in some women, the need for unscheduled surgery. These approaches may require more follow-up, may cause significant pain, and may carry time delays, all or one of which some women may not accept. Nielsen and Hahlin (1995) performed a randomized study comparing expectant management with curettage for missed abortions earlier than 13 weeks. Spontaneous resolution occurred within 3 days in 80 percent of women treated conservatively, although vaginal bleeding averaged 1 day longer. Complications were similar between the groups. Luise and colleagues (2002), in an observational study of almost 1100 women with suspected first-trimester abortion, reported spontaneous resolution in 81 percent. In this study, compared with the report by Nielsen and Hahlin (1995), however, pregnancies were aborted later, and only half of those with a fetal pole or gestational sac aborted within 2 weeks of diagnosis. Muffley and colleagues (2002) randomized 50 women with pregnancy failure prior to 12 weeks either to dilatation and curettage, or to 800 g of

misoprostol placed in the posterior vaginal fornix and repeated in 24 hours if necessary. Failure of medical therapy, defined as retained gestational sac at 48 hours, occurred in 60 percent of those treated medically. There were no differences between groups in hematocrit level changes or in the time to disappearance of serum hCG levels. One woman in the misoprostol group

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returned 6 hours after initial dosing with profuse vaginal bleeding. In another randomized trial, Chung and colleagues (1999) reported that approximately 50 percent of the group given medical treatment subsequently required surgical evacuation. Following abortion completion with medical therapy, vaginal or abdominal ultrasound can be used to document an empty uterine cavity. If significant amounts of material remain within the uterine cavity, curettage should follow. In some cases after prolonged retention of a dead fetus, serious coagulation defects develop and are more likely if there is fetal death after midpregnancy. Coagulopathies may cause troublesome maternal bleeding from the nose, gums, and sites of slight trauma. The pathogenesis and treatment of these defects are considered in Chapter 35 (see Consumptive Coagulopathy). Recurrent Abortion Defined by various criteria of number and sequence, recurrent abortion in its generally accepted definition refers to three or more consecutive spontaneous abortions. In the majority of cases, repeated spontaneous abortions are likely to be chance phenomena. Accepting an independent risk of spontaneous abortion occurrence to be 15 percent, a second loss could be calculated to occur at a rate of 2.3 percent and a third loss at a rate of 0.34 percent. Confirming this, a study of women physicians reported the occurrences of one, two, and three miscarriages to be 10.4, 2.3, and 0.34 percent, respectively. Prognosis The majority of women who attempt pregnancy after being diagnosed with recurrent abortion will have successful outcomes, with or without treatment. Warburton and Fraser (1964) reported that the likelihood of recurrent abortion was 25 to 30 percent regardless of the number of previous abortions. Poland and associates (1977) noted that if a woman with this diagnosis had previously

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delivered a liveborn infant, the risk for subsequent recurrent abortion was approximately 30 percent. If, however, a woman had no liveborn infants, and had at least one spontaneous fetal loss, the risk of abortion was 46 percent.

Induced Abortion Induced abortion is the medical or surgical termination of pregnancy before the time of fetal viability. In 2000, a total of 857,475 legal abortions were reported to the Centers for Disease Control and Prevention (2003). These numbers are underestimated because clinics inconsistently report medically induced abortions. Of those reported, about 20 percent involved women aged 19 years or younger, and the majority were younger than 25 years, white, and unmarried. Almost 60 percent of induced abortions were performed during the first 8 weeks, and 88 percent during the first 12 weeks of pregnancy. History of Abortion Until the United States Supreme Court decision of 1973, only therapeutic abortions could be performed legally in most states. The most common legal definition of therapeutic abortion until then was termination of pregnancy before the period of fetal viability for the purpose of saving the life of the mother. A few states extended their laws to read "to prevent serious or permanent bodily injury to the mother" or "to preserve the life or health of the woman." Some states allowed abortion if a pregnancy was likely to result in the birth of an infant with grave malformations. 10 The stringent abortion laws in effect prior to 1973 were of fairly recent origin. Abortion before quickeningthe first definite perception of fetal movement, which most often occurs between 16 and 20 weeks' gestationwas either lawful or widely tolerated in both the United States and Great Britain until 1803. In that year, as part of a general restructuring of British criminal law, a statute was enacted that made all induced abortions regardless of gestational age illegal. The

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Roman Catholic Church's traditional prohibition of abortion did not receive the ultimate sanction of universal law (excommunication) until 1869 (Pilpel and Norwich, 1969). In this country, it was not until 1821 that Connecticut enacted the first abortion law. Subsequently, abortion became illegal throughout the United States except to save the life of the mother. Because therapeutic abortion to save the life of the woman is rarely necessary or definable, it follows that the great majority of such operations previously performed in this country went beyond legal boundaries. Borgmann and Jones (2000) have extensively reviewed these legal issues. Indications Some indications for therapeutic abortion are discussed with the diseases that commonly lead to the operation. Well-documented indications include persistent heart disease after cardiac decompensation, advanced hypertensive vascular disease, and invasive carcinoma of the cervix. In addition to medical and surgical disorders that may be an indication for termination of pregnancy, there are others. Certainly, in cases of rape or incest, most authorities consider termination to be indicated. Another commonly cited indication is to prevent a viable birth of a fetus with a significant anatomical or mental deformity. The seriousness of fetal deformities is wide ranging and frequently defies social or legal classification.10

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CHAPTER III DISCUSSION

3.1 The Role of Ultrasound in The Management of Threatened Abortion

Threatened abortion may progress to spontaneous incomplete or complete abortion. While this event may be considered a part of the quality control process in human reproduction, it is important to know the possible etiologies and when therapy might prevent pregnancy loss. Obstetric ultrasound can be used to identify many conditions that would be harmful to the mother and the baby. Many health care professionals consider the risk of leaving these conditions undiagnosed to be much greater than the very small risk, if any, associated with undergoing an ultrasound scan.6 Routine ultrasound in early pregnancy (less than 24 weeks) appears to enable better gestational age assessment, earlier detection of multiple pregnancies and earlier detection of clinically unsuspected fetal malformation at a time when termination of pregnancy is possible. Sonography is used routinely in obstetric appointments during pregnancy, but the FDA discourages its use for non-medical purposes such as fetal keepsake videos and photos, even though it is the same technology used in hospitals.5 Ultrasound has an invaluable role inmpredicting the likelihood of successful expectant management enabling patients to make an informed choice about their medical care. Women with an ultrasound diagnosis of EPF at 714 weeks gestation were offered the option of expectant management or surgical evacuation. The routine use of ultrasound in the investigation and diagnosis of early pregnancy problems has also led to improvements in the management of early pregnancy loss. Improved access to early pregnancy units and increasing awareness amongst women of their choices in the management of early pregnancy problems has led to an increasing demand for more conservative management of

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early miscarriage. Up to 70% of women will choose expectant management of miscarriage if given the choice. The diagnosis of a complete miscarriage is generally accepted as an endometrial thickness < 15 mm with no evidence of retained products of conception1and TVS is a sensitive tool for detecting residual trophoblastic tissue. The finding of blood flow in the intervillous space in cases of firsttrimester miscarriage using color Doppler imaging also appears to be useful in the prediction of success of expectant management. Miscarriages with blood flow within the intervillous space are up to four times more likely to complete with expectant management. The success of expectant management is variable across studies, with a completion rate of 8096% within 2 weeks in women with incomplete miscarriage and a low complication rate. Completion rates are lower in missed miscarriages (5962%) and anembryonic pregnancies (52%) at 2 weeks and it is generally accepted that the likelihood of completion after this is low and evacuation of the retained products of conception (ERPC) should be offered. In cases of incomplete miscarriage, where subsequent completion rates are high, it has been shown that other ultrasound parameters such as endometrial thickness and the presence or absence of a gestational sac did not add any further information to the likely outcome. Expectant management of miscarriage, using ultrasound parameters to determine eligibility, could significantly reduce the number of unnecessary ERPCs, depending on the criteria used.
Role of ultrasound The first demonstration of an intrauterine pregnancy by means of transvaginal ultrasound was reported in 1967 [5]. Major improvements in ultrasound resolution since then have revolutionized the assessment and management of early pregnancy problems. For instance, longitudinal study of early pregnancy development can be made in terms of viability and growth in thesamepatie nt (Table12.1). Ultrasound plays a major role in maternal reassurance, where fetal cardiac activity is seen and is pivotal in the assessment of early pregnancy complications, such as vaginal bleeding [6]. However, there are limits to ultrasound resolution of normal early pregnancy development. Expert advice concludes that the diagnosis of an empty

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gestation sac can only be made when the mean gestation sac diameter is greater than 20 mm (Fig. 12.1), and that the crownrump length must be 6 mm or greater before one can say for certain that fetal heart activity is absent (Fig. 12.2). If measurements are below these thresholds a repeat transvaginal ultrasound examination after at least a week should be offered [7]. Ultrasound features such as a sac that is much smaller than expected from a certain last menstrual period; a sac that is low in the uterus or the presence of fetal bradycardia are strongly suggestivebut not diagnostic of impending miscarriage[8]. In addition, the possibility of incorrect dates should always be remembered by the alert clinician. Wherever possible, the term missed abortion should be replaced by delayed miscarriage [9]. As ultrasound findings arenot diagnostic in a significant number of women with early pregnancy failure,

3.1.1 Ultrasound in Clinically Diagnosed Threatened Abortion Patients with a clinical diagnosis of threatened abortion were examined ultrasonically to determine whether ultrasound was an accurate aid to clinical

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diagnosis which could shorten the stay in hospital and reduce the number of uterine evacuations. Before their 15th week of pregnancy most patients with a clinical diagnosis of threatened abortion were scanned ultrasonically with a Nuclear Enterprises Diasonograph. Donald's "full bladder technique" was used. 1. Threatened abortion was diagnosed if fetal heart movement was identified. 2. When this was not shown or if the features detailed by Donald et al. were present missed abortion was diagnosed. If echoes were seen in the line of the endometrial cavity incomplete abortion was diagnosed. When such echoes were absent or when the cavity showed as a straight line complete abortion was diagnosed. 3. Subsequent management was based entirely on the patient's clinical progress, and, apart from one hydatidiform mole, the ultrasonic findings were ignored.

Thus, though ultrasound may be a valuable aid in the diagnosis of bleeding in early pregnancy and may save the patient a long stay in hospital and unnecessary surgery fetal death should never be diagnosed without the confirmation of a second scan and without having made certain that the bladder is adequately filled.

3.1.2 Ultrasound to determine pharmacological treatment

In threatened abortion treatment consists of rest lying to increase blood flow to the uterus and reduce mechanical stimuli. 3 x 30 mg phenobarbital or diazepam 3 x 2 mg may be given to calm the patient. Administration hormones or tocolytics may be considered if the results of ultrasound shows the fetus is alive. 1

3.1.3 Ultrasound in Preoperative Evaluation Sonography to confirm a living fetus and to exclude major fetal anomalies should precede cerclage. Preoperatively, cervical specimens are tested for 23

gonorrhea and chlamydia. If positive, or if there are other obvious cervical infections, treatment is given. For at least a week before and after surgery, sexual intercourse should be restricted.2 Cerclage may be performed prophylactically before cervical dilatation, or emergently after the cervix has dilated. Although prophylactic surgery generally is performed between 12 and 16 weeks, experts disagree as to how late emergency cerclage should be performed. The more advanced the pregnancy, the more likely the risk that surgical intervention will stimulate preterm labor or membrane rupture. We usually do not perform cerclage after about 23.

Management
Data on the medical/gynecological history, symptoms of abdominal pain and vaginal bleeding, hematological (full blood count) and microbiological investigations (high vaginal swab) and ultrasound findings (Hitachi Sumi Portable EUB 405) were recorded prospectively on an EPAU computer database. The diagnosis of early pregnancy loss was based on clinical history and examination, positive urinary hCG and ultrasound findings. Incomplete miscarriage was diagnosed when the endometrial thickness was more than 5 mm with loss of midline echo suggestive of retained products13 Expectant management of early pregnancy loss was deemed to have failed if surgical evacuation was performed because of prolonged or heavy bleeding, excessive abdominal pain, suspected endometritis, ultrasound evidence of retained products (day 21), positive hCG (day 21) or if the woman chose to have surgery. The average duration of vaginal bleeding in women managed expectantly was 8.5 days (range 115). The vaginal bleeding appeared to follow a similar pattern in most women, with on average 3 days of heavy loss, followed by 2 days of moderate loss and very minimal loss thereafter. The mean hemoglobin The findings of this study have established that expectant management of miscarriage is feasible and effective, especially in the group of women with an ultrasound diagnosis of incomplete miscarriage. The investigators in the latter study allowed a very limited time of 3 days for spontaneous evacuation of products of conception, which may explain the discrepancy. Most other studies of expectant management of miscarriage have concentrated on missed miscarriages only or have primarily

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studied women with complete miscarriages, where the value of surgical management is questionable38. The current study indicates that expectant management is likely to result in spontaneous resolution with complete evacuation of the products of conception, in over 95% of women with an ultrasound diagnosis of incomplete miscarriage. Other studies have proposed the use of hormone assays or Doppler to predict the likelihood of successful expectant management 20,21 Ultrasound confirmed the clinical diagnosis of threatened abortion

Threatened identified.2

abortion

was

diagnosed

if

fetal

heart

movement

was

When this was not shown or if the features detailed by Donald et al.3 were present missed abortion was diagnosed. If echoes were seen in the line of the endometrial cavity incomplete abortion was diagnosed. When such echoes were absent or when the cavity showed as a straight line complete

abortion was diagnosed.4

from research
Ultrasound confirmed the clinical diagnosis of threatened abortion in 82 patients (34 6%), five of whom subsequently aborted. The remainder continued with normal pregnancies. Missed abortion was diagnosed in 69 patients (29-1%) and later became clinically obvious in 67, three of whom aborted completely and did not undergo surgery. The uterus was evacuated under general anaesthesia in 64 patients, in nine as an emergency procedure. The ultrasonic diagnosis was incorrect in two patients who later delivered healthy infants. Forty patients (16-9%) were diagnosed as having incomplete abortion, and evacuation was performed when the pregnancy test result became negative. The ultrasonic findings were confirmed in 37 patients. No curettings were obtained in two cases, and in the third proliferative endometrium was obtained 16 days after the ultrasonic report. Complete abortion was diagnosed in 45 patients (19%); 16 were discharged from hospital without operation and none had abnormal bleeding subsequently. The remaining 29 were curetted but tissue was obtained from only one. Hydatidiform mole was diagno'ed in one patient.

These results illustrate ultrasound's accuracy in diagnosing bleeding in early pregnancy. Misleading results were obtained in only six (2-5%) out of 237 patients. Had these findings been acted on the length of hospital stay for many patients could have been reduced (see table). The 28 patients reported as having complete abortions who were subsequently curetted woulc have avoided an unnecessary operation. The 67 who were correctly diagnosed as having missed abortion would have had evacuation performed as a planned procedure; while waiting for the clinical diagnosis to become obvious nine of them (13-4%) bled excessively and required emergency

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surgery. Of the six misdiagnoses three involved describing small quantities of retained products which were not present at curettage, though one of these could be explained by the 16-day interval between the scan and uterine evacuation. In another patient the scan missed a small quantity of decidua. The most serious errors were the diagnoses of missed abortion in two patients who proceeded with normal pregnancies. One was made in the sixth early pregnancy to be scanned and was almost certainly due to the inexperience of the observer. In the other the scan was unsatisfactory because of an insufficiently distended bladder. Thus, though ultrasound may be a valuable aid in the diagnosis of bleeding in early pregnancy and may save the patient a long stay in hospital and unnecessary surgery fetal death should never be diagnosed without the confirmation of a second scan and without having made certain that the bladder is adequately filled.

CHAPTER IV SUMMARY

Spontaneous abortion, which is the loss of a pregnancy without outside intervention before 20 weeks gestation, affects up to 20 percent of recognized pregnancies. Spontaneous abortion can be subdivided into threatened abortion, inevitable abortion, incomplete abortion, missed abortion, septic abortion, complete abortion, and recurrent spontaneous abortion. Ultrasonography is helpful

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in the diagnosis of spontaneous abortion, but other testing may be needed if an ectopic pregnancy cannot be ruled out. The role of ultrasound in the management of threatened abortion 1. Threatened abortion was diagnosed if fetal heart movement was identified. 2. Ultrasound in Clinically Diagnosed Threatened Abortion When this was not shown or if the features detailed by Donald et al. were present missed abortion was diagnosed. If echoes were seen in the line of the endometrial cavity incomplete abortion was diagnosed. When such echoes were absent or when the cavity showed as a straight line complete abortion was diagnosed. 3. Subsequent management was based entirely on the patient's clinical progress, and, apart from one hydatidiform mole, the ultrasonic findings were ignored. 4. Ultrasound in Preoperative Evaluation. 5. Ultrasound to determine pharmacological treatment

REFERENCES

1. Szab I, Szilgyi A. Management of threatened abortion. Source : Department of Obstetrics and Gynecology, University Medical School of Pcs, Hungary. (available on http://www.ncbi.nlm.gov.pub)

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2. Sairam. S., Khare. M., Michailidis. G., Thilaganathan. Dr B., The role of ultrasound in the expectant management of early pregnancy loss., 2002., Ultrasound in Obstetrics & GynecologyVolume 17, Issue 6, pages 506509, June 2001( available on http://onlinelibrary.wiley.com)

3. Craig P. GRIEBEL, MD, JOHN Halvorsen, MD, THOMAS B. GOLEMON, MD, dan Anthony A. HARI, MD., Mnagement of Spontaneous Abortion. 2005. University of Illinois College of Medicine di Peoria, Peoria, Illinois Am Fam Physician 2005 1 Oktober;. 72 (7) :12431250. 4. Tzeren, Aydn (2000). Human Body Dynamics: Classical Mechanics and Human Movement. Springer. pp. 610. 5. Pooh, K. Ritsuko; K. Asim. Donald School Journal of Ultrasound in Obstetrics and Gynecology. Recent Advances in 3D Assessment of Various Fetal Anomalies. 2009;3(3):1-23. 6. Turner, G.M.; P. Twining. Clinical Radiology Volume 47. The Skeletal profile in the diagnosis of fetal abnormalities. 1993; 389-395. 7. Pilu; Nicolaides; Ximenes ; Jeanty. Handbook of Fetal Abnormalities. Central Nervous System. 2000. 8. Pilu, Gianluigi. 2006. Three Dimensional Ultrasound of Craniofacial Anomalies. ( available on-line with updates at www.gehealthcare.com ). 9. Overton, Timothy G.; Edmonds, D. Keith. Dewhurst,s Textbook of Obstetric & Gynaecology 7th Edition. Antenatal Care. 2007; 6: 43.

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10. Cunningham F.G., Leveno K.J., Bloom S.L., etc. 2007.Ultrasonography and Doppler. Williams Obstetrics. USA : The McGraw-Hill Companies. Chapter 16.

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