Andrea Naranjo Blanco HCG 2013 ABORTO ESPONTÁNEO Andrea Naranjo Blanco HCG 2013

Definición Terminación involuntaria del embarazo antes de la semana 20 de gestación o expulsión espontánea de un feto con un peso menor de 500 gramos

Aborto espontáneo Epidemiología Cerca del 50 al 70% de los embarazos subclinicos y clínicos(10 a 15%) El 80% corresponden al primer trimestre (antes de las 8sem) La tasa de que se repita un aborto espontaneo es de un 20%, no debería de ser mayor Abortos recurrentes hasta un 50% Edad materna mayor de 40 años Approximately 20 percent of pregnant women will have some bleeding before 20 weeks' gestation, and roughly one half of these pregnancies will end in spontaneous abortion.3 Up to 20 percent of recognized pregnancies will end in miscarriage. However, when women were followed with serial serum human chorionic gonadotropin (hCG) measurements, the actual miscarriage rate was found to be 31 percent.4 Many pregnancies are lost spontaneously before a woman recognizes that she is pregnant, and the clinical signs of miscarriage are mistaken for a heavy or late menses.

Spontaneous Abortion: Definitions of Subcategories TABLE 1 Spontaneous Abortion: Definitions of Subcategories Complete abortion: all products of conception have been passed without the need for surgical or medical intervention Incomplete abortion: some, but not all, of the products of conception have been passed; retained products may be part of the fetus, placenta, or membranes Inevitable abortion: the cervix has dilated, but the products of conception have not been expelled Missed abortion: a pregnancy in which there is a fetal demise (usually for a number of weeks) but no uterine activity to expel the products of conception Recurrent spontaneous abortion: two or more consecutive pregnancy losses Septic abortion: a spontaneous abortion that is complicated by intrauterine infection Threatened abortion: a pregnancy complicated by bleeding before 20 weeks' gestation

Causas Genéticas Adquiridas Asociadas a patología crónica 80% de los abortos en el primer trimestre Adquiridas Asociadas a patología crónica

Recomendaciones en la práctica clínica

CLINICAL RECOMMENDATION EVIDENCE RATING *The possibility of ectopic pregnancy should be considered when transvaginal ultrasonography reveals an empty uterus and the quantitative serum human chorionic gonadotropin level is greater than 1,800 mIU per mL (1,800 IU per L) C *Transvaginal ultrasound should be performed in the first trimester of pregnancy when incomplete abortion is suspected and is extremely reliable in identifying intrauterine products of conception *Expectant management should be considered for women with incomplete spontaneous abortions. It has an 82 to 96 percent success rate without the need for surgical or medical intervention A *When misoprostol (Cytotec) is used to treat women with a missed spontaneous abortion, it should be given vaginally rather than orally. B

*Patients who have had a spontaneous abortion should be given the opportunity to choose a treatment option B *A 50-mcg dose of Rho(D) immune globulin (Rhogam) should be administered to Rh-negative patients who have a threatened abortion or have completed a spontaneous abortion C *Physicians should be alert to the development of psychologic symptoms that frequently occur following spontaneous abortion (e.g., depression, anxiety)

Differential Diagnosis of First-Trimester Vaginal Bleeding TABLE 2 Differential Diagnosis of First-Trimester Vaginal Bleeding Cervical abnormalities (e.g., excessive friability, malignancy, polyps, trauma) Ectopic pregnancy Idiopathic bleeding in a viable pregnancy Infection of the vagina or cervix Molar pregnancy Spontaneous abortion Subchorionic hemorrhage Vaginal trauma

Risk Factors for Spontaneous Abortion TABLE 3 Risk Factors for Spontaneous Abortion Advanced maternal age Alcohol use Anesthetic gas use (e.g., nitrous oxide) Caffeine use (heavy) Chronic maternal diseases: poorly controlled diabetes, celiac disease, autoimmune diseases (particularly antiphospholipid antibody syndrome) Cigarette smoking Cocaine use Conception within three to six months after delivery Intrauterine device use Maternal infections: bacterial vaginosis; mycoplasmosis, herpes simplex virus, toxoplasmosis, listeriosis, chlamydia, human immunodeficiency virus, syphilis, parvovirus B19, malaria, gonorrhea, rubella, cytomegalovirus Medications: misoprostol (Cytotec), retinoids, methotrexate, nonsteroidal anti-inflammatory drugs Multiple previous elective abortions Previous spontaneous abortion Toxins: arsenic, lead, ethylene glycol, carbon disulfide, polyurethane, heavy metals, organic solvents Uterine abnormalities: congenital anomalies, adhesions, leiomyoma

Aborto espontáneo Manejo - Paciente inestable SOP séptica - Aborto completo documentado Expectante Descartar ectópico - Aborto incompleto, retenido, anembriónico Expectante (endometrio menos de 15 mm) Médico Quirúrgico Prompt surgical evacuation of the uterus is the treatment of choice when the patient is unstable because of heavy bleeding or has evidence of a septic abortion. Patient choice is another reason to proceed with surgical evacuation. Some women may have already completed a spontaneous abortion by the time they present for clinical evaluation. If the ultrasound examination shows an empty uterus and evaluation of the expelled tissue confirms the presence of products of conception, no further action is needed; in these instances, patients have a completed spontaneous abortion and can be managed expectantly.16 If the products of conception are not physically confirmed when the uterus is empty, an ectopic pregnancy must be ruled out. Many studies17-24 have compared expectant management, medical therapy, and surgical management for women with incomplete spontaneous abortion. Expectant management proved to be successful, with no need for surgical intervention in 82 to 96 percent of women.17-22,24 Most patients who had surgical intervention were followed expectantly for two weeks before intervention was recommended.17,19,21 Medical therapy with misoprostol (Cytotec) or mifepristone (Mifeprex) does not confer significant additional benefit.23 The average time to completion of the miscarriage was nine days. In women with missed spontaneous abortions, expectant management has a variable but generally lower success rate than medical therapy, ranging from 16 to 76 percent.17,20,25,26 In contrast, medical therapy for missed spontaneous abortion results in high success rates for completion of a spontaneous abortion without surgical intervention. One study25 found that patients had an 80 percent success rate after using 800 mcg of misoprostol, administered intravaginally and repeated after four hours, if necessary. Intravaginal administration of misoprostol causes less diarrhea than oral administration.

Diagnóstico de la gestación interrumpida

EMBARAZO ANEMBRIÓNICO Ultrasonido y aborto EMBARAZO ANEMBRIÓNICO Se debe visualizar embrión en todas las gestaciones con un diámetro medio de saco gestacional de 25 mm (7 2/7 sem) si se utiliza sonda abdominal y de 18 mm si se utiliza la vaginal Se debe identificar vesícula vitelina en todas las gestaciones con un diámetro medio de saco gestacional de 20 mm (6 5/7 sem) con sonda abdominal y 13 mm con sonda vaginal GESTACIÓN INTERRRUMPIDA Se ha intentado hallar numerosos signos ecográficos que ayuden a predecir qué gestaciones serán evolutivas o no

ABORTO RETENIDO Ultrasonido y aborto Se debe identificar latido cardiaco en todos los embriones con un LCC mayor de 6 mm (seis semanas y media) La presencia de latido cardiaco es el signo de mejor pronóstico para una gestación amenazada y su presencia se relaciona entre un 70 y un 95% de probabilidades de que la gestación sea evolutiva

Patología del saco gestacional Se admite que el SG crece aproximadamente 1 mm por día. Desviaciones de este crecimiento se han asociado a mal pronóstico Cambios extremos en la forma del saco gestacional se han asociado a mal pronóstico Pobre reacción decidual: menos de 2 mm Mapa color pobre en la periferia Inserción baja de la vesícula Amenorrea y ausencia del SG intracavitario: embarazo ectópico Hay que tener en cuenta que los cambios en la forma del saco gestacional pueden ser producidos por distención de la vejiga o por patología intramiometrial y no todos los autores están de acuerdo en este punto

Patología de la vesícula vitelina Alteraciones en el tamaño: - VV menor o mayor de 2DS de la media (menor de 0,2 o mayor de 0,8 mm en la sexta semana) Alteraciones en la forma: - VV doble o de contorno irregular y la distorción persiste

Patología de la vesícula vitelina Alteraciones en la ecogenicidad: - La vesícula vitelina hiperecogénica es de mal pronóstico. Generalmente aparecen en gestaciones ya interrumpidas y son raras en gestaciones con latido cardiaco ya presente

Alteraciones en el embrión Las alteraciones de la frecuencia cardiaca se han postulado como predictoras de mala evolución La frecuencia cardiaca embrionaria aumenta progresivamente entre las semanas 5 y 8 desde 80 a 100 – 120 lpm Las bradicardias embrionarias (menos de 80 lpm) son frecuentes y su papel predictivo es controversial

Patología del amnios y del corion Durante el primer trimestre es posible diagnosticar bridas amnióticas que más que provocar abortos producen amputaciones y lesiones por constricción Se ha asociado la visualización de engrosamientos difusos del amnios y fusiones irregulares entre éste y el corion con infecciones intramnióticas y mal pronóstico final

Patología del amnios y del corion Es importante destacar la presencia de hematomas subcoriales, que pueden ser colecciones de sangre intracavitaria que disecan el espacio virtual entre la decidua capsular o el corion liso y la decidua parietal Se debe distinguir de los hematomas que se producen debajo del corion frondoso que actúan como auténticos abruptios con tasas de pérdida embrionaria de hasta 60%