Spontaneous Abortion: Diagnosis and Treatment

238 Pages·1992·6.78 MB·English

by  Isabel Stabile

Isabel Stabile . Gedis Grudzinskas
Tim Chard (Eds.)
Spontaneous
Abortion
Diagnosis and Treatment
With 32 Figures
Springer-Verlag
London Berlin Heidelberg New York
Paris Tokyo Hong Kong
Barcelona Budapest
Isabel Stabile, PhD, MRCOG
Center for Biomedical Research and Toxicology, Florida State University,
Tallahassee, Florida 32303, USA, and
Academic Unit of Obstetrics and Gynaecology, The Royal London Hospital,
Whitechapel, London E1IBB, UK
J. G. Grudzinskas, MD, FRCOG, FRACOG
Academic Unit of Obstetrics and Gynaecology, The Royal London Hospital,
Whitechapel, London E1IBB, UK
T. Chard, MD, FRCOG
Academic Unit of Reproductive Physiology, St Bartholomew's Hospital
Medical College, London EC1A 7BE, UK
Cover illustrations: Ch. 5, Fig. 5. TAS showing crumpled embryo surrounded by
reduced amniotic fluid volume. Ch. 5, Fig. 8. Histogram of ultrasonically diagnosed
complications of early pregnancy. (Adaptation.)
ISBN-13: 978-1-4471-1920-3 e-ISBN-13: 978-1-4471-1918-0
DOl: 10.1007/978-1-4471-1918-0
British Library Cataloguing in Publication Data
Spontaneous Abortion: Diagnosis and
Treatment
I. Stabile, Isabel
618.3
ISBN-13: 978-1-4471-1920-3
Library of Congress Cataloging-in-Publication Data
Spontaneous abortion: diagnosis and treatment/edited by Isabel
Stabile, Gedis Grudzinskas, Tim Chard.
p. cm.
Includes index.
ISBN-13: 978-1-4471-1920-3
1. Miscarriage. I. Stabile, Isabel, 1957- . II. Grudzinskas.
J. G. (Jurgis Gediminas) III. Chard, T.
[DNLM: 1. Abortion. WQ 225 S7636]
RG648.S683 1992
618.3'92----dc20
DNLMIDLC 92-2166
for Library of Congress CIP
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Preface
Spontaneous abortion is one of the commonest reasons for admission
to gynaecology wards. This book brings together the experience of
several distinguished workers in the field of early pregnancy failure.
The first chapters provide an overview of the classification of early
pregnancy failure as well as the epidemiology, aetiology and path
ology of spontaneous abortion. Later chapters focus on the diagnostic
tools available to clinicians in the management of this condition with
particular emphasis on abdominal and transvaginal ultrasound and
biochemical tests. The relative predictive value of such tests is
discussed in detail. The third part of the book describes specific
categories of miscarriage such as recurrent and septic abortion and
ectopic pregnancy. They also describe the knowledge developed as a
result of the expansion of assisted conception techniques and the
contribution of invasive procedures (chorion villus sampling and
amniocentesis) to the problem of spontaneous miscarriage. The last
part of the book focuses on treatment including surgical, immuno
logical and endocrine techniques.
The aim of the book is to provide better understanding of questions
such as:
What is the predictive value of symptoms and signs in the diagnosis of
spontaneous miscarriage?
Can ultrasound be used confidently to diagnose spontaneous
abortion?
Does ultrasound render biochemical tests obsolete in the management
of spontaneous miscarriage?
What are the useful specific treatments available to women who are at
risk of miscarrying?
What are the useful specific treatments available to women who have
had recurrent spontaneous miscarriages?
What are the current strategies of treatment for women who are
miscarrying?
Although it was intended to minimise repetition, which frequently
mars multi-author volumes of this kind, we have chosen to permit a
vi Preface
degree of overlap of views. Firstly, so that individual chapters may be
read independently and secondly, although some of the views on
specific treatment strategies may differ between various chapters,
because of the authoritative stature of the writer, the debate may be of
interest to the reader.
Given the magnitude of the problem of spontaneous miscarriage, it
is hoped that this book will stimulate further clinical research in this
field.
London Isabel Stabile
September 1991 Gedis Grudzinskas
Tim Chard
Contents
List of Contributors . . . . . . . . . . xiii
1 Definition and Clinical Presentation
Isabel Stabile, 1. G. Grudzinskas and T. Chard 1
Spontaneous Abortion 1
Threatened Abortion 1
Inevitable Abortion . . 2
Missed Abortion . . . 3
Anembryonic Pregnancy 3
Spontaneous Abortion of a Live Fetus 3
Trophoblastic Tumours 4
Septic Abortion . . . 4
Recurrent Abortion . 5
Induced Abortion . 5
Ectopic Pregnancy 5
Summary . 6
References .... 6
2 Spontaneous Abortions: Epidemiology
Eva Alberman. . . . . . . . . . . . . . 9
Introduction. . . . . . . . . . . . . . . 9
Problems of Definition and Ascertainment 9
Current Estimates of Early Reproductive Loss . 11
The Role of Chromosomal Anomalies . . . . 12
The Role of Malformations Other Than Those Caused by
Chromosomal Anomaly 13
Sex Ratio . . . . . . . . 14
Multiple Pregnancies . . . . . . . . . . . . . . . . . . .. 14
Maternal Age and Parity . . . . . . . . . . . . . . . . .. 14
Outcome of Other Pregnancies in Sibships with Spontaneous
Abortions . . . . . 16
Maternal Health 16
Maternal Smoking . . 17
Alcohol Consumption 17
viii Contents
Oral Contraceptives, Spermicides and Intrauterine Devices 17
Other Environmental Hazards 18
Conclusion 19
References .. . . . . . . . . 19
3 Aetiology of Pregnancy Failure
1. L. Simpson . . . . . . . . . . 21
Introduction. . . . . . . . . . . . . . . . . . . . . . . . 21
Numerical Chromosomal Abnormalities (Aneuploidy and
Polyploidy) . . . . 21
Preclinical Losses . . . . . . 21
First Trimester . . . . . . . 22
Second and Third Trimester 24
Pathological Findings in First Trimester Abortuses. 24
Fetal Conditions . . 24
Maternal Conditions 30
Maternal Health 39
References ...... 42
4 Pathology of Spontaneous Abortion
H. Fox ............... . 49
Introduction. . . . . . . . . . . . . . . . . . . . . . 49
Anatomo-pathological Classification of Material from
Abortions ..................... . 49
Histological Classification of Material from Abortions 51
Specific Pathological Abnormalities in Abortion . . 56
Infection .................... . 56
Placental Ischaemia and Inadequate Placentation 56
Immunological Factors . . . . . . 58
Anti-phospholipid Antibodies . . 58
Congenital Uterine Abnormalities 58
Conclusions 59
References ............ . 59
5 Ultrasound Diagnosis of Spontaneous Miscarriage
Isabel Stabile and S. C. Campbell . 63
Introduction. . . . . . . . 63
Am I Pregnant? . . . . . . 63
Is My Pregnancy Normal? 64
When Is My Baby Due? 68
Will I Miscarry? . . . . . . 70
Intrauterine Haematomata 70
Double Gestational Sacs . 72
Low Lying Placenta 72
Low Ratio of Amniotic Sac to Embryo 72
Uterine Abnormalities . . 73
Embryonic Growth Delay 73
Early Bradycardia .... 74
Contents ix
Is My Baby Normal? . . . . . . . . . . . 74
Specific Complications of Early Pregnancy 75
Early Embryonic Demise . . . . . . 75
Anembryonic Pregnancy . . . . . . . . 76
Complete and Incomplete Abortion . . 77
Doppler Ultrasound in the Diagnosis of Pregnancy Failure 77
References ..................... 82
6 Assessment of Early Pregnancy: Measurement of
Fetoplacental Hormones and Proteins
f. G. Grudzinskas and T. Chard 87
Diagnosis of Pregnancy . . . . . . 87
Normal Pregnancy ........ 88
Control of Synthesis and Secretion 90
Early Pregnancy Failure ..... 90
Threatened and Spontaneous Miscarriage 91
Anembryonic Pregnancy 91
Ectopic Pregnancy ............ 92
Trophoblastic Disease .......... 93
Prenatal Diagnosis: Chorionic Villus Sampling 93
Conclusions 94
References .... . . . . . . . . . . . . . . 95
7 The Aetiology and Management of Recurrent Miscarriage
Lesley Regan 99
Introduction. . . . . . . 99
Incidence . . . . . . . . 100
The Risk of Recurrence 100
Aetiology of Recurrent Miscarriage 102
Genetic Causes . . 102
Anatomical Causes . . . . . . . . 103
Infective Causes ......... 104
Chronic Maternal Disorders, Drugs and Environmental
Pollutants . . . . . . . 104
Endocrine Causes ....... 105
Immunological Causes . . . . . 106
Investigation and Management . 107
Summary and Conclusions 112
References .... . . . . . . . . 113
8 Septic Abortion
Felicity Ashworth 119
Relevance of Septic Abortion to Maternal Mortality Statistics 119
Risk Factors. . . 120
Clinical Features ......... 121
Microbiology . . . . . . . . . . . 122
Complications of Septic Abortion 122
Septicaemia . . . . . . . . . . . 123
x Contents
Endotoxic Shock . . . . . . . 123
Acute Tubular Necrosis 123
Management of Septic Abortion 124
Prevention . . . . 124
Antibiotic Therapy 125
Curettage .... . 125
Surgery ..... . 125
Management of Septic Shock 127
Conclusion 130
References ........ . 130
9 Miscarriage Following Assisted Conception
A. H. Balen and l. L. Yovich 133
Miscarriage in the Infertile Couple . . . . . . 133
Pregnancy Diagnosis . . . . . . . . . . . . 134
The Influence on Miscarriage of the Drugs used in Assisted
Conception . . . . . . . . . . . . . . . . . 135
Anti-oestrogens. . . . . . . . . . . . . . . 135
Ovulation Induction with Gonadotrophins . 138
Miscarriage after IVF and Related Procedures 140
Summary . 144
References .. . . . . . . . . . . . . . . . . 144
10 Abortion Following Invasive Diagnostic Procedures in
the First Trimester
M. D. Griffith-lanes and R. l. Lilford 149
Introduction. . . . . . . . . . . . . . 149
Safety . . . . . . . . . . . . . . . . . 149
Evaluating Safety of Invasive Prenatal Diagnostic Tests 149
Transabdominal versus Transcervical CVS . 150
CVS versus Midtrimester Amniocentesis. 151
Early Amniocentesis 153
Accuracy . . . . . . . . . . 154
Single Gene Defects . . . 155
Chromosomal Abnormalities 155
Cost Considerations. 156
References ......... 157
11 Diagnosis and Management of Ectopic Pregnancy
Isabel Stabile . . . . . . . . . . 159
Introduction . . . . . . . . . . . 159
Incidence of Ectopic Pregnancy 159
Aetiology of Ectopic Pregnancy 160
Clinical Features of Ectopic Pregnancy. 161
Diagnostic Tests 162
Biochemical Tests .......... 163
Sonographic Tests .......... 167
Combination of Ultrasound and Biochemical Tests 176
Contents xi
Management of Ectopic Pregnancy . 177
Conclusion 179
References ............ . 179
12 Surgical Treatmeut of Spontaneous Abortion
M. Macnaughton . . . . . . . . . . . . . . . . 183
Cervical Cerclage in the Management of Cervical
Incompetence . . . . . . . . . . . . . . . . . . 183
Operative Procedures for Cervical Incompetence 184
Choice of Patients .., . . . 185
Value of the Procedure. . . . . . . . 186
Randomised Controlled Trials . . . . 186
Management of Spontaneous Abortion . 188
Dilatation and Curettage . . . . . . . 189
Complications of Dilatation and Curettage 190
References .................. 191
13 Endocrine Treatment in the Prevention and Management
of Spontaneous Abortion
A. M. Lower and f. G. Grudzinskas 193
Introduction. . . . . 193
Prevention ..... 194
Systemic Disorders 194
Reproductive System Disorders 196
Empirical Treatment . . . . . . . 198
Timing of Treatment . . . . . . 198
Endocrine Treatment of Incomplete or Missed Abortion 199
Conclusion 200
References ......................... 200
14 Immunotherapy of Recurrent Spontaneous Miscarriage
W. D. Billington .................... 203
Introduction: Maternal Immunity in Normal Pregnancy 203
Rationale for Immunotherapy in Pregnancy Loss 204
Definition of Recurrent Pregnancy Loss 205
Methods of Treatment .. . . . . 205
Leucocyte Immunisation . . . . . . . 206
Trophoblast Membrane Infusion . . . 208
Seminal Plasma . . . . . . . . . . . . 209
Intravenous Immunoglobulin (IVIG) 210
Assessment of Outcome of Treatment: Difficulties of
Interpretation. . . . . . . . . . . . 210
Potential Hazards of Immunotherapy 211
Future Requirements 212
Conclusions 214
References . 214
Subject Index 219