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ESSENTIALS OF DIAGNOSIS

ESSENTIALS OF DIAGNOSIS

  • Intrauterine pregnancy at less than 20 weeks’ gestation.

  • Low or falling levels of hCG.

  • Bleeding, midline cramping pain.

  • Open cervical os.

  • Complete or partial expulsion of products of conception.

GENERAL CONSIDERATIONS

About three-fourths of spontaneous pregnancy losses (spontaneous abortions) occur before the 16th week; of these, three-fourths occur before the 8th week. Almost 20% of all clinically recognized pregnancies result in a spontaneous loss.

More than 60% of spontaneous losses result from chromosomal defects due to maternal or paternal factors; about 15% appear to be associated with maternal trauma, infections, dietary deficiencies, diabetes mellitus, hypothyroidism, antiphospholipid antibody syndrome, or anatomic malformations. There is no reliable evidence that spontaneous pregnancy loss may be induced by psychic stimuli such as severe fright, grief, anger, or anxiety. In about one-fourth of cases, the cause cannot be determined. There is no evidence that video display terminals or associated electromagnetic fields are related to an increased risk of spontaneous pregnancy loss.

It is important to distinguish women with a history of incompetent cervix from those with early pregnancy loss which typically occur in the first trimester. Factors that predispose to incompetent cervix, a problem of the second trimester, are a history of incompetent cervix with a previous pregnancy, cervical conization or surgery, cervical injury, diethylstilbestrol (DES) exposure, and anatomic abnormalities of the cervix. Before pregnancy or during the first trimester, there are no methods for determining whether the cervix will eventually be incompetent. After 14–16 weeks, ultrasound may be used to evaluate the internal anatomy of the lower uterine segment and cervix for the funneling and shortening abnormalities consistent with cervical incompetence.

CLINICAL FINDINGS

A. Symptoms and Signs

1. Incompetent cervix

Characteristically, incompetent cervix presents as “silent” cervical dilation (ie, with minimal uterine contractions) in the second trimester. When the cervix reaches 4 cm or more, active uterine contractions or rupture of the membranes may occur secondary to the degree of cervical dilation. This does not change the primary diagnosis.

2. Threatened spontaneous abortion

Bleeding or cramping occurs, but the pregnancy continues. The cervix is not dilated.

3. Inevitable spontaneous abortion

The cervix is dilated and the membranes may be ruptured, but passage of the products of conception has not yet occurred. Bleeding and cramping persist, and passage of the products of conception is considered inevitable.

4. Complete abortion

Products of conception are completely expelled. Pain ceases, but spotting may persist. Cervical os is closed.

5. Incomplete abortion

The cervix is dilated. Some portion of the products of conception remains in the uterus. Only mild cramps are ...

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