Thread: Sharp your Skills: How to Manage an Incomplete Abortion?

How to Manage an Incomplete Abortion?

Question 1

A 32-year-old G5P1 presents for her first prenatal visit. A complete obstetrical, gynecological, and medical history and physical exam is done. Which of the following would be an indication for elective cerclage placement?

a.Three spontaneous first-trimester abortions

b.Twin pregnancy

c.Three second-trimester pregnancy losses without evidence of labor or abruption

d.History of loop electrosurgical excision procedure for cervical dysplasia

e.Cervical length of 35 mm by ultrasound at 18 weeks

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Answer / Explanation:

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The answer is c, Three second-trimester pregnancy losses without evidence of labor or abruption.

The diagnosis of cervical insufficiency or incompetence is based on the presence of painless cervical dilation with a history of pregnancy loss in the second trimester or early-third-trimester preterm delivery. A patient with a history of three or more midtrimester pregnancy losses or early preterm deliveries is a candidate for a cerclage. Cerclage is not indicated for the prevention of first-trimester losses. Cerclage has not been shown to improve the preterm delivery rate or neonatal outcome in twin gestations.

A simple punch biopsy or loop electrosurgical excision procedure of the cervix is unlikely to disrupt functional structure of the cervix and prophylactic cerclage is not warranted. Serial transvaginal ultrasound evaluation of cervical length can be considered in women with a history of second and early-third-trimester deliveries. A cervical length less than 25 millimeters or funneling of more than 25% or both is associated with an increased risk of preterm delivery.
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How to Manage an Incomplete Abortion?

Question 2

A 22-year-old G1P0 presents to your clinic for follow-up of evacuation of a complete hydatiform mole. She is asymptomatic and her exam is normal. Which of the following would be an indication to start single-agent chemotherapy?

a.A rise in hCG titers

b.A plateau of hCG titers for 1 week

c.Return of hCG titer to normal at 6 weeks after evacuation

d.Appearance of liver metastasis

e.Appearance of brain metastasis

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Answer / Explanation:

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The answer is a, A rise in hCG titers .

Single-agent chemotherapy is usually instituted if levels of hCG remain elevated 8 weeks after evacuation of a hydatidiform mole. Approximately 50% of the patients who have persistently high hCG titers will develop malignant sequelae. If hCG titers rise or reach a plateau for 2 to 3 successive weeks following molar evacuation, a single-agent chemotherapy should be instituted, provided that the trophoblastic disease has not metastasized to the liver or brain. The presence of such metastases usually requires initiation of combination chemotherapy.[/HIDE]

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How to Manage an Incomplete Abortion?

Question 3

A 20-year-old G1P0 presents to your clinic for follow-up for a suction dilation and curettage for an incomplete abortion. She is asymptomatic without any vaginal bleeding, fever, or chills. Her exam is normal. The pathology report reveals trophoblastic proliferation and hydropic degeneration with the absence of vasculature; no fetal tissue is identified. A chest x-ray is negative for any evidence of metastatic disease. Which of the following is the best next step in her management?

a.Weekly hCG titers

b.Hysterectomy

c.Single-agent chemotherapy

d.Combination chemotherapy

e.Radiation therapy

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Answer / Explanation:

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The answer is a, Weekly hCG titers..

The condition of women who have hydatidiform moles but no evidence of metastatic disease should be followed routinely by hCG titers after uterine evacuation. Most authorities agree that prophylactic chemotherapy should not be employed in the routine management of women having hydatidiform moles because 85 to 90% of affected patients will require no further treatment. For a young woman in whom preservation of reproductive function is important, surgery is not routinely indicated.
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