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Emergency dilation and curettage
7%
7/104
Elective dilation and curettage
52%
54/104
Serial beta HCG titers
28%
29/104
Broad spectrum antibiotics
1%
1/104
Broad spectrum antibiotics followed by dilation and curettage
12%
12/104
Select Answer to see Preferred Response
This patient presents with a gestational sac without heart tones without vaginal bleeding or cervical dilation consistent with a missed abortion. Scheduling an elective dilation and curettage (D&C) is the most appropriate intervention. Spontaneous abortion occurs in 15% of pregnancies. Missed abortion refers to fetal demise without cervical dilation or vaginal bleeding. Ultrasonography showing an absence of fetal heart tones is diagnostic. In a hemodynamically stable woman without evidence of bleeding, treatment options include elective D&C, pharmacologic abortion (with misoprostol or mifepristone), or expectant management. All have similar efficacy, but varying time to completion of treatment. Surgery takes the least amount of time (< 48 hours on average) and expectant management takes the longest time (within 2 weeks) to expel all contents. Therefore, given the relative risks and benefits, choice in treatment mainly depends on patient preference. Griebel et al. review spontaneous abortion. Chromosomal abnormality occurs in about half of spontaneous abortions. Autosomal trisomy is the most commonly identified anomaly. Chromosomal abnormalities that result in spontaneous abortion are thought to be random events, including gametogenesis errors, dispermy, and nondisjunction. Chen and Creinin explain the term 'missed' abortion. Missed abortion refers to a nonviable pregnancy that has been retained in the uterus without spontaneous passage for at least 8 weeks since fetal demise. Thus the uterus has 'missed' recognizing an abnormal pregnancy. Illustration A is an ultrasound of the uterus showing an empty gestational sac, indicative of intrauterine fetal demise. Incorrect Answers: Answer 1: Emergency D&C is necessary in situations with cervical dilation, vaginal bleeding, or retained placental tissue, such as inevitable or incomplete abortion or in cases of missed abortion with symptoms of DIC. Answer 3: Treatment options include elective D&C, medication, or expectant managment. Serial beta HCG titers alone would not be appropriate. However, HCG levels should be used to monitor for complete evacuation of spontaneous abortion after expectant management or medication. Of note, HCG is not routinely monitored after surgical evacuation. Answers 4 and 5: Broad spectrum antibiotics followed by D&C is the appropriate intervention for septic abortion.
3.4
(5)
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