یکشنبه چهاردهم مرداد 1386

Patient information: Miscarriage

Patient information: Miscarriage
Togas Tulandi, MD, MHCM

.

These materials are for your general information and are not a substitute for medical advice. You should contact your physician or other healthcare provider with any questions about your health, treatment, or care. Please do not contact UpToDate or the physician authors of these materials.

INTRODUCTION — A miscarriage is a pregnancy that ends before the fetus is able to live outside the uterus. A brief review of the events of early pregnancy will help in the understanding of miscarriage.

A woman's reproductive system includes the uterus (including the cervix), two ovaries, two fallopian tubes, and the vagina. The fallopian tubes are a pair of hollowed tubes that run from each side of the uterus to the ovaries (show figure 1). Once a month, an egg is released by one of the ovaries and travels down the fallopian tube. If the egg is fertilized in the tube by the male's sperm, pregnancy begins.

Once the egg and sperm join, they rapidly develop new cells. This bundle of cells, called the embryo, normally implants on the inner wall of the uterus. Once implanted, the embryo continues to grow inside a sac of amniotic fluid, sometimes called the "bag of water." After several weeks, the embryo is called a fetus.

INCIDENCE — Miscarriage in early pregnancy is very common. Studies show that about 10 to 20 percent of women who know they are pregnant have a miscarriage some time before 20 weeks of pregnancy; 80 percent of these occur in the first 12 weeks. But the actual rate of miscarriage is even higher since many women have very early miscarriages without ever realizing that they are pregnant. One study that followed women's hormone levels every day in order to detect very early pregnancy found a total pregnancy loss rate of 31 percent.

CAUSES — Many different factors can lead to miscarriage, and it is difficult to say with certainty what causes a particular miscarriage to occur. One or more problems with the pregnancy can be found in a significant percentage of early miscarriages.

As an example, in 1/3 of miscarriages occurring before 8 weeks, there is a pregnancy sac but no embryo inside. This means the egg was fertilized and the cells began to divide, but an embryo did not develop. In other cases, the embryo develops but it is abnormal. Chromosomal abnormalities, in particular, are common. One study found that of 8841 miscarriages, 41 percent had chromosomal abnormalities.

In some cases, medical conditions in the mother, such as uncontrolled diabetes, or structural problems in the reproductive tract, such as uterine fibroids, can lead to miscarriage. (See "Patient information: Care during pregnancy for women with type 1 or 2 diabetes" and see "Patient information: Fibroids").

RISK FACTORS — Several risk factors are associated with a higher rate of miscarriage. Age — Older women are more likely to have a miscarriage than younger women. Number of pregnancies — The risk of miscarriage increases in women who have had been pregnant previously. That is, women who have been pregnant two or more times have an increased risk of miscarriage. Previous miscarriage — A history of previous miscarriage may increase the risk for a future miscarriage. As an example, the risk of miscarriage in future pregnancy is about 20 percent after one miscarriage, 28 percent after two, and 43 percent after three or more miscarriages. By comparison, only 5 percent of women whose previous pregnancy was successful miscarried in the next pregnancy. Smoking — There is evidence that smoking more than 10 cigarettes a day is associated with an increased risk of miscarriage. Alcohol — Consumption of more than 30 ounces of alcohol per month doubled the risk of miscarriage in one study. In another, there was an increased risk of miscarriage in women who drank more than 3 drinks per week in the first 12 weeks of pregnancy. No amount of alcohol is known to be safe during pregnancy. Fever — Pregnant women who develop fevers of 100ºF (37.5ºC) or more appear to have an increased risk of miscarriage. Trauma — Trauma to the uterus can increase the risk of miscarriage. This includes some forms of prenatal testing, such as amniocentesis or chorionic villus sampling. (See "Patient information: Amniocentesis" and see "Patient information: Chorionic villus sampling"). Caffeine — In one study, some women who ingested 500 mg of caffeine per day had a significantly increased risk of miscarriage (8 ounces of coffee contains 100 to 135 mg of caffeine). Other causes — Women who are exposed to certain substances or conditions may have an increased risk of congenital abnormalities and miscarriage. This includes exposure to certain infections, medications, radiation, physical stresses, and environmental chemicals.

SIGNS AND SYMPTOMS — The most common signs of miscarriage are vaginal bleeding and abdominal pain early in pregnancy. These problems should always be evaluated by a clinician. However, bleeding and discomfort can occur in normal pregnancies. In many cases, bleeding resolves on its own and the pregnancy continues normally without further problems.

Based on particular signs and symptoms, a woman may be diagnosed as follows:

Threatened miscarriage — A woman who has vaginal bleeding early in pregnancy but no other signs of problems is said to have a threatened miscarriage. The cervix, or opening to the uterus, is closed, and the uterus is the right size for the woman's particular stage of pregnancy. If the pregnancy is far enough along, a fetal heart beat may be noted. In many women with threatened miscarriage, the bleeding subsides and the pregnancy continues to term. In others, the bleeding becomes heavier and miscarriage occurs.

Inevitable miscarriage — This means a miscarriage cannot be avoided. The cervix is open, bleeding is heavy or increasing, and abdominal cramping is present.

Incomplete miscarriage — An incomplete miscarriage means that the woman has passed much of the pregnancy tissue, but some remains in the uterus. Typically, the fetus has been passed, but bits of the placenta remain. The cervix remains open, and bleeding may be heavy.

Complete miscarriage — A woman who passes all of the pregnancy tissue is said to have had a complete miscarriage. This is common in miscarriages that occur before 12 weeks of pregnancy. After the miscarriage there is a period of bleeding and cramping, which resolves without medical intervention. On examination, the clinician typically finds that the cervix is closed, and there is no sign of a pregnancy sac in the uterus. Ultrasound examination confirms the diagnosis.

Septic miscarriage — Some women who have miscarriage develop an infection in the uterus. This is known as a septic miscarriage. Symptoms include fever, chills, malaise, abdominal pain, vaginal bleeding, and vaginal discharge, which may be thick and may have an unpleasant odor.

DIAGNOSIS — In some cases, miscarriage is evident based on the woman's symptoms and the physical exam. As an example, with inevitable miscarriage, the cervix is open and pregnancy tissue may be seen in the cervix.

However, in many cases of vaginal bleeding in early pregnancy, ultrasound is used to establish a diagnosis, and/or to help determine if the pregnancy is "viable", that is, whether it is capable of progressing to term. Ultrasound uses sound waves to visualize the structures inside the uterus. In early pregnancy, the exam is often done through the vagina.

Ultrasound — In a woman who has had a complete miscarriage, no pregnancy sac or embryo will be seen on ultrasound. In other women, a pregnancy sac will be seen but it will be abnormal or an embryo will not be present, indicating that the pregnancy is not viable.

If an embryo is present, its size is measured and compared to the size that is expected at the woman's stage of pregnancy. The sac and other materials surrounding the embryo are also examined to look for abnormalities in these structures.

Fetal heart beat — At about 6 weeks after the last menstrual period, the motion of the fetal heart should be visible on ultrasound. If the pregnancy has progressed to the stage where a heart beat should be present, the failure to detect a heart beat during an ultrasound exam indicates that the pregnancy has likely ended.

On the other hand, the presence of a fetal heart beat (in the absence of other abnormalities in the pregnancy) indicates the pregnancy may still be viable and that miscarriage may not occur.

Doctors will also evaluate the rate of the fetal heart. A fetal heart beat that is slower than normal (120 to 170 beats per minute) can indicate that a miscarriage is likely.

TREATMENT OPTIONS — Once it has been determined that a miscarriage is inevitable or is already occurring , several options are available depending on the stage of the miscarriage, the condition of the mother, and other factors. The three main options are: observation, medical treatment, or surgical treatment.

Observation — In some situations, women having a miscarriage require little treatment. Many women with complete miscarriage fall into this group. In addition, women who miscarry at less than 13 weeks of pregnancy and have stable vital signs and no signs of infection can often be managed without medical or surgical treatment. In time, the contents of the uterus will pass, usually within two weeks of diagnosis, but sometimes as long as 3 to 4 weeks later. Once the contents have been passed, an ultrasound is done to ensure that the miscarriage is complete.

Medical treatment — In some cases, medications can be given to stimulate the uterus to pass the pregnancy tissue. The medicine can be given by mouth or vaginally, and works over several days.

Surgical treatment — The conventional treatment for early miscarriage is a surgical procedure called dilation and curettage, or D and C. The cervix (the opening to the uterus) is dilated, and an instrument is inserted that uses suction and/or a gentle scraping motion to remove the contents of the uterus.

As with any surgical procedure, there are risks of complications. The risks associated with D and C are small, and include perforation of the uterus, formation of scar tissue in the uterus, trauma to the cervix, and infection, which could lead to future fertility problems. The procedure is done in women who do not want to wait for spontaneous passage of the pregnancy, and in women with heavy bleeding or infection.

AFTER MISCARRIAGE — Following miscarriage, a woman is advised to avoid having sex or putting anything into the vagina, such as a douche or tampon. Women have traditionally been told to wait two to three months before trying to become pregnant again, although several studies have shown no increased risks with a shorter interval. Any type of contraception, including placement of an intrauterine device, may be started immediately.

Medications may be given to help decrease bleeding and reduce infection. In addition, women who have an Rh negative blood type (ie, A, B, AB, or O negative) need to receive a drug called Rh(D) immune globulin (RhoGam®). This medicine helps protect future fetuses against problems that can occur if an Rh negative mother is carrying a baby who is Rh positive.

Emotional health — Women experience a range of emotions following miscarriage; there is no right or wrong way to feel. The loss of a pregnancy can cause significant grief. Sometimes these reactions are strong and long-lasting. A woman should let her healthcare provider know if she is feeling profound sadness or depression following pregnancy loss, especially if it continues for greater than two weeks. Referral for grief counseling or other treatment may be beneficial. (See "Patient information: Depression").

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)
The March of Dimes

      (www.marchofdimes.com)
Pregnancy & Infant Loss Support, Inc.

       (www.nationalshareoffice.com)


[1-4]


Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Regan, L, Rai, R. Epidemiology and the medical causes of miscarriage. Baillieres Best Pract Res Clin Obstet Gynaecol 2000; 14:839. 
2. Wilcox, AJ, Weinberg, CR, O'Connor, JF, et al. Incidence of early loss of pregnancy. N Engl J Med 1988; 319:189. 
3. Ankum, WM, Wieringa-De Waard, M, Bindels, PJ. Management of spontaneous miscarriage in the first trimester: an example of putting informed shared decision making into practice. BMJ 2001; 322:1343. 
4. Demetroulis, C, Saridogan, E, Kunde, D, Naftalin, AA. A prospective randomized control trial comparing medical and surgical treatment for early pregnancy failure. Hum Reprod 2001; 16:365

UPTODATE2007

 

نوشته شده توسط دکتر مهدی چوقادی در 0:40 |  لینک ثابت   • 

شنبه سیزدهم مرداد 1386

Diagnosis and clinical manifestations of early pregnancy

Diagnosis and clinical manifestations of early pregnancy
Lori A Bastian, MD
Haywood L Brown, MD

 

UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.1 is current through December 2006; this topic was last changed on October 23, 2006. The next version of UpToDate (15.2) will be released in June 2007.

INTRODUCTION — Diagnosis of pregnancy and knowledge of normal findings associated with early pregnancy are common issues in the medical care of reproductive age women. More than 6 million women are diagnosed with pregnancy each year in the United States, and millions more have sought diagnostic testing [1]. Early diagnosis of pregnancy may prompt women to seek prenatal care earlier and to take measures, such as improving glucose control (in diabetics) or avoiding alcohol or potentially harmful drugs, that can benefit the fetus.

The diagnosis of early pregnancy is based primarily upon laboratory assessment of human chorionic gonadotropin (hCG). Characteristic findings on history and physical examination are not highly sensitive for diagnosis, but are important to help the clinician distinguish normal pregnancy from coexistent disorders.

SIGNS AND SYMPTOMS OF EARLY PREGNANCY — Most women experience some signs or symptoms of pregnancy as early as three weeks after conception [2]. The most common symptoms of early pregnancy include: Amenorrhea Nausea with or without vomiting Breast tenderness Increased frequency of urination Fatigue

Amenorrhea and bleeding — Amenorrhea is the cardinal sign of early pregnancy. Pregnancy should be suspected whenever a woman in her childbearing years notes cessation or delay of menses (>1 week), especially if she reports any sexual activity while not using contraception or with inconsistent use of contraception. Even in women using contraception, contraceptive failures occur (show table 1A-B). Secondary amenorrhea should be considered in women who are not pregnant.

Cessation of menses is a difficult symptom to evaluate because many women have irregular bleeding patterns or an occasional prolongation of a cycle. In addition, some women have bleeding on and off during the first few months of pregnancy and thus lack amenorrhea [3]. This was illustrated in a study of 221 healthy women who were recruited to keep daily diaries and provide daily urine samples while trying to become pregnant [4]. Of the 151 women who became pregnant, 14 women (9 percent) experienced at least one day of vaginal bleeding during the first eight weeks of pregnancy. The majority (12 of 14) of these pregnancies continued to a live birth. Bleeding tended to occur around the time when women would expect their periods to occur. This bleeding was typically light (requiring only one or two pads or tampons in 24 hours). The important conclusions from this study were that vaginal bleeding is fairly common in early pregnancy, and that it occurs more often at the time when a period would be expected, although there is no clear physiologic explanation for this phenomenon.

Bleeding in early pregnancy is of concern if it is heavier than a typical menstrual period or accompanied by pain, as it may represent an ectopic pregnancy or impending miscarriage. The differential diagnosis of bleeding in early pregnancy is discussed separately. (See "Overview of the etiology and evaluation of vaginal bleeding in pregnant women").

Nausea and vomiting — The term "morning sickness" refers to the tendency of most pregnant women to develop nausea, often with vomiting, between six and 12 weeks of gestation. This nausea is typically worse in the morning and tends to improve as the day progresses, but can occur at any time of day. Hyperemesis gravidarum may be considered the severe end of the spectrum of symptoms. (See "Hyperemesis gravidarum").

If nausea and vomiting are accompanied by pain, fever, vertigo, diarrhea, headache, or abdominal distension, a cause other than pregnancy should be considered. In addition, the onset of nausea and vomiting after the first 12 weeks of pregnancy should also prompt an evaluation because this would be after the typical period expected for pregnancy-related nausea and vomiting. (See "Approach to the adult patient with nausea and vomiting").

Breast tenderness — The pregnant woman often notices enlargement of her breasts with a heavy sensation associated with tingling and soreness. This is due to hCG stimulation of the secretory glands. Other breast changes related to early pregnancy include a darkening of the skin around the areola and more prominent veins across each breast. (See "Breast development and anatomy" section on Changes during pregnancy).

Urinary frequency — Urinary frequency and nocturia are common pregnancy-related complaints. Frequency appears to be related to increased total urinary output and can occur as early as six weeks of gestation. Cystitis should be suspected if dysuria, hematuria, or pyuria is present. (See "Renal and urinary tract physiology in pregnant women" section on Frequency and nocturia).

Fatigue — Fatigue is common in early pregnancy, but less prominent in the second trimester. The exact cause is not clear; possibilities include the rapid, large increase in concentrations of progesterone which may exert soporific effects and the extensive cardiovascular/hematological changes which increase cardiac output. (See "Maternal cardiovascular and hemodynamic adaptation to pregnancy").

Stress, depression, and lifestyle issues are common causes of fatigue in nonpregnant individuals. The evaluation of fatigue that is chronic or does not improve after the first trimester can be found separately (show table 2). (See "Approach to the patient with fatigue").

Other — Other symptoms women report in early pregnancy include food cravings and aversions, mood changes, lightheadness, abdominal bloating, constipation, low back pain, nasal congestion, and uterine cramps similar to those felt before or during menses. Most of these symptoms have been attributed to the changing hormonal milieu of pregnancy.

Bloating and constipation are probably due to increases in progesterone, which reduces intestinal motility. Constipation may also be aggravated by the use of prenatal vitamins containing iron. (See "Maternal gastrointestinal tract adaptation to pregnancy").

Pregnancy related dyspnea is usually mild, of gradual onset, and not associated with other pulmonary signs or symptoms (eg, no cough, wheezing, pleurisy). It is caused by progesterone effects on the respiratory center (ie, increased minute ventilation). If dyspnea occurs acutely, is associated with tachycardia, chest pain, hemoptysis, or signs of deep vein thrombosis, then pulmonary embolism should be considered. (See "Changes in the respiratory tract during pregnancy", see "Dyspnea during pregnancy" and see "Deep vein thrombosis and pulmonary embolism in pregnancy").

Lightheadedness is likely associated with the normal pregnancy related fall in vascular resistance. It typically occurs when the woman is erect and resolves by having her lie on her left side. Lightheadedness is of concern if it occurs in association with an abnormal heart rate/rhythm or signs suggestive of a seizure. (See "Maternal cardiovascular and hemodynamic adaptation to pregnancy").

Nasal congestion is related to hyperemia of the mucous membranes. (See "Physiologic changes of the skin; hair; nails; and mucous membranes during pregnancy").

Low back pain, and other musculoskeletal discomforts, typically occur after the first trimester, but may occur early in pregnancy. They are due to changes in the woman's center of gravity with advancing gestation and the effect of pregnancy hormones. (See "Pain related to the musculoskeletal system during pregnancy").

DIAGNOSIS

History — Specific questions to ask women if pregnancy is suspected include the following:

  (1) When was your last menstrual period, and was it normal?
  (2) Do you engage in sexual activity?
  (3) Do you use any form of contraception?
  (4) Do you have any symptoms of pregnancy?
  (5) Is there any chance you may be pregnant?

Several studies have examined the value of these questions in diagnosing early pregnancy. In one Emergency Department study, physicians were asked to complete a brief questionnaire on all patients for whom they ordered a qualitative serum beta-hCG test; 208 patients were included and 138 of these had abdominal pain [5]. Sixty-eight women (33 percent) were pregnant. Likelihood ratios (LR) were calculated to express the change in odds favoring the diagnosis of early pregnancy given a positive result (LR+=sensitivity/1-specificity) or a negative result (LR-=1-sensitivity/specificity) [6].

In this study, pregnancy was likely if there was a positive history of a period that was not on time and imperfect use of contraception and the patient thought she might be pregnant. For delayed menses the LR+ was 2.06 (95% CI 1.65-2.57) and the LR- was 0.25 (95% CI 0.14-0.45), for no birth control the LR+ was 1.31 (95% CI 1.14-1.5) and the LR- was 0.33 (95% CI 0.16-0.69), and for patient suspects she is pregnant the LR+ was 1.89 (95% CI 1.54-2.33) and the LR- was 0.27 (95% CI 0.15-0.48). If these factors were negative, however, there was a 10 percent chance that pregnancy was overlooked. In another Emergency Department study that included 191 consecutive reproductive age women presenting for any reason (70 had abdominal pain), patients were asked to complete a menstrual and sexual history questionnaire before pregnancy testing [7]. Twelve (6.3 percent) women had an unrecognized pregnancy (defined as a pregnancy not definitely known to exist before the visit). In this study, presence of a delayed menstrual period had a nonsignificant LR+ of 1.04 (95% CI 0.38-2.87) and LR- 0.99 (95% CI 0.7-1.38), patient stating there was a chance she might be pregnant had LR+ of 3.15 (95% CI 2.37-4.2) and LR- 0.12 (95% CI 0.02-0.77), and absence of contraceptive use had LR+ of 1.53 (95% CI 1.06-2.18) and LR- 0.49 (95% CI 0.18-1.32). A study of 283 women seeking pregnancy testing at a health center reported 118 (42 percent) were pregnant [8]. Women experiencing any pregnancy symptoms (defined as morning sickness, breast tenderness and fullness, urinary frequency or fatigue) had LR+ of 2.43 (95% CI 1.71-3.44) and LR- 0.63 (95% CI 0.52-0.77) and if the woman thinks she may be pregnant the LR+ was 1.6 (95% CI 1.39-1.85) and LR- 0.18 (95% CI 0.09-0.34). A similarly designed study of 2926 adolescents seeking pregnancy testing (36 percent were pregnant) reported delayed menses had LR+ of 1.13 (95% CI 1.05-2.92) and LR- 0.81 (95% CI 0.68-0.96) and patient thinks she may be pregnant had LR+ of 2.11 (95% CI 1.97-2.27) and LR- 0.38 (95% CI 0.34-0.42) [9]. Lastly, Scottish general practitioners asked 1592 women requesting pregnancy testing to complete a questionnaire that also asked about pregnancy symptoms [10]. Overall, 61.5 percent were pregnant. In this study, delayed menses had LR+ of 1.56 (95% CI 1.4-1.74) and LR- 0.62 (95% CI 0.56-0.69) and symptom of morning sickness had LR+ of 2.7 (95% CI 2.19-3.33) and LR- 0.71 (95% CI 0.67-0.76).

In summary, although a report of delayed menses, sexual activity with imperfect use of contraception, and patient suspicion of pregnancy are predictive that a pregnancy test will be positive, these historical factors are not sufficiently reliable to diagnose or exclude pregnancy. Morning sickness, if present, increases the likelihood of pregnancy, but some women do not experience this symptom or merely haven't experienced it before being tested (show table 3).

Physical examination — Findings suggestive of pregnancy on pelvic and general physical examination include the following [6,11,12]: The uterus becomes enlarged and globular and increases in size by about 1 cm per week after 4 weeks of gestation. The uterus remains a pelvic organ until approximately 12 weeks of gestation, when it becomes sufficiently large to palpate abdominally just above the symphysis pubis. (See "The gynecologic history and physical examination"). The cervix and uterus soften (called Goodell sign and Hegar sign, respectively). This allows the examiner to easily flex the uterine body against the cervix, which is called McDonald sign. This occurs ar about 6 weeks of gestation. Uterine artery pulsation can be palpated through the lateral vaginal fornices on bimanual examination. Because of the increased blood supply to the uterus, the mucous membranes of the vulva, vagina, and cervix become congested and take on a bluish-violet coloration (Chadwick sign). This occurs at about 8 to 12 weeks of gestation. The breasts become fuller, tender, and the areolar area darkens. The venous pattern under the skin over the breasts becomes increasingly visible as pregnancy progresses. Identification of a fetal heart rate distinct from the maternal heart rate is diagnostic of pregnancy. Hand held Doppler instruments typically are used to detect fetal heart activity at 10 to 12 weeks of gestation, but can be used earlier if the uterus is accessible abdominally, and are reliable if the fetal heart rate is identified. The fetal heart can usually be auscultated with a fetoscope by 20 weeks of gestation.

In the Scottish study discussed above, general practitioners also asked 1592 women requesting pregnancy testing to undergo physical examination prior to obtaining results of their pregnancy tests [10]. Overall, 61.5 percent were pregnant: 25 percent of women in this study were more than 63 days from LMP and the average was about 50 days from LMP. Physician's assessment of positive breast signs had LR+ of 2.71 (95% CI 2.3-3.2) and LR- 0.55 (95% CI 0.5-0.6), and positive pelvic examination findings had LR+ of 3.17 (95% CI 2.22-4.51) and LR- 0.87 (95% CI 0.8-0.9). Of interest, 19 women who were not pregnant had a palpable fundus.

A subsequent study examined 155 women to determine if uterine artery pulsations could be palpated [11]. Twenty-five women were pregnant. The examiner was blind to the patients' history and pregnancy test results. LR+ for uterine artery pulsations was 10.98 (95% CI 5.63-21.4) and LR- 0.26 (95% CI 0.13-0.52).

In summary, only a few studies have examined the value of physical examination in diagnosing early pregnancy. The likelihood of pregnancy increases if signs of pregnancy are present, but absence of these signs does not rule out pregnancy. Obviously, the ability to detect physical signs of pregnancy is highly dependent upon the experience of the examiner.

Laboratory tests — A diagnosis of early pregnancy based upon clinical findings or a home pregnancy test should be confirmed by office or laboratory based urine or serum testing. The laboratory diagnosis of pregnancy is based upon assessment of human chorionic gonadotropin (hCG). hCG structure and assay are discussed in detail separately. (See "Management of hydatidiform mole" section on Human chorionic gonadotropon).

  Home pregnancy test — Home pregnancy test (HPT) kits were introduced in 1975. They have become increasingly popular and work by detecting hCG in the urine using immunometric assay methods [13]. Most studies have found that women choose to use HPT kits because of the speed of obtaining results and the convenience of testing at home.

A woman may say that her HPT was negative and ask if this means that she is not pregnant. Specific questions to ask her include the following:

  (1) How many days after your missed period did you perform the test?
  (2) Did you understand how to do the test and feel comfortable doing it?
  (3) What brand of HPT did you use?
  (4) Did you repeat the test and get a similar result?

Although manufacturers claim these kits are 99 percent accurate, the accuracy of HPTs is greatly affected by the technique and interpretation of users. This was illustrated in a systematic review of five studies from 1997 that reviewed 16 HPT kits [14]. When urine samples were tested by volunteers, test sensitivity was 91 percent. In contrast, the sensitivity was only 75 percent in studies where subjects were actual patients who used the HPT kit on their own urine samples.

There is also significant variation in sensitivity among HPT kits. To demonstrate this variability, a blinded in vitro sensitivity analysis was performed on seven commonly used HPT kits [15]. Major findings from this study were: "First Response Early Result" was found to be the most sensitive HPT, with an analytical sensitivity of less than 6.3 mIU/ml. This product should detect more than 95 percent of pregnancies on the first day of a missed period. The same manufacturer, Scantibodies Laboratories Inc, also makes "Answer" and "Answer Quick & Simple" kits that are similar in design to "First Response Early Result" and therefore may have similar sensitivities. The second most sensitive HPT was "Clearblue Easy Earliest Results," having an analytical sensitivity of 25 mIU/ml [15]. This product should detect 80 percent of pregnancies on the first day of a missed period. "Clear Plan Easy" is a similar product made by the same manufacturer. The majority of products tested detected only a small percentage of pregnancies on the first day of a missed period because a higher level of hCG was required for a positive result.

Based on these data, we suggest practitioners advise their patients on selection of HPT kits and their limitations.

Regardless of the HPT kit used, the most common error with home kits is a negative result because the test is performed too early in pregnancy. If a pregnancy is suspected despite a negative test, the test should be repeated in one week. Many HPT kits make this recommendation and provide an extra kit for this purpose. Pregnancy always should be confirmed with an office-based test, even when a home-based test is positive.

  Urine pregnancy test — Urine pregnancy testing is the most common method used to confirm pregnancy in the office setting. A variety of affordable and reliable immunometric urine tests that take one to five minutes to perform are available for use in office practices. Immunometric tests specifically identify the beta subunit of hCG, thus rendering cross-reaction with subunits of other hormones, such as luteinizing hormone, follicle stimulating hormone, and thyrotropin, unlikely. These tests provide accurate qualitative results (positive or negative based upon a color change) at hCG levels as low as 5 mIU/mL [16]. Of note, a positive test indicates the presence of hCG from any source, it does not exclude the possibility of an ectopic or nonviable intrauterine pregnancy, gestational trophoblastic disease, or some types of ovarian tumors. (See "Clinical manifestations, diagnosis, and management of ectopic pregnancy").

Ultrasensitive urine hCG assays (hCG levels as low as 5 mIU/mL) can detect pregnancy seven days after fertilization in some women; however, the standard urine pregnancy tests used in clinical practice (hCG levels as low as 20 mIU/mL) are not reliably positive until later. This was illustrated in a study of 221 women age 21 to 42 years who were attempting to conceive and were tested with an extremely sensitive urine assay for hCG [17]. The test detected only 90 percent of pregnancies on the expected first day of missed menses. The authors estimated the proportion of pregnancies that could be detected by urine assay relative to the expected first day of menses: two days before (79 percent), seven days after (97 percent), and 11 days after (100 percent). These authors recommend waiting one week after the first day of the missed period to perform pregnancy testing. Adolescents with irregular cycles or an uncertain last menstrual period should wait at least 14 days from a sexual experience before obtaining a pregnancy test.

Testing one to two weeks after a missed menses minimizes false negative with urine testing. The higher the maternal hCG level, the more likely a urine test will be positive. Ultrasensitive tests will be positive within days of a missed menses while less sensitive tests may not be positive until later. Waiting for a week or two after a missed period not only minimizes false negatives but decreases the need for serum hCG testing to confirm early pregnancy when a negative urine test is obtained.

As noted, the most common reason for a false negative result is that the test has been performed too soon after ovulation (which often occurs later than expected) [18]. If a pregnancy is suspected despite a negative test, the test should be repeated in one week. In addition to false negative results, false positive tests can also occur. (See "Epidemiology; clinical manifestations and diagnosis of gestational trophoblastic disease" section on False positive tests).

Severe renal disease with elevated lipids, high immunoglobulin levels, and low serum protein levels can interfere with test results [19]. Test results also may be misinterpreted because of color blindness. A low urine specific gravity does not appear to alter the sensitivity of detecting hCG; however, detection of hCG levels in dilute urine can be adversely affected by using pregnancy tests with higher thresholds for hCG positivity [20,21]. Thus, awareness of the tests hCG detection limits is important when pregnancy is suspected.

  Serum pregnancy test — Serum beta hCG concentrations rise soon after implantation (ie, 7 to 11 days after ovulation). The concentration doubles every 29 to 53 hours during the first 30 days after conception in a viable, intrauterine pregnancy and reaches peak concentrations of 60,000 IU/L (in relation to the First International Reference Preparation) at about 8 to 10 weeks after the last menstrual period, but the range of normal is quite wide: 5,000 to 150,000 IU/L or more [22,23]. In the next 10 weeks, circulating hCG levels decline, reaching a median concentration of about 12,000 IU/L, again with a wide variation of normal: 2,000 to 50,000 IU/L.The hCG concentration stays fairly constant from about the 20th week until term.

The serum hCG concentration can be measured qualitatively or quantitatively using a radioimmunoassay technique that provides reliable results at hCG levels as low as 3 mIU/mL. If a qualitative test is needed, serum and urine test results are equivalent as long as both tests are set to have the same sensitivity [24]. However, in some institutions, the sensitivity of the qualitative serum pregnancy test is different from that of urine pregnancy tests (eg, threshold for a positive test 10 versus 25 mIU/mL).

Quantitative tests are not useful for estimating gestational age because there is a wide range in hCG values at any given point in pregnancy [23]. Serial quantitative test specimens are sometimes obtained to check doubling time or disappearance time in evaluating and managing ectopic pregnancy or nonviable intrauterine pregnancy [19]. (See "Clinical manifestations, diagnosis, and management of ectopic pregnancy").

The quantitative test procedure requires use of radioisotopes and may be processed only in a commercial or hospital-based laboratory. It takes at least two hours to obtain results; additional delay occurs because the test is often performed in batches.

  Ultrasound examination — On transvaginal ultrasound examination, a gestational sac or cavity compatible with pregnancy is usually visible at 4.5 to 5 weeks of gestation (three to four weeks after ovulation) with the double decidual sign at 5.5 to 6 weeks. The yolk sac appears at five to six weeks and remains until approximately 10 weeks, and a fetal pole with cardiac activity is first detected at 5.5 to 6 weeks by transvaginal ultrasound. These structures are noted slightly later with the transabdominal approach. The transvaginal sonographic visualization of the gestational sac at four to five weeks typically corresponds to an hCG level of at least 1000 to 1500 IU/L. Once a pregnancy has been visualized sonographically, there is no value to hCG measurement. (See "Prenatal assessment of gestational age and fetal weight" and see "Clinical manifestations, diagnosis, and management of ectopic pregnancy" section on Discriminatory zone and see "Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic evaluation").

SUMMARY AND RECOMMENDATIONS The diagnosis of early pregnancy is based primarily upon laboratory assessment of human chorionic gonadotropin (hCG). (See "Laboratory tests" above). The most common signs and symptoms of pregnancy are amenorrhea, nausea/vomiting, breast tenderness, urinary frequency, and fatigue. (See "Signs and symptoms of early pregnancy" above). A report of delayed menses, sexual activity with imperfect use of contraception, and patient suspicion of pregnancy are predictive that a pregnancy test will be positive; however, these historical factors are not sufficiently reliable to diagnose or exclude pregnancy. (See "History" above). Signs suggestive of pregnancy on physical examination include a soft, enlarged, globular uterus; bluish discoloration of the mucous membranes of the vulva, vagina, and cervix; darkening of the breast areola and increased prominence of veins under the skin of the breast; and palpation of uterine artery pulsation on bimanual examination. Detection of fetal heart beat distinct from the maternal heart rate is diagnostic of pregnancy. (See "Physical examination" above). The accuracy of home pregnancy tests is greatly affected by the technique and interpretation of users. On the first day after a missed period, the best tests were negative in 5 to 20 percent of women. (See "Home pregnancy test" above). Almost all pregnant women will have a positive urine pregnancy test by one week after the first day of a missed menstrual period. (See "Urine pregnancy test" above). Qualitative urine and serum pregnancy tests have similar sensitivity; urine tests are less expensive and usually results are available sooner than with serum tests. A quantitative serum pregnancy test is not needed to diagnose pregnancy. (See "Serum pregnancy test" above). Transvaginal ultrasound examination can visualize a gestational sac at 4.5 to 5 weeks of gestation. (See "Ultrasound examination" above).


Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ventura, SJ, Mosher, WD, Curtin, SC, et al. Highlights of trends in pregnancies and pregnancy rates by outcome: estimates for the United States 1976-1996. Natl Vital Stat Rep 1999; 47:1. 
2. Sayle, AE, Wilcox, AJ, Weinberg, CR, Baird, DD. A prospective study of the onset of symptoms of pregnancy. J Clin Epidemiol 2002; 55:676. 
3. Ananth, CV, Savitz, DA. Vaginal bleeding and adverse pregnancy outcomes: a meta-analysis. Paediatr Perinat Epidemiol 1994; 8:62. 
4. Harville, EW, Wilcox, AJ, Baird, DD, Weinberg, CR. Vaginal bleeding in very early pregnancy. Hum Reprod 2003; 18:1944. 
5. Ramoska, EA, Sacchetti, AD, Nepp, M. Reliability of patient history in determining possibility of pregnancy. Ann Emerg Med 1989; 18:48. 
6. Bastian, LA, Piscitelli, JT. Is this patient pregnant? Can you reliably rule in or rule out early pregnancy by clinical examination? JAMA 1997; 278:586. 
7. Stengel, CL, Seaberg, DC, Macleod,BA. Pregnancy in the emergency department: risk factors and prevalence among all women. Ann Emerg Med 1994; 24:697. 
8.  Bachmann, GA. Myth or fact: can women self-diagnose pregnancy?. J Med Soc N J 1984; 81:857. 
9. Zabin, LS, Emerson, MR, Ringers, PA, Sedivy, V. Adolescents with negative pregnancy test results: an accessible at-risk group. JAMA 1996; 275:113. 
10.  Robinson, ET, Barber, JH. Early diagnosis of pregnancy in general practice. J R Coll Gen Pract 1977; 27:335. 
11. Meeks, GR, Cesare, CD, Bates, GW. Palpable uterine artery pulsation as a clinical indicator of early pregnancy. J Reprod Med 1995; 40:194. 
12. Paul, M, Schaff, E, Nichols, M. The roles of clinical assessment, human chorionic gonadotropin assays, and ultrasonography in medical abortion practice. Am J Obstet Gynecol 2000; 183:S34. 
13. Cole, LA, Khanlian, SA, Sutton, JM, et al. Accuracy of home pregnancy tests at the time of missed menses. Am J Obstet Gynecol 2004; 190:100. 
14. Bastian, LA, Nanda, K, Hasselblad, V, Simel, DL. Diagnostic efficiency of home pregnancy test kits. A meta-analysis. Arch Fam Med 1998; 7:465. 
15. Cole, LA, Sutton-Riley, JM, Khanlian, SA, et al. Sensitivity of over-the-counter pregnancy tests: comparison of utility and marketing messages. J Am Pharm Assoc (Wash DC) 2005; 45:608. 
16. Snyder, JA, Haymond, S, Parvin, CA, et al. Diagnostic Considerations in the Measurement of hCG in Aging Women. Clin Chem 2005; 51:1830. 
17. Wilcox, AJ, Baird, DD, Dunson, D, et al. Natural limits of pregnancy testing in relation to the expected menstrual period. JAMA 2001; 286:1759. 
18. McChesney, R, Wilcox, AJ, O'Connor, JF, et al. Intact HCG, free hCG beta subunit and hCG beta core fragment: longitudinal patterns in urine during early pregnancy. Hum Reprod 2005; 20:928. 
19.  Pediatric and Adolescent Gynecology, 5th ed, Emans, SJ, Laufer, MR, Goldstein, DP (Eds), Lippincott Williams Wilkins, Philadelphia 2005. 
20. Neinstein, L, Harvey, F. Effect of low urine specific gravity on pregnancy testing. J Am Coll Health 1998; 47:138. 
21. Ikomi, A, Matthews, M, Kuan, AM, Henson, G. The effect of physiological urine dilution on pregnancy test results in complicated early pregnancies. Br J Obstet Gynaecol 1998; 105:462. 
22. Braunstein, GD, Rasor, J, Danzer, H, et al. Serum human chorionic gonadotropin levels throughout normal pregnancy. Am J Obstet Gynecol 1976; 126:678. 
23.  www.hcglab.com/hCG%20levels.htm (accessed October 23, 2006). 
24.  O'Connor, RE, Bibro, CM, Pegg, PJ, Bouzoukis, JK. The comparative sensitivity and specificity of serum and urine hCG determination in the ED. Am J Emerg Med 1993; 11:434. 
 
GRAPHICS


Pregnancy rate (percent) during first year of use

                                                                          T ypical use                            Perfect use
Cervical cap
Previous births 32 26
No previous birth 16 9
Condom
Male 15 2
Female 21 5
Diaphragm with spermacide 16 6
Sponge
Previous births 32 20
No previous births 16 9
Fertility awareness
Cervical murus 22 3
Symptothermal 13-20 2
Calendar (rhythm) 13 5
Standard days 12 5
Lactational amenorrhea* 5 <2
Withdrawal 27 4
Depot-provera 3 <1
IUD
Copper T or Mirena <1 <1
Patch 8 <1
OCPs
Progestin only or combination estrogen-progestin 8 <1
Ring 8 <1
Female sterilization <1 <1
Vasectomy <1 <1
Emergency contraception
Pills Pregnancy rate decreased by 75 to 89 percent, depending on the regimen used (higher pregnancy rate is for combined estrogen-progestin pills, lower pregnancy rate is for levonorgetrel alone)
IUD Pregnancy rate decreased by 99 percent
No method 85 85


* Rate reflects cumulative pregnancy rate in the first 6 months following birth.


 
 


Efficacy contraception methods
 
Data refer to number of pregnancies per 100 women during first year of use
Typical Use: refers to failure rates for women and men whose use is not consistent or always correct. Correct Use: refers to failure rates for those whose use is consistent and always correct.


Data adapted from: Contraceptive Technology, 18th edition, 2004 p. 226.

 
 


Major causes of chronic fatigue

Psychologic
Depression
Anxiety
Somatization disorder
Pharmacologic
Hypnotics
Antihypertensives
Antidepressants
Drug abuse and drug withdrawal
Endocrine-metabolic
Hypothyroidism
Diabetes mellitus
Apathetic hyperthyroidism
Pituitary insufficiency
Hypercalcemia
Adrenal insufficiency
Chronic renal failure
Hepatic failure
Neoplastic-hematologic
Occult malignancy
Severe anemia
 Infectious
Endocarditis
Tuberculosis
Mononucleosis
Hepatitis
Parasitic disease
HIV infection
Cytomegalovirus
Cardiopulmonary
Chronic congestive heart failure
Chronic obstructive pulmonary disease
Connective tissue disease
Rheumatoid disease
Disturbed sleep
Sleep apnea
Esophageal reflux
Allergic rhinitis
Psychologic causes (see above)
Idiopathic (diagnosis by exclusion)
Idiopathic chronic fatigue
Chronic fatigue syndrome
 


Adapted from Gorroll, AH, May, LA, Mulley, AG Jr (Eds), Primary Care Medicine: Office Evaluation and Management of the Adult Patient, 3rd ed, JB Lippincott, Philadelphia, 1995.

 
 


Summary of studies reporting likelihood ratios for prediction of pregnancy

History Positive likelihood ratio (95% confidence interval)
Delayed menses  2.06 (95% CI 1.65-2.57)
1.04 (95% CI 0.38-2.87)
1.13 (95% CI 1.05-2.92)
1.56 (95% CI 1.4-1.74)
No birth control  1.31 (95% CI 1.14-1.5)
1.53 (95% CI 1.06-2.18)
Patient suspects that she is pregnant 1.6 (95% CI 1.39-1.85)
3.15 (95% CI 2.37-4.2)
1.6 (95% CI 1.39-1.85)
2.11 (95% CI 1.97-2.27)
Morning sickness 2.7 (95% CI 2.19-3.33)
Any pregnancy symptoms (defined as morning sickness, breast tenderness and fullness, urinary frequency, or fatigue) 2.43 (95% CI 1.71-3.44)
Characteristic breast changes on physical examination 2.71 (95% CI 2.3-3.2)
Palpable fundus on physical examination 2.77 (95% CI 1.7-4.51).
Chadwick sign present 3.17 (95% CI 2.22-4.51)
Uterine artery pulsations present 10.98 (95% CI 5.63-21.4)

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نوشته شده توسط دکتر مهدی چوقادی در 7:4 |  لینک ثابت   • 

شنبه سیزدهم مرداد 1386

Patient information: Dilation and curettage D&C

Patient information: Dilation and curettage (D&C)
Richard S Guido, MD
Dale W Stovall, MD

UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.1 is current through December 2006; this topic was last changed on September 12, 2006. The next version of UpToDate (15.2) will be released in June 2007.

INTRODUCTION — Dilation and curettage (D&C) is a procedure in which material from the inside of the uterus is removed. The "dilation" refers to dilation of the cervix, the lower part of the uterus that opens into the vagina (show figure 1). "Curettage" refers to the scraping or removal of tissue lining the uterine cavity (endometrium) with a surgical instrument called a curette. Some curettes are sharp while others use suction.

REASONS FOR DC — There are a number of reasons a D&C might be performed. In some cases, the procedure is used to gain information about the uterus to diagnose a medical condition (called diagnostic D&C). In other cases, the procedure is used to treat a medical problem or condition (called therapeutic D&C).

Diagnostic DC — The primary reason for a diagnostic D&C is to obtain samples of the endometrium to evaluate abnormal uterine bleeding or abnormal cells found during routine screening for cervical cancer. (See "Patient information: Abnormal Pap smear").

In most cases, a healthcare provider will try to obtain a tissue sample with an office procedure called endometrial biopsy. In some cases, endometrial biopsy is not possible or insufficient tissue is obtained. When this occurs, D&C must be done to obtain an adequate tissue sample.

Diagnostic D&C is usually done with hysteroscopy; this involves dilating the cervix and inserting a small instrument that allows the physician to examine and photograph the inside of the uterus. The images are displayed on a monitor, allowing the physician to visualize the endometrium. This helps the physician to avoid missing small polyps and ensures that the most visibly abnormal areas are sampled. (See "Patient information: Abnormal uterine bleeding").

Examination of the endometrial tissue by a pathologist can help establish certain diagnoses, including endometrial (uterine) cancer, endometrial polyps, or precancerous conditions of the lining of the uterus (endometrial hyperplasia).

Therapeutic DC — Therapeutic D&C is done to remove the contents of the uterus in the following circumstances:

  Miscarriage — In some miscarriages, the tissues from a pregnancy are passed completely. In other cases, a D&C is needed to remove this tissue or to ensure that all of it has been passed. (See "Patient information: Miscarriage").

  Abortion — A D&C can be done to remove the contents of the uterus when a woman chooses to end a pregnancy.

  Treatment of molar pregnancies — A molar pregnancy occurs when a tumor forms in place of normal pregnancy placenta. It is often treated with a D&C.

  Prolonged or excessive vaginal bleeding — D&C may be done as a treatment in some cases of prolonged or excessive bleeding that do not respond to medical treatment. (See "Patient information: Abnormal uterine bleeding").

  Postpartum hemorrhage — Curettage may be done to manage excessive bleeding after delivery of an infant (postpartum hemorrhage).

PREPARING FOR DC — Some patients will need to have blood testing before D&C (such as a blood count), although this is not always necessary. Patients should not eat or drink anything before the procedure. All patients will need someone to accompany them home because it will not be safe to drive after receiving anesthesia, which causes sedation.

Some patients will need to have a device or medication placed in the cervix the day before their procedure. The purpose is to safely and gradually enlarge the cervical opening, reducing the risk of cervical injury. Devices are used when the cervix must be dilated to a larger size than is typically needed for D&C, such as with pregnancy terminations and some types of hysteroscopy. Some patients will be instructed to insert a medicine in the vagina to soften the cervix prior to the procedure.

After arriving for the procedure, a nurse may place an intravenous (IV) line, which can be used to give fluids and medicine before, during, and after the procedure. The nurse or doctor will review the patient's medical history, list of medications used, and any drug allergies.

PROCEDURE — D&C can be performed in an operating room in a hospital or clinic. Many patients have a D&C performed in an outpatient setting. A woman's blood pressure, pulse, and blood oxygen levels are monitored during the procedure. The procedure takes 15 to 30 minutes to complete.

Anesthesia — The procedure can be done using general, regional, or local (paracervical) block anesthesia. The type of anesthesia chosen depends upon the reason for the procedure as well as the medical history.

  General anesthesia — General anesthesia induces sleep and completely relaxes the muscles, which makes it easier for the doctor to perform a pelvic examination.

  Regional anesthesia — Reginonal anesthesia uses an injection of an anesthetic into the area around the spinal cord to block pain sensation during surgery. The patient may be sedated with medicine given through an intravenous (IV) line.

  Paracervical block — Anesthetic agents are injected directly into and around the cervix, numbing the area. The woman is given a sedative through an intravenous (IV) line.

POST-PROCEDURE CARE — After the procedure, the patient will be cared for in a recovery or post-anesthesia care unit for a few hours. This is necessary to monitor for excessive vaginal bleeding or other complications, and allows time for recovery from the anesthesia. Patients who received general anesthesia occasionally have nausea and vomiting, which can be treated with medications.

Most patients should be able to resume their regular activities within a day or two. Mild cramping and spotting may occur for a few hours or days; cramping can be treated with nonsteroidal antiinflammatory medications such as ibuprofen (Advil®, Motrin®). Patients should not put anything into the vagina (tampons, douches) during this time and should ask when they can safely have sexual intercourse. The next menstrual period usually occurs within 4 to 6 weeks of the procedure.

A woman should call her physician if she develops fever (temperature greater than 100.4º F), cramps lasting longer than 48 hours, increasing rather than decreasing pain, prolonged or heavy bleeding, or foul-smelling vaginal discharge.

COMPLICATIONS — D&C is a commonly performed procedure that is usually very safe. Yet as with any operation, complications occur. Complications of D&C can include:

Uterine perforation — Uterine perforation occurs when one of the surgical instruments makes a hole in the uterus. It is more common when the procedure is done during pregnancy due to softening of the uterine wall.

Fortunately, most uterine perforations heal on their own and do not require any treatment. Two potential problems caused by perforation are bleeding from injury to a blood vessel and injury to other internal organs. A second procedure may be needed to repair these types of injury.

Cervical injury — Injuries to the cervix can occur during dilation or from trauma related to the curettage. Lacerations (cuts) to the cervix are managed with pressure to the area, application of medications that help stop bleeding, or in some cases, stitches in the cervix.

Infection — Infection from D&C is rare.

Intrauterine adhesions — Adhesions (areas of scar tissue) can sometimes form in the uterus following D&C. Adhesion is most common when D&C is performed postpartum or postabortion. In some cases, this can lead to abnormalities in the menstrual cycle, painful menstrual cycles, infertility, or miscarriage. If adhesions are extensive, a woman can be treated with hormones to encourage growth of healthy uterine tissue and the scar tissue can be removed with a surgical procedure.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)
The Mayo Clinic

      (www.mayoclinic.com)


[1-3]


Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1.  APGO educational series on women's health issues. Clinical management of abnormal uterine bleeding. Association of Professors of Gynecology and Obstetrics, May 2002. 
2. Chen, SS, Lee, L. Reappraisal of endocervical curettage in predicting cervical involvement by endometrial carcinoma. J Reprod Med 1986; 31:50. 
3. Gebauer, G, Hafner, A, Siebzehnrubl, E, Lang, N. Role of hysteroscopy in detection and extraction of endometrial polyps: results of a prospective study. Am J Obstet Gynecol 2001; 184:59. 
 
GRAPHICS


Normal female reproductive anatomy

 
Normal female reproductive anatomy Dilation and curettage (D&C) abortion  

 

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©2007 UpToDate

15.1

نوشته شده توسط دکتر مهدی چوقادی در 6:48 |  لینک ثابت   • 

شنبه سیزدهم مرداد 1386

سقط جنین-چرا سقط جنین اهمیت دارد؟ (جهت استفاده عموم)

چرا سقط جنین اهمیت دارد؟

حاملگی موفق به بارداری اطلاق می شود که طی آن جنین رشد و تکامل خود را پیدا کرده و ضمن حفظ سلامت مادر منجر به تولد نوزادی سالم شود.
در خلال حاملگی ، سه ماهه اول ، دوم و سوم هر کدام خصوصیات مهم و خاص خود را دارا هستند . هر مرحله دارای عوامل خاص برای مادر و جنین است که می تواند تهدید کننده سلامت آنها باشد

سقط جنین شایعترین عارضه حاملگی در سه ماهه اول حاملگی می باشد که موجب استرس روحی شدید در زوجهای مشتاق فرزند می شود.
۷۰-۸۰% حاملگی ها به مرحله حیات نمی رسد و براورد می شود ۵۰% بارداري ها قبل از تاخیر در اولین قاعدگی دفع می شوند.

حدود ۲۰-۱۵% بارداری های شناخته شده به سقط جنین منتهی می شوند.
سقط جنین یعنی به مقصد نرسیدن حاملگی و  در واقع یکی از فوریتهای زنان و مامایی می باشد.

عوارض جدی سقط جنین شامل خونریزی ، عفونت ، شوک باکتریال( شوکی که در اثر عفونت ایجاد می شود) می باشند. همچنین خطر مرگ و میر مادر به دنبال سقط جنین وجود دارد .

در بیمارانی که سابقه یک بار سقط جنین داشته اند احتمال سقط جنین در حاملگی بعدی انها حدود ۲۰% است.

پیامدهای سقط جنین برای یک زن چیست؟

به دلیل اینکه در اکثر موارد سقط جنین به هر شكل همراه با خونریزی می باشد ادامه خونریزی به دنبال سقط جنین و یا خونریزی در طی آن می  تواند برای سلامت مادر زیان بار بوده و منجر به کمخونی و مشکلات جسمی و روحی حتی به مرگ مادر منجر شود.

بروز عفونت و زخمهای عفونی در خارج و داخل رحم به دلیل دستکاری های انجام شده در حین ختم حاملگی می تواند منجر به عفونت لوله و چسبندگی داخل رحمی و عقیمی  دائم زن شود.

زنانی که دچار سقط می شوند گرفتار واکنش سوگواری فوق العاده شدیدی می شوند. مهمترین پاسخ با احساس گناه مشخص می شود . کاملا” منطقی است که اگر فرض کنیم این ناراحتی عاطفی با از دست دادن بارداری های مکرر پیچیده تر خواهد شد.

پدیده سقط جنین چگونه اتفاق می افتد؟

بیش از ۸۰% سقط ها در سه ماهه اول حاملگی رخ می دهد و پس از آن این میزان به سرعت کاهش می یابد. علت بروز سقط جنین همیشه مشخص نیست ولی در ماههای اول حاملگی تقريبا” در همه موارد مرگ جنین ، قبل از سقط جنین صورت می گیرد. به این دلیل بررسی علل سقط جنین شامل تعیین علت مرگ جنین در صورت امکان می باشد.

عوامل ایجاد کننده سقط جنین در زنان به دو دسته عمده تقسیم می شود که عبارتند از :

۱. عوامل جنینی شامل :

الف- نمو غیر طبیعی تخم  که در ۴۰% موارد اختلال رشد منجر به سقط جنین خود به خود می شود.
 ب-  ناهنجاریهای ارثی و ژنتيكي جنین: آمار به دست آمده نشان میدهد حدود ۲۰-۱۵% حاملگی ها منجر به سقط جنین می شود که ۶۰-۵۰% موارد سقط جنین به دلیل ناهنجاری های ارثی و ژنتيكي جنین می باشند.

۲.عوامل مربوط به مادر :

الف- بیماریهای عفونی مادر:  عفونتهای مادری به ویژه سرخچه ، تب مالت و عفونتهای مقاربتی می تواند منجر به سقط جنین شود.
 ب- بیماری های مزمن ناتوان کننده در مادر: بیماری هایی نظیر سل ، سرطان ، افزایش فشار خون ، بیماری کلیوی می تواند منجر به مرگ جنین و سقط جنین شود.
ج - بیماریهای غدد
: بیماری های غدد نظیر کم کاری تیروئید ، دیابت قندی می تواند منجر به سقط جنین شود.
د- مصرف دارو و عوامل محیطی
: مصرف سیگار ، الکل ، داروهای ضد بارداری و سموم محیطی نظیر سرب ، آرسنیک در مادر می تواند منجر به سقط جنین شود.
ه - عدم پذیرش ایمنی بدن
: جنین از لحاظ ژنتیک یک عامل خارجی برای مادر است و بدن مادر بر علیه آن آنتی بادی ساخته و جنین را دفع می نماید. در یک بارداری طبیعی جفت آنتی بادی های متوقف کننده می سازد که مانع دفع جنین می شود
و - ناهنجاری های رحمي
: در بعضی زنان نقص تکاملی رحم در دوران جنینی منجر به ایجاد رحم دو شاخ یا یک شاخ و یا انواع ناهنجاری های شكلي رحم می شود که این نقایص می تواند منجر به سقط جنین شود همچنین وجود فیبروم یا چسبندگی رحم نیز می تواند باعث سقط جنین در زن باردار شود.
ز - نارسایی دهانه رحم
: باز بودن بیش از حد دهانه رحم به دلیل مادرزادی یا کشش بیش از حد در باز کردن آن در هنگام سقط یا زایمان قبلی منجر به نارسایی و ضعف دهانه رحم شده و می تواند ایجاد سقط خود به خودی نماید. سقط در این موارد معمولا” پس از سه ماهه اول حاملگی اتفاق می افتد .

 خطر سقط جنین با تعداد زایمانها و نیز سن مادر زیاد می شود به طوریکه مطالعات انجام شده نشان می دهد که سقط جنین در زنان باردار زیر ۲۰ سال و بالای ۴۰ سال بیشتر است . همچنین در پدران خیلی جوان یا پیر نیز افزایش سقط جنین مشاهده شده است. بالاخره میزان بروز سقط با حامله شدن خانمها در عرض سه ماه پس از زایمان افزایش می یابد.

انواع سقط جنین چیست؟

بروز سقط جنین در زنان اکثرا” به صورت خود به خودی اتفاق می افتد .مگر اینکه سقط به طور عمدی انجام شود
زمانی که سقط خود به خودی بدون استفاده از راههای دارویی یا مکانیکی برای تخلیه رحم صورت می گیرد به آن سقط خود به خودی اطلاق می شود. در این حالت پس از مرگ جنین در داخل رحم خونریزی در داخل بافت رحم اتفاق می افتد و تخم از دیواره رحم جدا می شود و انقباضات رحم را تحریک کرده که در نهایت منجر به دفع محصولات حاملگی می شود.

در زنان باردار همه این مراحل ذکر شده در بالا به دنبال هم اتفاق نمی افتد و ممکن است هر زن در یکی از این مراحل متوقف شده و دچار خونریزی شود به همین دلیل سقط خود به خودی به موارد ذیل تقسیم بندی می شود.

۱.     تهدید به سقط
۲.     سقط غیر قابل اجتناب
۳.     سقط ناقص
۴.     سقط کامل
۵.     سقط فراموش شده
۶.     سقط مکرر

 در موارد تهدید به سقط مقدار خونریزی زنانه و درد شكمي بسیار کم ، علائم بارداری پابر جا و حاملگی ممکن است ادامه یابد.
در سقط غیر قابل اجتناب، بیمار  آبریزش داشته و دهانه رحم باز می شود . بنابر این سقط جنین غیر قابل اجتناب است.
در سقط جنین ناقص دهانه رحم کاملا” باز بوده و خونریزی زیاد و دردهای انقباضی در زیر شکم وجود دارد در این حالت مقداری از محصولات حاملگی دفع شده اما چون مقدار زیادی از این محصولات در رحم باقی می ماند سقط ناقص است.
 در سقط کامل به دنبال خونریزی قبلی که رخ داده است محتویات رحم به طور کامل خارج شده است.

در سقط فراموش شده جنین مرده است ولی برای مدتی (حتی ماهها) در رحم باقی مانده و هنوز دفع نشده است در این حالت علائم حاملگی نیز ناپدید شده اند.

 سقط مکرر یا عادتی :

بیشتر از سه سقط جنین پشت سر هم را که احتمالا” در اثر یک علت مشترک رخ داده سقط مکرر گویند

سقط عمدی در چه مواردی اتفاق می افتد؟

سقط جنین عمدی به معنای ختم حاملگی با دارو یا عمل جراحی قبل از زمانی است که جنین بتواند زنده متولد شود این سقط به دو دسته تقسیم می شود:

۱-     سقط غیر قانونی
۲-     سقط درمانی

از آنجایی که سقط جنین در بعضی موارد جهت پیشگیری از صدمات جدی یا دائمی به مادر یا جهت حفظ زندگی یا سلامت مادر قابل اجرا می باشد لذا سقط جنین عمدی از سال ۱۹۷۳ تاکنون مرجعیت پیدا کرده است.

سقط درمانی یکی از انواع سقط جنین عمدی بوده که به منظور حفظ سلامت مادر در موارد ذیل انجام می شود:

۱-  زمانی که ادامه حاملگی زندگی مادر را به مخاطره می اندازد یا شدیدا” به سلامت او صدمه وارد می کند.
۲-  زمانی که ادامه حاملگی منجر به تولد نوزادی با ناهنجاريهاي فيزيكي شدید یا کند ذهنی می گردد.

سقط جنین غیر قانونی در واقع سقط جنین هایی است که توسط پزشکان غیر مسئول ، افراد غیر پزشک و با استفاده از امکانات غیر قانونی صورت می گیرد و اکثرا” توسط شخصی انجام می گیرد که مورد تایید قانون کشور نمی باشد . این گونه سقط های غیر قانونی اغلب با خونریزی شدید ، عفونت ، شوک عفونی و نارسایی حاد کلیه همراه هستند و در اکثر موارد منجر به مرگ مادر می شوند.

در هر کشور مباحث مذهبی و قومی قابل توجهی درباره سقط جنین غیر قانونی یا عمدی وجود دارد و در اکثر قوم ها و مذاهب از جمله دین اسلام انجام سقط جنین عمدی حرام می باشد.

روشهای تشخیص سقط جنین چیست؟

شایعترین علامت و نشانه سقط جنین وجود خونریزی واژینال می باشد.


خونریزی واژینال در زنان باردار در اوایل حاملگی ۴ علت شناخته شده دارد که عبارتند از :

۱-     بچه انداختن یا سقط جنین
۲-     حاملگی خارج رحمی
۳-     بیماری جفت ( بچه خوره یا مول)
۴-     ضایعه بافت دهانه رحم یا مهبل

بروز هرگونه خونریزی واژینال در زنان باردار غیر طبیعی است و بایستی علت خونریزی واژینال توسط پزشک یا ماما بررسی شود ولی در اکثر موارد خونریزی در سه ماهه اول حاملگی نشان دهنده سقط جنین می باشد .

بر حسب نوع سقط جنین علائم ایجاد شده متفاوت است بطوريكه :

در تهدید به سقط مقدار خونریزی واژینال بسیار کم و حتی در حد لکه بینی می باشد .
در سقط ناقص یا غیر قابل اجتناب خونریزی واژینال اغلب زیاد و دردهای انقباضی در زیر شکم همراه با انقباضات رحمی وجود دارد . ممکن است مقداری از محصولات حاملگی دفع شوند.

در سقط کامل خونریزی واژینال زن باردار زیاد و محتویات رحم کاملا” خارج می شود.
در سقط عفونی که اغلب بعد از سقط جنین ناقص یا دستکاری رحم تحت شرایط غیر بهداشتی رخ می دهد علاوه بر درد و خونریزی بسیار شدید ، تب و ترشح بدبو نیز وجود داشته و ممکن است علائم شوک عفونی نیز بروز کند.

در سقط فراموش شده به دلیل مرگ جنین ، جفت فعالیت خود را از دست داده و بنابر این علائم حاملگی نظیر ویار حاملگی ، تغییر رنگ نوک پستان ها و … از بین می رود. علاوه  بر این زن باردار احساس سنگینی در لگن کرده و رشد رحم او متوقف می شود. ترشحات مهبلی در این نوع سقط جنین اکثرا” آبکی و قهوه ای رنگ ( به رنگ خون مانده ) می باشد.

در سقط مکرر مهمترین علامت وجود خونریزی و خارج شدن محصولات حاملگی سه بار یا بیشتر در سه بارداری می باشد.

برای زن بارداری که دچار علائم سقط جنین شده است چه کار می توان کرد؟

در صورت وجود هر گونه خونریزی واژینال در دوران بارداری فورا” زن باردار را نزد پزشک ببرید.
در صورت وجود لکه بینی بدون درد با پزشک وی مشورت کنید .
در صورت توصیه پزشک به استراحت در منزل به محض افزایش میزان خونریزی یا ادامه خونریزی پس از استراحت ، زن باردار را به بیمارستان ببرید.
در صورت وجود خونریزی همراه با درد و حساسیت شكمي حتما” زن باردار را به بیمارستان ببرید.


خانمی که علائم بروز سقط جنین را دارد پس از مراجعه به پزشک بهتر است استراحت در بستر داشته و با آنها مشاوره انجام شود.
در صورتيكه گروه خون مادر منفی است بایستی پس از سقط جهت تزریق آمپول روگام با پزشک مشورت شده و اقدام لازم انجام شود.

پزشکان بدون مرز:http://www.pezeshk.us/?p=3754

نوشته شده توسط دکتر مهدی چوقادی در 5:20 |  لینک ثابت   • 

شنبه سیزدهم مرداد 1386

تعاریف سقط عوارض فتوای مقام معظم رهبری

 

سقط جنين چيست ؟

سقط به معنای  ختم حاملگی است ، قبل از اينكه جنين قدرت زنده ماندن در محيط خارج از رحم مادر را داشته باشد.

سقط به دو دسته عمده تقسيم می شود سقط خود به خودی و سقط عمدی يا القا شده. سقط خود بخودی بدلايل غير ارادی رخ می دهد .سقط القا شده می تواند سقط درمانی باشد، يعنی ختم حاملگی به منظور حفظ سلامت مادر و يا بيماری جدی جنين صورت گيرد يا سقط انتخابی باشد كه قطع حاملگی بنا به درخواست مادر و به هر دليلی باشد .

 

سقط درمانی در حالتهای  زير انجام می شود

- برای  نجات جان مادر

- حفظ سلامتی روانی و جسمی مادر

- ختم حاملگی هاي، توام با اختلالات مادرزادی كه مغاير با حيات يا همراه با بيماری شديد نوزاد است

 

سقط جنين غير ايمن چيست ؟

سقط جنين زمانی نا ايمن تلقی می شو دكه توسط فردی انجام شود كه مهارت لازم را نداشته باشد يا در محيطی انجام شو دكه فاقد حداقل استانداردهای  پزشكی باشد يا هر دو مورد فوق اتفاق بيافتد. زنانی كه بارداری ناخواسته دارند و خواستار ختم حاملگی به صورت انتخابی هستند بيشتر در معرض سقط غير ايمن قرار دارند.

 

برخی روش های  معمول سقط های  غير ايمن:

- استفاده از داروهای  گياهی كه می تواند خطرات و عوارض جدی به همراه داشته باشد.

- وارد كردن ضربه به شكم

- استفاده نابجا و بدون نظر پزشك (استفاده خودسرانه) از داروهای  شيمياي

- دستكاری دستگاه تناسلی (مانند استفاده از پرمرغ و ميل بافتنی در داخل واژن و رحم)

- وارد كردن مواد سوزاننده و شيميايی و در نتيجه آسيب ديدن دستگاه تناسلی و سوراخ شدن رحم

 

علل سقط غير ايمن

مهمترين علل سقط غير ايمن عبارتند از:

- عدم پيگيری جدی برنامه های  تنظيم خانواده و پيشگيری از بارداری های  ناخواسته از طرف خانواده ها

- عدم آگاهی به قوانين حاكم در زمينه سقط جنين

- عدم آگاهی در زمينه مسايل مربوط به بهداشت باروري( بين زنان و مردان ) ، مسئوليت پدر و مادری و مسئوليت جنسي

- عدم مهارت كافی پرسنل

- عدم دسترسی به مراكز درمانی با استاندارهای  بهداشتی

- مراجعه به مراكز غير بهداشتی و غير استاندارد

- مراجعه به مراكز غير سالم و افراد غير متبحر

- بالا بودن هزينه سقط ايمن (غير قانوني)

- فقر

- اضطرار مادر، پدر يا هر دو

 

خطر ها و عوارض سقط چه هستند

- مرگ مادر

- شوك عفوني

- آسيب به احشاء داخل شكم مثل مثانه يا روده

- پارگی رحم

- نازايي

- بروز مشكلات در بارداری های  بعدي

- عفونت

- سقط ناقص كه منجر به جراحی يا كورتاژ می شود.

- خونريزی

- تهوع ، استفراغ

- دل پيچه

- تب

- احساس گناه و افسردگی و تاثيرات منفی هيجانی

- عوارض ديررس كه طيف وسيعی دارد مثل كم خونی و نارسايی كليه به دنبال شدت خونريزي

بايد خاطر نشان ساخت هر چه سن حاملگی بيشتر شود، خطر خاتمه دادن آن هم افزايش می يابد بنابراين سقط قبل از 3 ماهگی كمترين عوارض را دارد.

هر دارويی می تواند در مقادير زياد دارای  عوارض جدی و خطرناك باشد حتی جوشانده ها و داروهای  گياهی 

 

سقط درماني

در سال های  اخير رويه ای  در سازمان پزشكی قانونی ايران برای  انجام سقط قانونی وجود داشته كه شامل 51 شرط برای  صدور مجوز سقط بوده است. 22 مورد از اين سقط های  قانونی مربوط به وضع مادران است و 29 مورد ناظر به مشكلات مربوط به جنين ميشود. همه اين 51 مورد بيماری های  وخيم و درمان ناپذيری هستند كه مادر يا جنين يا كودك آتی را رنج می دهند.

 

قانون سقط

آخرين قانون سقط جنين در ايران كه در 25/3/1384 به تاييد شورای  نگهبان رسيد

سقط درمانی با تشخيص قطعی سه پزشك متخصص و تاييد پزشكی قانونی مبنی بر بيماری جنين كه به علت عقب افتادگی يا ناقص الخلقه بودن موجب حرج مادر است و يا بيماری مادر كه با تهديد جانی مادر توام باشد قبل از ولوج روح ( چهار ماه) با رضايت زن مجاز می باشد و مجازات و مسووليتی متوجه پزشك مباشر نخواهد بود.

 

آيين نامه

آيين نامه اجرايی سقط جنين دردست تدوين می باشد. هرچند هنوز راه های  نرفته بسياری برای  حفظ سلامت مادر وجود دارد، چرا كه موارد عسر و حرج مادر طيف وسيعی را شامل می شود، كه نياز به بررسی های  كارشناسانه و واقع بينانه دارد.

 

 

فتوای  مقام معظم رهبری آيت ا... خامنه اي

اگر تشخيص بيماری در جنين قطعی است و داشتن و نگه داشتن چنين فرزندی موجب حرج است كما اينكه نوعا چنين است در اين صورت جايز است قبل از دميده شدن روح در جنين آن را ساقط كنند ولی بنا بر احتياط ديه آن بايد پرداخت شود

انجمن تنظیم خانواده جمهوری اسلامی ایران :http://www.fpairi.org

نوشته شده توسط دکتر مهدی چوقادی در 2:54 |  لینک ثابت   • 
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