Documenti di Didattica
Documenti di Professioni
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November 2010
November 2010
REGTA L. PICHAY, MD
President
Philippine Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2010
REGTA L. PICHAY, MD
INTRODUCTION!
OFFICERS
Regta L. Pichay, MD
President
Gil S. Gonzales, MD
Public Relations Officer
BOARD OF TRUSTEES
Efren J. Domingo, MD, PhD
Virgilio B. Castro, MD
Blanca C. de Guia-Fuerte, MD
Raul M. Quillamor, MD
Rey H. delos Reyes, MD
Ma. Cynthia Fernandez-Tan, MD
COMMITTEE ON CLINICAL PRACTICE GUIDELINES
MEMBERS
Ann Marie C. Trinidad, MD Ma. Victoria V. Torres, MD
Lisa T. Prodigalidad-Jabson, MD Christine D. Dizon, MD
Rommel Z. Duenas, MD
MANAGING EDITOR
Ana Victoria V. Dy Echo, MD
Rommel Z. Duenas, MD
Chair
Members
Sybil Lizanne R. Bravo, MD
Maria Lourdes B. Coloma, MD
Lorina Q. Esteban, MD
Aida V. San Jose, MD
Florentina A. Villanueva, MD
Ma. Corazon N. Zaida-Gamilla, MD
Regional Directors
Betha Fe M. Castillo, MD (Region 1) Noel C. de Leon, MD (Region 2)
Concepcion P. Argonza, MD (Region 3) Ernesto S. Naval, MD (Region 4)
Diosdado V. Mariano, MD (Region 4A NCR) Cecilia Valdes-Neptuno, MD (Region 5)
Evelyn R. Lacson, MD (Region 6) Belinda N. Pañares, MD (Region 7)
Fe G. Merin, MD (Region 8) Cynthia A. Dionio, MD (Region 9)
Jana Joy R. Tusalem, MD (Region 10) Ameila A. Vega, MD (Region 11)
Definition
1. Abortion is any loss of a fetus that is less than 20 weeks age of gestation
(AOG), or that which weighs less than 500 g.
Supporting Statement
Supporting Statement
Supporting Statements
Table 1. Terminologies
Previous Term Recommended Term
Spontaneous abortion Miscarriage
Threatened abortion Threatened miscarriage
Inevitable abortion Inevitable miscarriage
Incomplete abortion Incomplete miscarriage
Complete abortion Complete miscarriage
Missed abortion / anembryonic pregnancy / Missed miscarriage / early fetal demise /
blighted ovum (these reflect different stages in delayed miscarriage / silent miscarriage
the same process)
Septic abortion Miscarriage with infection (sepsis)
Recurrent abortion Recurrent miscarriage
Causes of Abortion
I. Embryonic abnormalities
Chromosomal abnormalities (e.g. Trisomy)
Clinical Manifestations
Supporting Statements
This may develop in 20-25% of women during early gestation and may
persist for days or weeks. According to Tongson, et. al., approximately half of
these pregnancies will abort, although the risk is substantially lower if fetal
cardiac activity is visualized. In 2006, Eddleman stated that the bleeding
during the current pregnancy was the most predictive risk factor for pregnancy
loss. Authors mentioned that even if abortion does not follow early bleeding,
these fetuses are at increased risk for preterm delivery, low birthweight, and
perinatal death.1
Supporting Statements
Summary of Evidence
Supporting Statements
Supporting Statements:
Diagnosis
Supporting Statements
Supporting Statements
Supporting Statements
Supporting Statements
Supporting Statement
TVS, serial serum !-hCG levels, and progesterone may all be required
in order to establish a definite diagnosis.2
References
Threatened Abortion
Supporting Statements
Supporting Statements
Incomplete Abortion
Supporting Statements
Supporting Statements
Forna, et. al. reviewed trials comparing the safety and effectiveness of
those procedures.7 MVA was associated with statistically significantly
decreased blood loss (-17 ml weighted mean difference [WMD], 95% CI -24
to -10 ml), less pain (RR 0.74, 95% CI 0.61-0.90), and shorter duration of
procedure (-1.2 minutes WMD, 95% CI -1.5 to -0.87 minutes), than sharp
curettage, in the single study that evaluated these outcomes. Complications
such as uterine perforation and other morbidity were rare and the sample sizes
of the trials were not large enough to evaluate small or moderate differences.
Similarly, the 11 trials studied by Kulier, et. al. do not indicate overall
benefits of one over the other method.11 MVA can be used for early first
trimester surgical abortion, but maybe more difficult when used after the 9th
week of gestation. A retrospective study by Milingos, et. al. of 246 patients
who were scheduled to undergo MVA for first trimester early fetal demise and
first and mid-trimester incomplete miscarriage demonstrated 94.7% (232/245)
efficacy of the procedure. Incomplete uterine evacuation was seen in 5.3%
(13/245) patients.12
Supporting Statements
Missed Abortion
Supporting Statements
Supporting Statements
3. The use of uterotonics in the form of oxytocic and oxytocin had been well
established as standards in the pharmacologic management of this type.
(Level I, Grade A)
Supporting Statements
Supporting Statements
!
References
1. Aleman A, Althabe F, Belizan J, Bergel E. Bed rest during pregnancy for preventing
miscarriage. Cochrane Database Syst Rev 2005.
2. Rumbold A, Middleton P, Crowther CA. Vitamin supplementation for preventing miscarriage.
Cochrane Database Syst Rev 2005, Issue 2. Art. No.: CD004073. DOI:
10.1002/14651858.CD004073.pub2.
3. Haas DM, Ramsey PS. Progestogen for preventing miscarriage. Cochrane Database Syst Rev
2008.
4. Butler C, Kelsberg G, St. Anna L, Crawford P. Clinical inquiries: How long is expectant
management safe in first trimester miscarriage? J Fam Pract 2005;54(10):889-90.
5. Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage:
expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment
(MIST) trial). BMJ. 2006 May 27;332(7552):1235-40. Epub 2006 May 17.
6. Nanda K, Peloggia A, Grimes D, Lopez L, Nanda G. Expectant care versus surgical treatment
for miscarriage. Cochrane Database Syst Rev 2007, Issue 4. Art. No.: CD003518. DOI:
10.1002/14651858.CD003518.pub2
7. Forna F, Gülmezoglu, AM. Surgical procedures to evacuate incomplete abortion. Cochrane
Database Syst Rev 2001, Issue 1.
8. Neilson JP, Gyte GM, Hickey M, Vazquez JC, Dou L. Medical treatments for incomplete
miscarriage (less than 24 weeks). Cochrane Database Syst Rev.2010 Jan 20;(1):CD007223.
9. Prager, Oyer. Second trimester surgical abortion. Clinical Obstet Gynecol 2009;52(2).
10. Kulier R. Geneva Foundation for Medical Education and Research. March 2003.The
Cochrane Collaboration. Wiley, 2010.
11. Kulier R, Cheng L, Fekih A, Hofmeyr GJ, Campana A. Surgical methods for first trimester
termination of pregnancy. Cochrane Database Syst Rev 2001, Issue 4. Art. No.: CD002900.
DOI: 10.1002/14651858.CD002900.
12. Milingos DS, Mathur M, Smith NC, Ashok PW. Manual vacuum aspiration: a safe alternative
for the surgical management of early pregnancy loss. BJOG 2009 Aug;116(9):1268-71.
13. Stubblefield PG. Surgical techniques of uterine evacuation in first- and second-
trimester abortion. Clin Obstet Gynaecol. 1986 Mar;13(1):53-70.
14. May W, Gülmezoglu AM, Ba-Thike K. Antibiotics for incomplete abortion. Cochrane
Database Syst Rev. 2007 Oct 17;(4):CD001779.
15. Boulvain M, Kelly A, Lohse C, Stan C, Irion O. Mechanical methods for induction of labour.
Cochhrane Database Syst Rev. 2001;(4):CD001233.
16. Kapp N, Lohr PA, Ngo TD, Hayes JL. Cervical preparation for first trimester surgical
abortion. Cochrane Database Syst Rev 2010, Issue 2. Art. No.: CD007207. DOI:
10.1002/14651858.CD007207.pub2
17. Kelly AJ, Tan B. Intravenous oxytocin alone for cervical ripening and induction of labor.
Cochrane Database Syst Rev. 2009;(4):CD003246.
18. Alfirevic Z, Kelly AJ, Dowswell T. Intravenous oxytocin alone for cervical ripening and
induction of labour. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD003246.
RECURRENT ABORTION
Definition, Clinical Findings and Diagnosis
Aida V. San Jose, MD and Florentina A. Villanueva, MD
Definition
2. For patients with history of RPL, the risk of subsequent pregnancy loss is
estimated to be:
24% - after 2 clinically recognized losses
30% - after 3 losses
40-50% - after 4 losses1
Although the definition includes three or more miscarriages, many agree that
evaluation should at least be considered following two consecutive losses.
This is because the risk of subsequent loss after two successive miscarriages is
similar to that following three losses – approximately 30%.
Causes
Paternal Factors
Cytogenetic Factors
4. Women aged between 34 and 39 years at the time of the second miscarriage
should be offered karyotyping on the basis of the number of miscarriages
experienced by them personally and the occurrence of two or more
miscarriages in first degree family members, i.e., parents or siblings. In
women of 39 years old or older at the time of the second miscarriage there is
no need to offer karyotyping regardless of the number of miscarriages.
Table 1: Recommendation for Investigations in Couples with Recurrent Miscarriage
Do Don't Evidence Level
Karyotyping of both partners
Woman < 34 years old at the time
X B
of 2nd miscarriage
Woman 34-39 years old at the time Dependent on
of 2nd miscarriage family history
and number of
miscarriages
Woman > 39 years old at the time
of 2nd miscarriage (irrespective of X
the number of miscarriages)
Karyotyping of conceptus X C
Progesterone in luteal phase X B
Thyroid function X C
Glucose X C
Lupus anticoagulant (LAC),
anticardiolipin antibody (ACA),
X B
immunoglobulin G (IgG) and
immunoglobulin M (IgM)
Anti-thrombin (AT), protein C,
protein S, Factor V Leiden,
X* B
prothrombin 20210 G/A mutation,
and Factor VIII
Random homocysteine X B
Determine body mass index (BMI) X B
Determine lifestyle (smoking /
X B
alcohol / coffee)
*Assessment of thrombophilia factors should take place if there is venous thromboembolism in the
woman's medical history and/or if there is a first-degree family member with a known thrombophilia
defect as well as a venous thromboembolism.
Fetal Factors
Endocrine Factors
Research has been carried out into the question as to whether women with
recurrent miscarriage who were given !-hCG or progesterone had a reduced
chance of a miscarriage compared to those receiving a placebo or no
treatment. From an analysis of four randomized trials, it appeared that
prescribing !-hCG reduced the chances of a miscarriage, but this conclusion is
mainly based on the results of two methodologically weak studies. The two
methodologically superior studies show no difference in the risk of
miscarriage.
Supporting Statements
Supporting Statements
10. Maternal Infection: Infection of the reproductive tract with bacterial, viral,
parasitic, zoonotic, and fungal organisms has been linked theoretically to
pregnancy loss.1 (Level II-1, Grade A)
Supporting Statements
11. Uterine Factors: Congenital uterine anomalies are associated with recurrent
miscarriages. (Level II-3, Grade B).
Supporting Statements
12. Immunologic Factors: Patients with RPL should be investigated for possible
antiphospholipid antibody syndrome. (Level III, Grade A)
Supporting Statements
Supporting Statements
1. Berek, Jonathan S (Eds). Berek and Novak's Gynecology, 14th Edition. Lippincott Williams
& Wilkins, 2007.
2. The Dutch Society of Obstetrics and Gynaecology (NVOG). Guideline on recurrent
miscarriage. The Netherlands 2007;6:20.
3. Cuningham G, et al (Eds). “Abortion” In: Williams Obstetrics. McGraw-Hill Companies, Inc.
2010.
4. Royal College of Obstetricians and Gynaecologists (RCOG). The management of early
pregnancy loss. Royal College of Obstetricians and Gynaecologists (RCOG) Guideline No.
25. 2006;18.
5. European Society of Human Reproduction and Embryology (ESHRE) Special Interest Group
for Early Pregnancy (SIGEP). Updated and revised nomenclature for description of early
pregnancy events. Human Reproduction 2005;20(11):3008-3011.
6. Gaufberg SV. Early pregnancy loss. Contributor Information and Disclosures. Updated: April
16, 2010.
7. Shields AD. Pregnancy diagnosis. Contributor Information and Disclosures. Updated: April
20, 2009.
8. Bottomley C, Van Belle V, Mukri F, Kirk E, Van Huffel S, Timmerman D, Bourne T. The
optimal timing of an ultrasound scan to assess the location and viability of an early pregnancy.
Human Reproduction 2009;24(8):1811-1817.
9. Stubblefield PG, Grimes DA. Septic abortion. New Engl J Med 1994;331(5): 310-314.
10. Broklehurst TJ, et al. Management of miscarriage: expectant, medical, or surgical? Results of
randomised controlled trial (miscarriage treatment (MIST) trial). Br Med J 2006;332:1235-
1240.
11. Finkielman JD, De Feo FD, Heller PG, Afessa B. The clinical course of patients with septic
abortion admitted to an intensive care unit. Intensive Care Med 2006;30(6).
12. Davis VJ. Induced abortion guidelines. SOGC Clinical Practice Guidelines 2006;184.
13. Chan FY, Ghosh A, Tang M, Ng J. Ultrasound in prenatal diagnosis: use and pitfalls. J Hong
Kong Med Assoc 1991;43(2).
UNSAFE ABORTION
Sybil Lizanne R. Bravo, MD and Lorina Q. Esteban, MD
Definition
The basic status of abortion in the Philippines is that it is illegal, or banned by rule of
law.
The act is criminalized by the Revised Penal Code of the Philippines, which was
enacted in 1930 and remains in effect today. Articles 256, 258 and 259 of the Code
mandate imprisonment for the woman who undergoes the abortion, as well as for any
person who assists in the procedure, even if they be the woman's parents, a physician
or midwife. Article 258 further imposes a higher prison term on the woman or her
parents if the abortion is undertaken "in order to conceal [the woman's] dishonor".
There is no law in the Philippines that expressly authorizes abortions in order to save
the woman's life; and the general provisions which do penalize abortion make no
qualifications if the woman's life is endangered. It may be argued that an abortion to
save the mother's life could be classified as a justifying circumstance (duress as
opposed to self-defense) that would bar criminal prosecution under the Revised Penal
Code. However, this has yet to be adjudicated by the Philippine Supreme Court.
Proposals to liberalize Philippine abortion laws have been opposed by the Catholic
Church, and its opposition has considerable influence in the predominantly Catholic
country. However, the constitutionality of abortion restrictions has yet to be
challenged before the Philippine Supreme Court. (see Appendix)
Clinical Manifestations
1. Symptoms1-3
a. fever
b. chills
c. malaise
d. abdominal pain
e. vaginal bleeding
f. passage of placental tissues
2. Signs1,3,4
a. elevated temperature
b. tachycardia
c. tachypnea
d. with sepsis: agitation, patients appears toxic/disoriented
e. lower abdominal tenderness
f. absence of fever with leukemoid reaction (white blood cell [WBC] 45-
120,000/mm")
g. fluid sequestration
h. hypotension
i. edema of infected tissues
3. Abdominopelvic examination
a. most often an open cervix with bleeding and foul smelling products of
conception or discharge
b. cervical/vaginal lacerations
c. open cervix with or without a catheter
d. bimanual examination: uterine tenderness (with or without parametrial
cellulitis or abscess)
e. with gas gangrene of the uterus: crepitation in the pelvis
f. abdominal tenderness, guarding, and rebound, and whether tenderness
is limited to the lower abdomen (pelvic peritonitis) or is present over
the entire abdomen (generalized peritonitis)
Supporting Statements
Supporting Statement
Supporting Statements
3. Submit endometrial tissue specimen for gram stain and culture. (Level
III, Grade C)
Supporting Statements
Gram stain of the endometrium will show mixed flora admixed with
white blood cells. If peritoneal signs are present, baseline tissue culture of the
endometrium is recommended.
Doing sampling of the endometrium and sending it for culture will lead
to identification of the bacterium responsible for the infection. This will be
helpful in managing complicated infections following abortion. The specimen
should be placed in aerobic and anaerobic transport media and sent to the
laboratory for processing.11-12
4. Blood culture should be done in all patients who have: (a) advanced
disease, (b) peritoneal signs, and (3) rigor.11 (Level III, Grade A)
5. Transvaginal ultrasound (TVS) can detect retained secundines or fluid
within the endometrial cavity and myometrial disruption. It can detect
the presence of a pelvic mass and should be obtained if pelvic tenderness
or examination prohibits the performance of adequate examination.
(Level III, Grade A)
Supporting Statement
Supporting Statements
Supporting Statement
Management
Supporting Statements
Supporting Statement
3. The antibiotic regimen should be continued until the following sought for
therapeutic response is attained:
a. No temperature equal to or greater than 37.6°C
b. Absence of local physical findings
c. A normal white blood cell count (Level III, Grade A)
Supporting Statements
Supporting Statement
Supporting Statements
9. Properly timed surgery for evacuation of septic products and/or pus and
for repairing damaged bowels is important.20 (Level III, Grade B)
Algorithm for Management of Induced Abortion
(Adopted and modified from POGS Clinical Practice Guidelines on Infectious
Diseases)21
1
after thorough history taking and physical examination
2
severity/grading of abortion (see table below)
3
empiric antimicrobial therapy before shifting to culture-guided treatment
4
alternative choice includes clindamycin for penicillin-allergic patients, and other higher-generation
beta-lactam antibiotics
5
may give anti-tetanus vaccine if insult is within 24 hrs
6
consider exploratory laparotomy if without/poor response to initial antimicrobial therapy or if
high index of suspicion for retained products of conception (or when TVS shows retained
products), or if cannot rule out organ injury
Determining the severity of the condition is critically important in appropriately
prioritizing therapeutic intervention. A scoring mechanism for classification of the
severity of infected abortion modified from Hager (1985) is recommended in the table
below:22
Interpretation
TOTAL SCORE
Mild <8
Moderate 8-12
Severe >20
Notes:
• The infection is considered “Severe” if any one of the following conditions are
present REGARDLESS OF THE SCORE:
1. Hypotension with tachycardia unless secondary to blood loss
2. Tachypnea (respiratory rate >24)
• Initial response of hypotension and tachycardia to hydration may signify
hypovolemia.
• Presence of bilateral adnexal masses is considered “Severe”.
References
Art. 255. Infanticide. — The penalty provided for parricide in Article 246 and for
murder in Article 248 shall be imposed upon any person who shall kill any child less
than three days of age. If the crime penalized in this article be committed by the
mother of the child for the purpose of concealing her dishonor, she shall suffer the
penalty of prision correccional in its medium and maximum periods, and if said crime
be committed for the same purpose by the maternal grandparents or either of them,
the penalty shall be prision mayor.
Art. 256. Intentional abortion. — Any person who shall intentionally cause an
abortion shall suffer:
1. The penalty of reclusion temporal, if he shall use any violence upon the
person of the pregnant woman.
2. The penalty of prision mayor if, without using violence, he shall act without
the consent of the woman.
Art. 258. Abortion practiced by the woman herself of by her parents. — The penalty
of prision correccional in its medium and maximum periods shall be imposed upon a
woman who shall practice abortion upon herself or shall consent that any other person
should do so.
Any woman who shall commit this offense to conceal her dishonor, shall suffer the
penalty of prision correccional in its minimum and medium periods. If this crime be
committed by the parents of the pregnant woman or either of them, and they act with
the consent of said woman for the purpose of concealing her dishonor, the offenders
shall suffer the penalty of prision correccional in its medium and maximum periods.