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Blighted Ovum

Blighted Ovum (BO) is a type of early miscarriage in which the fertilized egg implants in the uterus but does not develop into a fully-developed embryo.


Presentation

When blighted ovum occurs, the woman might experience classical signs of early pregnancy or vaginal bleeding, abdominal pain, and periods heavier than usual. It is important to pay attention to the quantity of bleeding. Of course, a number of pads and tampons used which is much higher than usual might suggest the presence of a significant and worrisome amount of bleeding which might require medical attention. Pain, instead, usually lies in the suprapubic area, but frequently also in lower quadrants, and might radiate to the lower back, buttocks, genitalia, and perineum. Furthermore, the pain might unilateral, and this suggest the possible occurrence of an ectopic pregnancy or a ruptured ovarian cysts. These signs are usually accompanied by a positive outcome of pregnancy test and the occurrence of missed periods.

Pathologist
  • It may also be helpful if you want a pathologist to examine tissues to confirm the reason for the miscarriage. Using a medication such as misoprostol on an outpatient basis may be another option.[webmd.com]
  • It is also helpful if the couple had planned on having a pathologist examine the tissue to determine the reason for miscarriage. It is important to note that blighted ovum is often a one-time occurrence.[fertilityauthority.com]
  • A D&C would, however, be beneficial if you were planning on having a pathologist examine the tissues to determine a reason for the miscarriage. Some women feel a D&C procedure helps with closure, mentally and physically.[americanpregnancy.org]
  • Some women choose this to have physical closure of the miscarriage and it may also assist a pathologist to determine the cause of any miscarriage. As a miscarriage may be a long process, some women choose a medication such as misoprostol.[healthresearchfunding.org]
Vaginal Discharge
  • Initially you will see slight reddish-brown stained vaginal discharge accompanied with abdominal cramps. Some women often consider it harmless and neglect its importance. The uterus does not grow in accordance with the period of amenorrhea.[beingtheparent.com]
Tampon Use
  • Of course, a number of pads and tampons used which is much higher than usual might suggest the presence of a significant and worrisome amount of bleeding which might require medical attention.[symptoma.com]
Uterine Cramps
  • In particular, many studies have underlined the occurrence of side effects, like abdominal pain, uterine cramping, and vaginal bleeding. In addition to these, many women also show nausea, vomiting, diarrhea, dizziness, fatigue, and even fever.[symptoma.com]
Pelvic Pain
  • Often women will experience irregular bleeding and/or some type of pelvic pain. Dr. Cannon says the drug methotrexate is often used to stop the pregnancy from continuing, particularly if it’s in a place that may be hard to surgically remove.[doctorsthatdo.org]
Cervical Incompetence
  • The maternal etiological factors of blighted ovum include genetic and structural abnormalities, especially involving the reproductive tract like uterine defects, fibroids, and cervical incompetence.[symptoma.com]

Workup

Blighted ovum can be diagnosed both with laboratory tests and imaging studies. The laboratory tests include:

  • Complete blood count (CBC) can help measure the blood loss and make sure no anemia is present. CBC also allows detection of possible infections, which might have severe consequences for the woman.
  • Beta-hCG is useful to determine whether bleeding is due to pregnancy or a dysfunctional uterine state. 
  • Urinalysis are done to rule out the presence of infections in the urinary tract, which are frequent in pregnant women due to the effects of progesterone on the smooth muscle of the ureters. 

The main imaging technique employed in the diagnosis of blighted ovum is ultrasonography of the pelvis using a vaginal probe, which can be performed to rule out other possible etiological factors. With this methodology it is possible to observe the gestational sac without the embryo within it.

Treatment

The treatment of blighted ovum consists of either a drug therapy or surgery. Several medications have been studied for the medical management of early pregnancy failure. These include treatment with mifepristone, an antiprogestin which causes the weakening of the uterine attachment of a pregnancy. This then leads to capillary breakdown and synthesis of prostaglandins. Mifepristone is the first antiprogestin to be developed and its use as abortifacient has been extensively evaluated.

Another commonly used drug is misoprostol, a prostaglandin E1 analogue working as an uterotonic administered vaginally, orally, buccally, or sublingually, which results in cervical softening and contractions. This medication is used to start labor, induce abortion, and treat stomach ulcers and postpartum bleeding. There are trials which are trying to develop a clinically-effective combination of mifepristone and misoprostol, even though their results are still conflicting [11] [12]. In particular, many studies have underlined the occurrence of side effects, like abdominal pain, uterine cramping, and vaginal bleeding. In addition to these, many women also show nausea, vomiting, diarrhea, dizziness, fatigue, and even fever [13]. Pelvis inflammatory disease is rare, but serious and dangerous [14]. There are no data available regarding the safety and efficiency of mifepristone in women suffering from chronic medical conditions or those who are older than 35 and smoke more than 10 cigarettes per days, since there were not included in the clinical trials previously mentioned.

In some cases when drug therapy proves to be ineffective and expulsion is incomplete, clinician might consider using surgical procedure to treat blighted ovum. In this case, the most important procedure employed is surgical aspiration

Prognosis

The prognosis of blighted ovum is excellent. The occurrence of an episode does not increase at all the risk of experiencing another one, and future pregnancies might continue to have good outcomes especially with the help of supportive care [8] [9] [10].

Etiology

Blighted ovum is responsible for about 50% of the miscarriages in the first trimester of pregnancy. It is usually due to chromosomal abnormalities occurring in the fertilized egg, frequently deriving from chromosomal problems of poor-quality sperm or egg or abnormal cell division. The most common chromosomal anomalies include 45,X karyotype, with an incidence of 14,6%, and many forms of trisomies accounting for around 20% of all genetic abnormalities. The body of the woman recognizes these abnormalities and in response stops embryonic development because the fetus will not develop into a healthy baby.

Teratogenic and mutagenic factors might also play an important etiological role, but it is difficult to quantify it. The maternal etiological factors of blighted ovum include genetic and structural abnormalities, especially involving the reproductive tract like uterine defects, fibroids, and cervical incompetence. There might even be issues relating to chronic maternal health such as poorly controlled diabetes mellitus, polycystic ovary syndrome, renal diseases, systemic lupus erythematosus, severe hypertension, antiphospholipid syndrome, and untreated thyroid disease [2]. Blighted ovum can also be ascribed to exogenous factors which include tobacco, alcohol, cocaine, and high doses of caffeine.

Epidemiology

About 80% of all miscarriages occur within the first trimester of pregnancy and the frequency decreases as the gestational age increases. The risk factors that might trigger episodes of blighted ovum include advance age, extremes of age, stress and advanced paternal age [3] [4] [5]. The risk increases with the appearance of vaginal bleeding.

Mortality is unlikely, unless sign of anemia and infection develops. Some surveillance data suggest that about 4% pregnancy-related deaths in the US are due to cases of abortions and miscarriages [6].

The incidence of blighted ovum, as for all types of miscarriages, increases with age. Interestingly enough, the rate of miscarriages of women who receive donor eggs is related to donor’s age rather than to the recipient’s age, and this suggests that the increase of miscarriages is mainly due to aging oocytes rather than aging uterus.

Sex distribution
Age distribution

Pathophysiology

Frequently it is possible to observe vaginal bleeding and mild cramps without cervical dilatation, change in cervical consistency, and significant pain. On examination, blood and brownish discharge can be seen in the vagina, with the cervix which is not tender and the cervical canal not closed. The ultrasound shows signs of a continuing intrauterine pregnancy, with the presence of a gestational sac and the levels of human chorionic gonadotropin within the discriminatory zone. Sometime, despite positive result of the pregnancy test ultrasound does not reveal the location of the pregnancy [7].

Prevention

Unfortunately, in many cases blighted ovum cannot be prevented. If a couple experiences multiple cases of early pregnancy loss, a systematic factor might exist which prevent the embryonic development, and a genetic testing is highly advised. However, the situation rarely occurs, because the condition is frequently a once time occurrence which does not appear again. Furthermore, if an episode of blighted ovum has occurred, experts recommend couples to wait from 1 to 3 regular menstrual cycles before trying to conceive again.

Summary

When a woman becomes pregnant, the fertilized egg attaches to the wall of the uterus and begins to develop. Within six weeks an embryo should develop, present in a sac 18 millimeters wide called gestational sac. Blighted ovum occurs when, although the gestational sac has formed and grown, there is no embryo in it, either because it has never developed or it has been reabsorbed [1].

Sometime this miscarriage is called anembryonic pregnancy, to indicate that the embryonic development is stopped at a so early stage that the woman concerned doesn't even get to know she has become pregnant. This event is quite frequent, causing around one third of all the miscarriages taking place in the first trimester of pregnancy. The woman might miss a period and have a positive pregnant test, which indicates that the placenta is secreting human chorionic gonadotropin. It is also possible that the woman shows the early signs of pregnancy, like breast tenderness, but after a while they subside preceding the occurrence of abdominal cramping, light spotting, or bleeding.

Blighted ovum occurs often due to chromosomal abnormalities in the fertilized egg. However, women who experience an episode of blighted ovum should not be afraid, because most of them go oo having successful pregnancies with no problem at all. Medical attention should be sought in case of multiple consecutive miscarriages, because this succession of unsuccessful pregnancies might underline the presence of some other type of problem.

Patient Information

Blighted ovum is a type of early miscarriage in which the fertilized egg implants in the uterus but does not develop into an embryo. After six weeks, when an embryo should have developed in the uterus, no sign of it can be seen, apart from the gestational sac which was supposed to contain the developing embryo. In this type of miscarriage, the failure of the embryo development happens at a so early stage the woman does not even get to know she had a miscarriage. She might also experience some of the signs of pregnancy, such as breast tenderness and abdominal pain or vaginal bleeding, but after while they subside as soon as the miscarriage debris has been discharged.

The causes of this particular type of miscarriage are mostly chromosomal abnormalities present in the sperm and egg, or problems in cell division. However, blighted ovum can also be triggered by exogenous factors such as tobacco, alcohol, cocaine, and too high doses of caffeine.

The condtion is diagnosed through laboratory tests as well as imaging studies. Moreover, it can be treated both through drug therapy and surgical procedure, according to the severity and nature of the case. The prognosis is usually excellent, and the occurrence of an episode of blighted ovum does not increase at all the risk of experiencing another one. Therefore, future pregnancies might continue to have good outcomes especially with the help of supportive care.

Unfortunately, in many cases blighted ovum cannot be prevented. If a couple experiences multiple cases of early pregnancy loss a systematic factor might exist which prevent the embryonic development, and a genetic testing is highly advised. However, the situation rarely occurs, because blighted ovum is very frequently a once time occurrence which does not appear again. Furthermore, if an episode of blighted ovum has occurred, experts recommend couples to wait from 1 to 3 regular menstrual cycles before trying to conceive again.

References

Article

  1. Huancahuari N. Emergencies in early pregnancy. Emerg Med Clin North Am. 2012 Nov;30(4):837-47.
  2. Thangaratinam S, Tan A, Knox E, et al. Association between thyroid autoantibodies and miscarriage and preterm birth: meta-analysis of evidence. BMJ. 2011 May 9. 342:d2616. 
  3. Arck PC, Rucke M, Rose M, et al. Early risk factors for miscarriage: a prospective cohort study in pregnant women. Reprod Biomed Online. 2008 Jul. 17(1):101-13. 
  4. Maconochie N, Doyle P, Prior S, Simmons R. Risk factors for first trimester miscarriage--results from a UK-population-based case-control study. BJOG. 2007 Feb. 114(2):170-86. 
  5. Gracia CR, Sammel MD, Chittams J, Hummel AC, Shaunik A, Barnhart KT. Risk factors for spontaneous abortion in early symptomatic first-trimester pregnancies. Obstet Gynecol. 2005 Nov. 106(5 Pt 1):993-9. 
  6. Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA, et al. Pregnancy-related mortality surveillance--United States, 1991--1999. MMWR Surveill Summ. 2003 Feb 21. 52(2):1-8. 
  7. Condous G, Kirk E, Lu C, et al. There is no role for uterine curettage in the contemporary diagnostic workup of women with a pregnancy of unknown location. Hum Reprod. 2006 Oct. 21(10):2706-10. 
  8. Clifford K, Rai R, Regan L. Future pregnancy outcome in unexplained recurrent first trimester miscarriage. Hum Reprod. 1997 Feb. 12(2):387-9. 
  9. Liddell HS, Pattison NS, Zanderigo A. Recurrent miscarriage--outcome after supportive care in early pregnancy. Aust N Z J Obstet Gynaecol. 1991 Nov. 31(4):320-2.
  10. Stray-Pedersen B, Stray-Pedersen S. Etiologic factors and subsequent reproductive performance in 195 couples with a prior history of habitual abortion. Am J Obstet Gynecol. 1984 Jan 15. 148(2):140-6. 
  11. Stockheim D, Machtinger R, Wiser A, et al. A randomized prospective study of misoprostol or mifepristone followed by misoprostol when needed for the treatment of women with early pregnancy failure. Fertil Steril. 2006;86(4):956-960. 
  12. Kollitz KM, Meyn LA, Lohr PA, Creinin MD. Mifepristone and misoprostol for early pregnancy failure: a cohort analysis. Am J Obstet Gynecol. 2011;204(5):386.e1-386.e6. 
  13. Mifeprex label. FDA. 2005-07-19. 
  14. Lawton BA, Rose SB, Shepherd J. Atypical presentation of serious pelvic inflammatory disease following mifepristone-induced medical abortion. Contraception 2006 73 (4): 431–2.

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Last updated: 2018-06-22 11:59