AbortionAbortion

The term abortion usually designates The term abortion usually designates termination of gestation before the termination of gestation before the end of the 28th week of pregnancy. It end of the 28th week of pregnancy. It implies the expulsion of all or any implies the expulsion of all or any part of the placenta or membranes, part of the placenta or membranes, with or without an identifiable fetus with or without an identifiable fetus or with a live-born or stillborn infant or with a live-born or stillborn infant weighing less than 1000 g. If weighing less than 1000 g. If abortion occurs before 12 weeks it is abortion occurs before 12 weeks it is referred to as early abortion, and referred to as early abortion, and thereafter the term is late abortion.thereafter the term is late abortion.

Types of abortionTypes of abortion Threatened abortionThreatened abortion Inevitable abortionInevitable abortion Incomplete AbortionIncomplete Abortion Complete AbortionComplete Abortion Missed AbortionMissed Abortion Recurrent AbortionRecurrent Abortion

Threatened abortionThreatened abortion The term threatened abortion is used The term threatened abortion is used

when a pregnancy is complicated by when a pregnancy is complicated by vaginal bleedingvaginal bleeding before the 20th week. before the 20th week. Pain may not be a prominent feature of Pain may not be a prominent feature of threatened abortion, although a lower threatened abortion, although a lower abdominal dull ache sometimes abdominal dull ache sometimes accompanies the bleeding. Vaginal accompanies the bleeding. Vaginal examination at this stage usually reveals a examination at this stage usually reveals a closed cervix. 25% to 50% of threatened closed cervix. 25% to 50% of threatened abortion eventually result in loss of the abortion eventually result in loss of the pregnancy.pregnancy.

Inevitable abortionInevitable abortion In case of inevitable abortion, a In case of inevitable abortion, a

clinical pregnancy is complicated clinical pregnancy is complicated by both by both vaginal bleedingvaginal bleeding and and cramp-like cramp-like lower abdominal painlower abdominal pain. . The cervix is frequently partially The cervix is frequently partially dilated, attesting to the dilated, attesting to the inevitability of the process. inevitability of the process.

Incomplete AbortionIncomplete Abortion In addition to In addition to vaginal bleeding, cravaginal bleeding, cra

mp-like pain, and cervical dilatationmp-like pain, and cervical dilatation,, an incomplete abortion involves th an incomplete abortion involves the e passage of products of conceptionpassage of products of conception,, often described by the women as lo often described by the women as looking like pieces of skin or liver. oking like pieces of skin or liver.

Complete AbortionComplete Abortion In complete abortion, after passage In complete abortion, after passage

of of allall the products of conception, the the products of conception, the uterine contractions and bleeding uterine contractions and bleeding abate, the cervix closes, and the abate, the cervix closes, and the uterus is smaller than the period of uterus is smaller than the period of amenorrhea would suggest. In amenorrhea would suggest. In addition, the symptoms of pregnancy addition, the symptoms of pregnancy are no longer present, and the are no longer present, and the pregnancy test becomes negative. pregnancy test becomes negative.

Missed AbortionMissed Abortion The term missed abortion is used The term missed abortion is used

when the fetus has died but is when the fetus has died but is retained in the uterus, usually for retained in the uterus, usually for some weeks. After 16 weeks’ some weeks. After 16 weeks’ gestation, dilatation and curettage gestation, dilatation and curettage may become a problem. Fibrinogen may become a problem. Fibrinogen levels should be checked weekly until levels should be checked weekly until the fetus and placenta are expelled. the fetus and placenta are expelled.

Recurrent AbortionRecurrent Abortion Recurrent abortionRecurrent abortion refers to any refers to any

case in which there have been case in which there have been three consecutivethree consecutive spontaneous spontaneous abortions. Possible causes are abortions. Possible causes are known to be genetic error, known to be genetic error, anatomic abnormalities of the anatomic abnormalities of the genital tract, hormonal genital tract, hormonal abnormalities, infection, abnormalities, infection, immunologic factors, or systemic immunologic factors, or systemic diseasedisease. .

The development of abortion is as follows:The development of abortion is as follows:

continuing continuing

pregnancy pregnancy completecomplete

inevitable abortion inevitable abortion

abortion abortion

incompleteincomplete

abortionabortion

threatened threatened abortionabortion

EtiologyEtiology Much confusion exists about the Much confusion exists about the

etiology of spontaneous abortion. etiology of spontaneous abortion. Although many factors may result in Although many factors may result in the loss of a single pregnancy, the loss of a single pregnancy, relatively few factors are present in relatively few factors are present in couples who abort recurrently. couples who abort recurrently. Cause-effect relationships in Cause-effect relationships in individual patients are frequently individual patients are frequently difficult to ascertain.difficult to ascertain.

General Maternal FactorsGeneral Maternal Factors

InfectionsInfections Environmental ExposureEnvironmental Exposure Psychological FactorsPsychological Factors Systemic DisordersSystemic Disorders

InfectionsInfections

Despite the present recognition that micDespite the present recognition that microorganisms may cause spontaneous abroorganisms may cause spontaneous abortions, it is frequently difficult to identifortions, it is frequently difficult to identify unequivocally the infectious agent resy unequivocally the infectious agent responsible for the loss of a specific pregnaponsible for the loss of a specific pregnancy. Some microorganisms have a specifncy. Some microorganisms have a specific local effect on the conceptus, whereas ic local effect on the conceptus, whereas infections with others may cause generainfections with others may cause general systemic effects and a fever that result il systemic effects and a fever that result in abortion. n abortion.

Very few microorganisms have been Very few microorganisms have been implicated in recurrent abortions. Inimplicated in recurrent abortions. Infection with Mycoplasma, Listeria, ofection with Mycoplasma, Listeria, or Toxoplasma should be specifically r Toxoplasma should be specifically sought in women with recurrent absought in women with recurrent abortions, since despite being infrequortions, since despite being infrequently found, they are all treatable wiently found, they are all treatable with modern antibioticsth modern antibiotics..

Environmental ExposureEnvironmental Exposure

Epidemiologic evidence of a causal link Epidemiologic evidence of a causal link between exposure to potentially mutagebetween exposure to potentially mutagenic or teratogenic agents and subsequenic or teratogenic agents and subsequent abortion is sparse. Such exposures arnt abortion is sparse. Such exposures are likely to be uncommon and not an impe likely to be uncommon and not an important cause of reproductive loss in the ortant cause of reproductive loss in the general population. Exceptions to this argeneral population. Exceptions to this are maternal smoking and alcohol consume maternal smoking and alcohol consumption, for which there is evidence of an iption, for which there is evidence of an increased incidence of chromosomally nncreased incidence of chromosomally normal abortions. ormal abortions.

Women who smoke 20 cigarettes Women who smoke 20 cigarettes daily and consume more than seven daily and consume more than seven standard alcoholic drinks per week standard alcoholic drinks per week have a fourfold increase in their risk have a fourfold increase in their risk of spontaneous abortion. It has also of spontaneous abortion. It has also been reported that there is a been reported that there is a doubling of the risk of spontaneous doubling of the risk of spontaneous abortion with as little as two drinks a abortion with as little as two drinks a week.week.

Psychological FactorsPsychological Factors

Systemic DisordersSystemic Disorders The three general medical disorThe three general medical disor

ders commonly related to spontders commonly related to spontaneous abortion are diabetes maneous abortion are diabetes mellitus, hypothyroidism, and systellitus, hypothyroidism, and systemic lupus erythematosus(SLE). emic lupus erythematosus(SLE).

The risk of abortion increases with maternal aThe risk of abortion increases with maternal age, and studies linked to prenatal diagnostic pge, and studies linked to prenatal diagnostic procedures have revealed that if a live fetus is drocedures have revealed that if a live fetus is demonstrated by ultrasonography at 8 weeks gemonstrated by ultrasonography at 8 weeks gestational age, fewer than 2% will abort spontestational age, fewer than 2% will abort spontaneously if the mother is younger than 30 yearaneously if the mother is younger than 30 years. If, however, she is older than 40 years, the riss. If, however, she is older than 40 years, the risk exceeds 10%, and it may be as high as 50% ak exceeds 10%, and it may be as high as 50% at age 45 years. The probable explanation is the t age 45 years. The probable explanation is the increased incidence of chromosomally abnorincreased incidence of chromosomally abnormal conceptuses in older women. mal conceptuses in older women.

Local Maternal FactorsLocal Maternal Factors

Endocrine Factors Endocrine Factors Uterine AbnormalitiesUterine AbnormalitiesTraumaTrauma

Endocrine FactorsEndocrine Factors It has been claimed that insufficiIt has been claimed that insuffici

ent production of progesterone ent production of progesterone by the corpus luteum before the by the corpus luteum before the placenta is fully formed will lead placenta is fully formed will lead to inadequate development of tto inadequate development of the decidua and abortion.he decidua and abortion.

Uterine AbnormalitiesUterine Abnormalities

The incidence of abortion iThe incidence of abortion is increased if the uterus is s increased if the uterus is double or septatedouble or septate..

Retroversion of the uterus is not Retroversion of the uterus is not a cause of miscarriage.a cause of miscarriage.

A fibromyoma of the uterus whicA fibromyoma of the uterus which is closely related to the uterine h is closely related to the uterine cavity may cause abortion, but ocavity may cause abortion, but other fibromyoma will not do so.ther fibromyoma will not do so.

Lacerations of the cervix which exteLacerations of the cervix which extend as far as internal os may result in nd as far as internal os may result in abortion in the middle trimester or iabortion in the middle trimester or in premature labor. Very rarely the cn premature labor. Very rarely the cervical weakness is congenital, but iervical weakness is congenital, but it is usually the result of obstetric dat is usually the result of obstetric damage or of injurious surgical dilatatimage or of injurious surgical dilatation of the cervixon of the cervix. .

TraumaTrauma Abortion may follow surgical opAbortion may follow surgical op

erations, for example myomectoerations, for example myomectomy, or removal of an ovary contamy, or removal of an ovary containing the corpus luteum of pregnining the corpus luteum of pregnancy or appendectomy.ancy or appendectomy.

Fetal FactorsFetal Factors The most common cause of spontaThe most common cause of sponta

neous abortion is a significant genetneous abortion is a significant genetic abnormality of the conceptus. In sic abnormality of the conceptus. In spontaneous first-trimester abortion,pontaneous first-trimester abortion, approximately two thirds of aborte approximately two thirds of aborted fetuses have significant chromosod fetuses have significant chromosomal anomalies.mal anomalies.

PathologyPathology In spontaneous abortion, usually the embryo In spontaneous abortion, usually the embryo

or fetus is compromised first and this is followor fetus is compromised first and this is followed by hemorrhage into the decidua basalis. Need by hemorrhage into the decidua basalis. Necrosis and inflammation appear in the region crosis and inflammation appear in the region of implantation. The detached conceptus is, in of implantation. The detached conceptus is, in effect, a foreign body in the uterus which causeffect, a foreign body in the uterus which causes strong uterine contractions. Uterine contraes strong uterine contractions. Uterine contractions and dilatation of the cervix result in expctions and dilatation of the cervix result in expulsion of partial or all the products of conceptiulsion of partial or all the products of conception.on.

An abortion is a miniature labour, the rhythmiAn abortion is a miniature labour, the rhythmical uterine contractions cause the cervix to dilcal uterine contractions cause the cervix to dilate and embryo or fetus to be expelled with or ate and embryo or fetus to be expelled with or without its accompanying membranes. If all thwithout its accompanying membranes. If all the products of conception are expelled, the cone products of conception are expelled, the contractions cease and the bleeding stops. In somtractions cease and the bleeding stops. In some cases of incomplete abortion a piece of place cases of incomplete abortion a piece of placental tissue may remain in the uterus because ental tissue may remain in the uterus because it is fixed at its base. Bacterial invasion of the rit is fixed at its base. Bacterial invasion of the retained products may occur.etained products may occur.

ManagementManagement

Threatened AbortionThreatened Abortion The patient is kept at rest in bed until 2 The patient is kept at rest in bed until 2

days after blood loss has ceased. days after blood loss has ceased. Intercourse is forbidden. As soon as the Intercourse is forbidden. As soon as the initial bleeding has stopped an ultrasound initial bleeding has stopped an ultrasound scan is performed. This will reveal whether scan is performed. This will reveal whether or not the pregnancy is intact. The or not the pregnancy is intact. The prognosis is good when all abnormal signs prognosis is good when all abnormal signs and symptoms disappear and when the and symptoms disappear and when the resumption of the progress of pregnancy is resumption of the progress of pregnancy is apparent.apparent.

Inevitable AbortionInevitable Abortion The uterus usually expels its contents unThe uterus usually expels its contents un

aidedaided, , and examination must be made and examination must be made with strict aseptic technique. If the abortwith strict aseptic technique. If the abortion is not quickly completed, or if hemorion is not quickly completed, or if hemorrhage becomes severe, the contents of trhage becomes severe, the contents of the uterus are removed with a suction cuhe uterus are removed with a suction curettege.rettege.

Incomplete AbortionIncomplete Abortion

Patients require admission to the hPatients require admission to the hospital. Treatment is aimed at preveospital. Treatment is aimed at preventing infection, controlling bleeding nting infection, controlling bleeding and obtaining an empty and involutand obtaining an empty and involuting uterus. The chief risks associateing uterus. The chief risks associated with retained products are hemord with retained products are hemorrhage and sepsisrhage and sepsis. .

Missed AbortionMissed Abortion Once the diagnosis has been Once the diagnosis has been

made the uterus should be made the uterus should be emptied. Early in gestation emptied. Early in gestation evacuation of the uterus is evacuation of the uterus is usually accomplished by suction usually accomplished by suction curettage. The prognosis for the curettage. The prognosis for the mother is good. Serious mother is good. Serious complications are uncommoncomplications are uncommon..

Recurrent abortion Recurrent abortion Paternal and maternal chromosomes shPaternal and maternal chromosomes sh

oud be evaluated.oud be evaluated. The mother should be ruled out the presThe mother should be ruled out the pres

ence of systemic disorders such as DM,Sence of systemic disorders such as DM,SLE, and thyroid disease.LE, and thyroid disease.

It should rule out the presence of MycopIt should rule out the presence of Mycoplasma, Listeria, Toxoplasma etc. infectiolasma, Listeria, Toxoplasma etc. infectious disease.us disease.

Pelvic examination Pelvic examination

1 All of the following may be the caus1 All of the following may be the cause of recurrent abortion except:e of recurrent abortion except:

A cervical incompetenceA cervical incompetenceB infectionB infectionC chromosome aberrantionsC chromosome aberrantions

D retroversion of the uterusD retroversion of the uterus

2 A patient of 8th week pregnancy, presents 2 A patient of 8th week pregnancy, presents with vaginal bleeding, low abdominal pain, vwith vaginal bleeding, low abdominal pain, vaginal examination revealing partially dilatataginal examination revealing partially dilatated cervix, without expelling any tissue, she sed cervix, without expelling any tissue, she should be diagnosed as :hould be diagnosed as :A threatened abortionA threatened abortionB inevitable abortionB inevitable abortionC complete abortionC complete abortionD incomplete abortionD incomplete abortion