Definition: Abortion is expulsion of or extraction from it’s mother of a fetus or an
embryo weighting 500g .or less(WHOdefinition).
This nearly equal to 20 weeks of gestation
*British law definition of abortion:(Termination of pregnancy before 24weeks
gestation)
*Abortion maybe:
-Early abortion: i.e.before the 12thweek
-Late abortion: i.e. between the 12th and the 22nd week
Incidence: It differs according to definition“10-20%”
Etiology
Several causative factors have been implicated in etiology of abortion .
How ever in many cases there is no demonstrable cause or it is difficult to pin point to any
cause. In general
“Abortion in the first quarter of pregnancy, is more likely to be due to factors in
the conceptus or it’s implantation. Where as in the second quarter uterine factors
such as cervical incompetence play amore important role"
a)Blighted Ovum: i.e. empty sac in which anembryo has not developed “an embryonic sac”
.b)Chromosomal defect : In about 60% of cases ,the most common are:
Auto somaltrisomy 16,22,21,15.
Monosomy 45,x.
Triploidy Tetraploidy
c)Structural abnormalities:
As placental abnormalities “hydatidi form degenerationofvilli” umbilical cord abnormalities and neural tube defect:
d)Genetic:
Introduction Abnormalenzymes“stillunderstudy”.
The main causes of bleeding in early pregnancy are:
1-Abortion General maternal factors:
2-Ectopicpregnancy.
3-Hydatidiformmole. a)Maternal diseases
-These mostly result in early pregnancy loss: -Hypertension.
Although early pregnancy loss is often considered to be less important than loss of baby in later pregnancy ,this attitude is -Chronic Renal disease
inappropriate.The loss of wanted pregnancy is always disturbing to the mother (family) irrespective of it’s timing and this -S.L.E.
particularly true in recurrent abortion. -Vonwill brand’s disease
Further more abortion, ectopic pregnancy and H.mole can have serious maternal consequences with appreciable risks of -Uncontrolled D.M.
maternal mortality and long termmorbidity. b)Immunological causes: When acouple sharing more HLA antigens than usual the trophoblast fail to stimulate the production of the maternal blocking antibodies, which inhibit cell-
Other causes of bleeding in early pregnancy mediated rejection process resulting in pregnancy rejection.
• Cervicalpolyp c)Infection:
• Cervicalcancer Acute infection which lead to general toxicillness or chronic infection:-
• Cervicalerosion • Pyelitis • Appendicitis. • Malaria. • TORCH infection. • Typhoid fever •Syphilis.
d)Endocrine cause:
-Critical progesterone production phase:
Abnormal conceptus
Abortion: This is the commonest cause of early abortion as:
i.e. time when progesterone production transfer from corpus luteum to placenta at which inadequate production may occur(4%).
-Hyperthyroidism or hypothyroidism.
-P.C.O.D.(PolycysticOvarianDisease).
Bleeding In Early Pregnancy Uterine factors
a) Congenital anomalies:
(1) Abortion – Septateuterus. – Doubleuterus. – Bicornateuterus. – Subseptateuterus.
b)Retrovertion:
Rare“when retroverted gravid uterusis trapped in the pelvis.
c)Cervical incompetence:
Either congenital or acquired.
d)Fibroiduterus:
“submucose”
e)Asherman’s syndrome:
types signs and symptoms examination investigation Differential Diagnosis: treatment prognosis Intrauterine synechia due multiple curettage
e)Trauma:
- Surgery
• “Pelvic examination is not advised but if done • Advise the patient to remain at home, avoid heavy work - Falling down
• Symptoms and signs of pregnancy should be gentle”. and coitus. -When the amount of lost blood is less than -Severe: trauma to the uterus
- Pregnancy test +ve. Role out other causes of bleeding in - I.U.C.D.
•Bleeding usually scanty and may occur repeated in the • Cervix is closed “You may see blood oozing from •If bleeding increased up to the amount of normal normal menstruation ,the chance to continue
-Ultrasound early pregnancy i.e other stages of
THREATENED ABORTION course of many days It may be bright red spotting at first then cervical Os”.
• No tissue contents in the blood or clots.
“To see viability of the fetus and correlate intact gestational abortion ,ectopic ,H.mole ,cervical
menstruation hospitalization is indicated.
• Sedatives as Phenobarbital 60mg or diazepam 5mg.
the pregnancy approach 97%. -Amniocentesis.&CVS(chrionvillisampling)
- Coitus.(Recurrentabortion)
become dark. -Controversially whenit is more late
sac size with duration of amenorrhea” erosion, carcinoma and polyps) f)Psychological causes:Due to effect on hypothalamus secretion of oxytoxin and miscarriage should follow the accident immediately.
• Lower abdominal cramps or back ache may be present. • uterine sizes correlate with the history of • Hormonal therapy by progesterone is controversial. complications and pregnancy loss is possibility.
amenorrhea. • Follow-up by ultrasound if bleeding is recurrent g)Drugs and toxins:
Cytotoxicdrugs → Quinine → Anesthetics
h)Malnutrition:
🔹management of inevitable and incomplete
abortion:
Clinical Aspect:
At home: • Symptoms and signs of pregnancy“Amenorrhea”
• Remove tissue from cervical os by fingers or sponge • Vaginal bleeding– Spotting– Clots– Tissue
forceps. • Painsupra-pubic cramping.
incomplete abortion: • Give ergometrine to decrease bleeding. • Condition of cervix “open or closed"
inevitable abortion: •when fragments of the conception protrude from • Give analgesics. • Size of uterus.
An abortion isconsidered inevitable when the internal cervical the external cervical os,are found in the vagina or • Transfer patientbto hospital.
INEVITABLE ABORTION Os is dilated to the point that afinger can be introduced and
the patient has painful uterine contractions and severe clotted
have been passed but part had been retained.
•The bleeding is severe,and signs of shock may be ------------- -----------------
At hospital:
• Admission and assessment of blood loss and vital signs. ---------------
Clinical varieties:
• Threatened a abortion.
INCOMPLETE ABORTION bleeding. present ,bleeding some times intermittent and pain is •Resuscitate the patient by IV fluids and if bleeding is • Inevitable abortion.
-The lower pole of the gestational sac could be palpated, and present. severe,prepare for transfusion by grouping ,Rh ,And cross • Incomplete abortion.
passage of finger in cervicalcanal The cervical os is opened and uterus stilllarge.U/S matching and give ergometrine. • Complete abortion.
show retained .products. • Evacuation underG.A. Pethidinordiazepam. • Missed abortion.
• If uterinesize is<12weeks, give ergometrine then evacuate • Septic abortion
•if it is>12weeks with fetus inside (ininevitable) give • Recurrent abortion.
Oxytocin infusion to expel the contents then evacuate. •According to etiology abortion may be spontaneous in which there is no active interference has
•If cervix still closed, embedding curetage and uterine size precipitated the abortion. and induced which may be legal, therapeutic or criminals.
is larger than 14 weeks with severe bleeding hystrotomy is The classification is according,to the clinical findings when the patient is first seen but one variety mayc
indicated. hange to another by progress of time.
•complete if upon gross examination it appeared
that the fetus ,cord ,placenta and membranes had
been delivered intact. Even though necros is of the
• Bleeding is slight and may last for aweek.
remaining deciduas is a common cause of post • Advise the patient to reportat once if any pain,fever or
• No pain.
COMPLETE ABORTION • Uterus size is smaller than duration of amenorrhea.
abortion bleeding and infection and it is rarely that
the deciduas is passed as a cast along with the
--------------- --------------- new bleeding. -------------------
• Anti-D in Rh negative
• Os is slight open and may last for aweek.
concept us.
• U/S show empty uterus.
clinical varieties
For this reason abortion is now considered
incomplete until curettage is performed.
of abortion • The treatment should be individualized.
• The aim is to:
Any abortion associated with fever&signs of
– Control the infection by the use of appropriate antibiotics.
pelvicorgeneralized peritonitis.
– Correct blood volume in incomplete and inevitable
Mostly,it results from criminal interference ,but sepsis may
abortion.
follow incomplete ,spontaneous or elective abortion and non-
– Prevent further bleeding.
sterile evacuation.
– Begin empties the uterus.
Signs&Symptoms: • Antibiotics:-
• .Malaise Sweating Headache Joint pain. • Blood for:
– Combination depends on severity&sensitivity.
• Fever some times with chills or rigor. Hb WBC ESR grouping & X-matching Urea &creatinin
– Ampicillin.
• Iliac pain,vomiting &diarrhea. S.electrolytes. LFT.BT (BLEEDINGTIME).
– Metronidazol.
• Bleeding with badsmell purulent vagina discharge. • Urineanalysis.
– Gentamycin.
SEPTIC ABORTION • Tachycardia ,hypotension either due to bleeding or septic
shock.
--------------- • Vaginal swab for Gramstain and culture and sensitivity
• Blood culture in septicemia.
------------------- – Cephalosporin could be used: -------------
– Give Anti-Tetanus antitoxins.
• Rigidity & tenderness over abdomen. • X-Ray in erect position tosee:→ gasunderdiaphragm• → – Give Anti-Gasgangrene.
• Bowel sound may be sluggish or absent. Foreignbodyinperitonealcavity →Air-fluidlevelparalyticileus. – Give freshbloodtransfusion.
• Os may be opened, and cervical movement cause severe pain. • Ultrasound to see if remnant – Give Hydrocortisone with high does i.v. antibiotics in
•Uterus is bulky ,soft and crepitus may be noted in gas septic shock.
gangrene. Fullness or bogginess of (DouglasPouch). Surgery:– After the Pt.respond or well covered by
• You may find surgical trauma if criminal abortion. antibiotics, Wedo exploration & evacuation of retained
•On rare occasions a piece of gar or omentum protrude per os products.
confirm criminality – Hysterectomy is indicated in:
• Oliguria may present due to hypovolemia ,Endotoxic shock. – Uterine perforation
• Jaundice may present with anemia – Failure of treatment and evacuation.
– Gas gangrene infection
Retention of the concepts for several weeks or months
• Hb,rh,group BT, CT ,Fibrinogen
following it’s death in uterus
Uterus is smaller than period of amenorrhea and os •If uterus <12weeks evacuation under anesthesia after
Missed Abortion Symptoms of pregnancy regress after occurrence of slight
vaginal bleeding (brown) ,in some cases there is no bleeding
is closed. dilatation with Hegar dilators
---------------- -------------- ----------
• If uterus >12weeks induction by prostaglandins or oxytocin
and amenorrhea continues.
• Three or more consecutive abortion
• it is mostly due to any cause that isnt treated or diagnosed Condition to do circulage
•When late abortion it could be due to incompetent cervix • No uterine contraction
• Cervical canal canpass Hegar’s dilat or No.8 in • Cofirm viability and exclude congenital anomaly by U/S
• Best gestational age 14-16weeks
Recurrent-“habitual”- wether congenital or acquired
•Cervical incompetent is inability of cervix to maitain the fetus
premenstrual phase
• Funnel shape cervix on HSG ----------------- ------------------
• Do cervical circulage at level of internal cervical os
• Shirhodkhar stitch under mucosa of vagina
• No infection or vaginal bleeding
• Normal fetus
abortion till term due to weakness of it’s sphencteric function • U/S during pregnancy short cervical canal and
wide internal cervical os
•mcDonalds stitch multiple simple bites around cervical os
at high level
• Removal of stitch two weeks before EDD
History of previous abortion, painless bloodless, late and •Patient informed to come to near by hospital
regress in G.age any gestation if pain or bleeding
by fatema okoff
embryo weighting 500g .or less(WHOdefinition).
This nearly equal to 20 weeks of gestation
*British law definition of abortion:(Termination of pregnancy before 24weeks
gestation)
*Abortion maybe:
-Early abortion: i.e.before the 12thweek
-Late abortion: i.e. between the 12th and the 22nd week
Incidence: It differs according to definition“10-20%”
Etiology
Several causative factors have been implicated in etiology of abortion .
How ever in many cases there is no demonstrable cause or it is difficult to pin point to any
cause. In general
“Abortion in the first quarter of pregnancy, is more likely to be due to factors in
the conceptus or it’s implantation. Where as in the second quarter uterine factors
such as cervical incompetence play amore important role"
a)Blighted Ovum: i.e. empty sac in which anembryo has not developed “an embryonic sac”
.b)Chromosomal defect : In about 60% of cases ,the most common are:
Auto somaltrisomy 16,22,21,15.
Monosomy 45,x.
Triploidy Tetraploidy
c)Structural abnormalities:
As placental abnormalities “hydatidi form degenerationofvilli” umbilical cord abnormalities and neural tube defect:
d)Genetic:
Introduction Abnormalenzymes“stillunderstudy”.
The main causes of bleeding in early pregnancy are:
1-Abortion General maternal factors:
2-Ectopicpregnancy.
3-Hydatidiformmole. a)Maternal diseases
-These mostly result in early pregnancy loss: -Hypertension.
Although early pregnancy loss is often considered to be less important than loss of baby in later pregnancy ,this attitude is -Chronic Renal disease
inappropriate.The loss of wanted pregnancy is always disturbing to the mother (family) irrespective of it’s timing and this -S.L.E.
particularly true in recurrent abortion. -Vonwill brand’s disease
Further more abortion, ectopic pregnancy and H.mole can have serious maternal consequences with appreciable risks of -Uncontrolled D.M.
maternal mortality and long termmorbidity. b)Immunological causes: When acouple sharing more HLA antigens than usual the trophoblast fail to stimulate the production of the maternal blocking antibodies, which inhibit cell-
Other causes of bleeding in early pregnancy mediated rejection process resulting in pregnancy rejection.
• Cervicalpolyp c)Infection:
• Cervicalcancer Acute infection which lead to general toxicillness or chronic infection:-
• Cervicalerosion • Pyelitis • Appendicitis. • Malaria. • TORCH infection. • Typhoid fever •Syphilis.
d)Endocrine cause:
-Critical progesterone production phase:
Abnormal conceptus
Abortion: This is the commonest cause of early abortion as:
i.e. time when progesterone production transfer from corpus luteum to placenta at which inadequate production may occur(4%).
-Hyperthyroidism or hypothyroidism.
-P.C.O.D.(PolycysticOvarianDisease).
Bleeding In Early Pregnancy Uterine factors
a) Congenital anomalies:
(1) Abortion – Septateuterus. – Doubleuterus. – Bicornateuterus. – Subseptateuterus.
b)Retrovertion:
Rare“when retroverted gravid uterusis trapped in the pelvis.
c)Cervical incompetence:
Either congenital or acquired.
d)Fibroiduterus:
“submucose”
e)Asherman’s syndrome:
types signs and symptoms examination investigation Differential Diagnosis: treatment prognosis Intrauterine synechia due multiple curettage
e)Trauma:
- Surgery
• “Pelvic examination is not advised but if done • Advise the patient to remain at home, avoid heavy work - Falling down
• Symptoms and signs of pregnancy should be gentle”. and coitus. -When the amount of lost blood is less than -Severe: trauma to the uterus
- Pregnancy test +ve. Role out other causes of bleeding in - I.U.C.D.
•Bleeding usually scanty and may occur repeated in the • Cervix is closed “You may see blood oozing from •If bleeding increased up to the amount of normal normal menstruation ,the chance to continue
-Ultrasound early pregnancy i.e other stages of
THREATENED ABORTION course of many days It may be bright red spotting at first then cervical Os”.
• No tissue contents in the blood or clots.
“To see viability of the fetus and correlate intact gestational abortion ,ectopic ,H.mole ,cervical
menstruation hospitalization is indicated.
• Sedatives as Phenobarbital 60mg or diazepam 5mg.
the pregnancy approach 97%. -Amniocentesis.&CVS(chrionvillisampling)
- Coitus.(Recurrentabortion)
become dark. -Controversially whenit is more late
sac size with duration of amenorrhea” erosion, carcinoma and polyps) f)Psychological causes:Due to effect on hypothalamus secretion of oxytoxin and miscarriage should follow the accident immediately.
• Lower abdominal cramps or back ache may be present. • uterine sizes correlate with the history of • Hormonal therapy by progesterone is controversial. complications and pregnancy loss is possibility.
amenorrhea. • Follow-up by ultrasound if bleeding is recurrent g)Drugs and toxins:
Cytotoxicdrugs → Quinine → Anesthetics
h)Malnutrition:
🔹management of inevitable and incomplete
abortion:
Clinical Aspect:
At home: • Symptoms and signs of pregnancy“Amenorrhea”
• Remove tissue from cervical os by fingers or sponge • Vaginal bleeding– Spotting– Clots– Tissue
forceps. • Painsupra-pubic cramping.
incomplete abortion: • Give ergometrine to decrease bleeding. • Condition of cervix “open or closed"
inevitable abortion: •when fragments of the conception protrude from • Give analgesics. • Size of uterus.
An abortion isconsidered inevitable when the internal cervical the external cervical os,are found in the vagina or • Transfer patientbto hospital.
INEVITABLE ABORTION Os is dilated to the point that afinger can be introduced and
the patient has painful uterine contractions and severe clotted
have been passed but part had been retained.
•The bleeding is severe,and signs of shock may be ------------- -----------------
At hospital:
• Admission and assessment of blood loss and vital signs. ---------------
Clinical varieties:
• Threatened a abortion.
INCOMPLETE ABORTION bleeding. present ,bleeding some times intermittent and pain is •Resuscitate the patient by IV fluids and if bleeding is • Inevitable abortion.
-The lower pole of the gestational sac could be palpated, and present. severe,prepare for transfusion by grouping ,Rh ,And cross • Incomplete abortion.
passage of finger in cervicalcanal The cervical os is opened and uterus stilllarge.U/S matching and give ergometrine. • Complete abortion.
show retained .products. • Evacuation underG.A. Pethidinordiazepam. • Missed abortion.
• If uterinesize is<12weeks, give ergometrine then evacuate • Septic abortion
•if it is>12weeks with fetus inside (ininevitable) give • Recurrent abortion.
Oxytocin infusion to expel the contents then evacuate. •According to etiology abortion may be spontaneous in which there is no active interference has
•If cervix still closed, embedding curetage and uterine size precipitated the abortion. and induced which may be legal, therapeutic or criminals.
is larger than 14 weeks with severe bleeding hystrotomy is The classification is according,to the clinical findings when the patient is first seen but one variety mayc
indicated. hange to another by progress of time.
•complete if upon gross examination it appeared
that the fetus ,cord ,placenta and membranes had
been delivered intact. Even though necros is of the
• Bleeding is slight and may last for aweek.
remaining deciduas is a common cause of post • Advise the patient to reportat once if any pain,fever or
• No pain.
COMPLETE ABORTION • Uterus size is smaller than duration of amenorrhea.
abortion bleeding and infection and it is rarely that
the deciduas is passed as a cast along with the
--------------- --------------- new bleeding. -------------------
• Anti-D in Rh negative
• Os is slight open and may last for aweek.
concept us.
• U/S show empty uterus.
clinical varieties
For this reason abortion is now considered
incomplete until curettage is performed.
of abortion • The treatment should be individualized.
• The aim is to:
Any abortion associated with fever&signs of
– Control the infection by the use of appropriate antibiotics.
pelvicorgeneralized peritonitis.
– Correct blood volume in incomplete and inevitable
Mostly,it results from criminal interference ,but sepsis may
abortion.
follow incomplete ,spontaneous or elective abortion and non-
– Prevent further bleeding.
sterile evacuation.
– Begin empties the uterus.
Signs&Symptoms: • Antibiotics:-
• .Malaise Sweating Headache Joint pain. • Blood for:
– Combination depends on severity&sensitivity.
• Fever some times with chills or rigor. Hb WBC ESR grouping & X-matching Urea &creatinin
– Ampicillin.
• Iliac pain,vomiting &diarrhea. S.electrolytes. LFT.BT (BLEEDINGTIME).
– Metronidazol.
• Bleeding with badsmell purulent vagina discharge. • Urineanalysis.
– Gentamycin.
SEPTIC ABORTION • Tachycardia ,hypotension either due to bleeding or septic
shock.
--------------- • Vaginal swab for Gramstain and culture and sensitivity
• Blood culture in septicemia.
------------------- – Cephalosporin could be used: -------------
– Give Anti-Tetanus antitoxins.
• Rigidity & tenderness over abdomen. • X-Ray in erect position tosee:→ gasunderdiaphragm• → – Give Anti-Gasgangrene.
• Bowel sound may be sluggish or absent. Foreignbodyinperitonealcavity →Air-fluidlevelparalyticileus. – Give freshbloodtransfusion.
• Os may be opened, and cervical movement cause severe pain. • Ultrasound to see if remnant – Give Hydrocortisone with high does i.v. antibiotics in
•Uterus is bulky ,soft and crepitus may be noted in gas septic shock.
gangrene. Fullness or bogginess of (DouglasPouch). Surgery:– After the Pt.respond or well covered by
• You may find surgical trauma if criminal abortion. antibiotics, Wedo exploration & evacuation of retained
•On rare occasions a piece of gar or omentum protrude per os products.
confirm criminality – Hysterectomy is indicated in:
• Oliguria may present due to hypovolemia ,Endotoxic shock. – Uterine perforation
• Jaundice may present with anemia – Failure of treatment and evacuation.
– Gas gangrene infection
Retention of the concepts for several weeks or months
• Hb,rh,group BT, CT ,Fibrinogen
following it’s death in uterus
Uterus is smaller than period of amenorrhea and os •If uterus <12weeks evacuation under anesthesia after
Missed Abortion Symptoms of pregnancy regress after occurrence of slight
vaginal bleeding (brown) ,in some cases there is no bleeding
is closed. dilatation with Hegar dilators
---------------- -------------- ----------
• If uterus >12weeks induction by prostaglandins or oxytocin
and amenorrhea continues.
• Three or more consecutive abortion
• it is mostly due to any cause that isnt treated or diagnosed Condition to do circulage
•When late abortion it could be due to incompetent cervix • No uterine contraction
• Cervical canal canpass Hegar’s dilat or No.8 in • Cofirm viability and exclude congenital anomaly by U/S
• Best gestational age 14-16weeks
Recurrent-“habitual”- wether congenital or acquired
•Cervical incompetent is inability of cervix to maitain the fetus
premenstrual phase
• Funnel shape cervix on HSG ----------------- ------------------
• Do cervical circulage at level of internal cervical os
• Shirhodkhar stitch under mucosa of vagina
• No infection or vaginal bleeding
• Normal fetus
abortion till term due to weakness of it’s sphencteric function • U/S during pregnancy short cervical canal and
wide internal cervical os
•mcDonalds stitch multiple simple bites around cervical os
at high level
• Removal of stitch two weeks before EDD
History of previous abortion, painless bloodless, late and •Patient informed to come to near by hospital
regress in G.age any gestation if pain or bleeding
by fatema okoff
