Miscarriage (Abortion)

Definition
Miscarriage: spontaneous termination of pregnancy.
Abortion: induced termination of pregnancy.
It is expulsion or extraction of products of conception before
fetal viability i.e. before 24 weeks of gestation (during the 1 st 2
trimesters).
Incidence
Is the commonest gynecological & obstetric disorder

~ 15% (clinically recognized) & rise to 30% (unrecognized

pregnancies).

Most abortions occur between 8-12 weeks of pregnancy.

Causes of 1st Trimester Abortion (up to 12w):
Chromosomal abnormalities
50-70% The commonest cause of abortion
Particularly trisomy, triploidy & monosomy
The incidence increased with the increase in the
maternal age
Multiple gestation
Blighted ovum (Anembryonic pregnancy)
Parental balanced translocation
Infections: genital tract infection, systemic infection & ToRCH
syndrome
Endocrine abnormalities (DM, thyroid dysfunction, PCOS,
corpus luteal insufficiency)
Uterine disorders
Uterine anomalies (septated uterus)
Ashermans syndrome (adhesions inside the uterine
cavity)

Sub-mucous fibroid
Thrombophilia: anti-phospholipids syndrome, congenital
deficiency of protein C, S & anti-thrombin III
Immunological disorders : Anticardiolipin syndrome & SLE

 Cigarette smoking, anaesthetic agents & chemical agents.

Trauma, Rh isoimmunization, Psychological & neurological
disorders
Causes of 2nd Trimester Abortion (13-24w):
Multiple pregnancy
Cervical incompetence (congenital & acquired )
Uterine anomalies & sub-mucous fibroid
Genital tract infection & PROM
Types:
Threatened abortion ""
Inevitable abortion ""
Incomplete abortion ""
Complete abortion ""
Missed abortion ""
Septic abortion ""
Recurrent abortion ""
Threatened abortion:
History
Mild vaginal bleeding (main complaint).
No or mild abdominal pain
Examination
Good general condition
Closed cervix
The uterus is usually the correct size for date
U/S (essential for the diagnosis)
Showed the presence of fetal heart activity
Management:
1. Reassurance (If fetal heart activity is present, > 90% of cases will be
progressed satisfactorily)
2. Advice (decrease activity & avoid intercourse for 1-2wks until the
condition get stabilized because semen contain PG which cause
softening and dilatation of the cervix)
3. Hormones (Progesterone & hCG used in the 1st trimester to support
pregnancy)
4. Anti-D (Rh ve, non-immunised patients, whose husbands are Rh +ve)

5. ANC as high risk patients (more liable to late pregnancy

complications such as APH & preterm labor).
The definition of abortion is not exactly applied, because there is no
expulsion or extraction.

Inevitable & incomplete abortions:

History
Heavy vaginal bleeding with:
No passage of products conception (inevitable)
Passage of products of conception (incomplete)
Severe lower abdominal pain which follows the bleeding
Examinations
Poor general condition (maybe shock).
Dilated cervix & products of conception may be passing
through the os
The uterus size:
Correct for date (inevitable)
Small for date (incomplete)
U/S (not essential for diagnoses): fetal heart activity may or may not
present.
Management
1. CBC, blood grouping, XM 2 units of blood
2. Resuscitation large IV line, fluids & blood
transfusion
3. Oxytoxic drugs Ergometrine 0.5 mg IM + Oxytocin infusion (20-40
units in 500 cc saline) or PG to encourage the uterine contraction &
minimize the bleeding.

4. Evacuation & curettage.

5. Post-abortion management.
Complete abortion:
History (history of things happened days ago)
Heavy vaginal bleeding
Lower abdominal pain which follows the bleeding
Passage of all conceptive material
Examination
Closed cervix
Small for date
U/S

 Empty uterine cavity

RPOC
Management
Evacuation & curettage in the presence of RPOC.
Post-abortion management

Missed abortion:
Most of missed abortions are diagnosed accidentally during
routine U/S in early pregnancy.
History (in some cases there may be):
Episodes of mild vaginal bleeding
Regression of early symptoms of pregnancy.
Stop of fetal movements after 20 weeks gestation.
Examination
Closed cervix
Small or compatible for date
U/S (essential for diagnosis):
Diagnosed if 2 U/S (T/V or T/A) at least 7 days apart showed
an embryo of >7 weeks gestation (CRL > 6mm in diameter &
gestational sac > 20 mm in diameter) with no evidence of
heart activity.
2 U/S 7 days apart because of the possibility of wrong dating due to
irregular period, lactating or OCPs If there was heart activity in
previous ultrasound in the previous visit and now there is no heart
activity then almost no need for 2nd ultrasound.
Management (the best method is the medical & the worst one is the
conservative)

1. CB , blood grouping, XM 2 units of blood

2. Platelets count to exclude the risk of DIC (not occur before 5
weeks of missed abortion or IUFD and if occurred will be of mild grade)
3. Conservative management (More psychological trauma & risk of
DIC)

Leave the dead fetus inside the uterus until

spontaneous expulsion
4. Active management (less psychological trauma & risk of DIC)
a. Surgical evacuation (D & C)

 Only in the 1st trimester (< 12 weeks) because the head

development

Shorter time, GA, surgical complications

b. Medical evacuation by Misoprostol (Cytotec a PGE1)
At any gestation 1st or 2nd trimesters
Vaginal (the best) or oral tab 200 g 2x/3h up to 5 doses
daily, which can be repeated next day if no response in
the 1st day.
In 90% will be complete abortion & 10% will need
subsequent surgical evacuation in cases of RPOC
S/E: nausea, vomiting & fever (no GA or surgical
complications)
5. Post-abortion management
Anembryonic pregnancy (Blighted ovum)
It is due to an early death and resorption of the embryo with
the persistence of the placental tissue
Diagnosis & treatment similar way to missed abortion.
Septic abortion
Definition:
Incomplete abortion complicated by infection of the uterine
contents.
This may be due to criminal interference
Features:
Poor general condition
Incomplete abortion features with or without history of
evacuation.
Pelvic infection features: pyrexia, tachycardia, general
malaise, lower abdominal pain, pelvic tenderness & purulent
vaginal discharge.
Bacteriology: Mixed infection
The commonest organisms are G-ve E.coli , strep,
staphylococcu & anaerobics (bacteroides)
Rarely Cl. tetani , which is potentially lethal if not treated
adequately.
Types:

 Mild 80% the infection is confined to decidua

Moderate 15%the infection extended to myometrium
Severe 5%the infection extended to pelvis + Endotoxic
shock + DIC
Management:
1. Investigations:
CBC, blood grouping, XM 2 units of blood.
Cervical swabs (not vaginal) for culture and sensivity
Coagulation profile, serum electrolytes & blood culture if
pyrexia > 38.5
2. Antibiotics: IV Cephalosporin & Metronidazole
3. Surgical evacuation of uterus usually 12 hrs after antibiotic
therapy (until a reasonable tissue levels of antibiotics have
been achieved)
4. Post-abortion management.

Complications of abortion:
1. Hemorrhage (abortion is one of the leading cause of maternal
death & mostly due to hemorrhage).
2. D&C or E&C (surgical) complication:
a. Uterine perforation rupture uterus in the subsequent
pregnancy.
b. Cervical tear & excessive cervical dilatation cervical
incompetence.
c. Infection infertility & Asherman's syndrome.
d. Excessive curettage Adenomyosis
3. Rh-iso immunizations (anti-D is not given or the dose is
inadequate).
4. Psychological trauma.
Post-abortion management:
1. Support from the husband, family& obstetric staf
2. Anti-D (Rh ve, nonimmunized patients, whose husbands are
Rh+ve)
3. Counseling & explanation:

a. Contraception should start immediately after abortion,

because ovulation can occur 14 days after abortion and
the pregnancy can occur before the expected next period.
b. Its better to wait for 3 months before trying again.
Regulate the cycles & knowing the LMP.
Give folic acid.
To be in the best shape (physically & emotionally) for the
next pregnancy.
c. Why has it happened: the majority of cases there is no
obvious cause. In the 1st trimester the most common
cause is fetal chromosomal abnormality.
d. Can it happen again? As the commonest cause is the fetal
chromosomal abnormality which is not a recurrent cause,
so the chance of successful pregnancy next time in the
absence of obvious cause is very high even after 2-3
abortions. Success rate in the next pregnancy is 85%.
e. Not to feel guilty: as it is extremely unlikely that anything
the patient did can cause abortion
f. No evidence that intercourse in early pregnancy is harmful
g. No evidence that bed rest will prevent it

Recurrent abortion

Definition:
3 or more consecutive spontaneous abortions.
Types:
1. Primary: All pregnancies have ended in loss (before 24w).
2. Secondary: One or more pregnancies has proceeded to viability
(>24 w) with all others ending in loss.
Incidence: 1% of women of reproductive age.
Causes (50% Idiopathic & 50% known causes):
1. Chromosomal disorders:
Fetal chromosomal & structural abnormalities.
Parental balanced translocation (not afects the parents but
afect their fertility).

2. Anatomical disorders:
Cervical incompetence (congenital and acquired)
Uterine causes
Submucous fibroids
Uterine anomalies
Ashermans syndrome
3. Medical disorders:
Endocrine disorders (DM, thyroid disorders, PCOS & corpus
luteum insufficiency.
Immunological disorders: Anticardiolipin syndrome & SLE.
Thrombophilia:
Acquired: anti-phospholipid syndrome
Congenital deficiency of Protein C&S, anti-thrombin III &
presence of factor V Leiden.
4. Infections:
ToRCH, esp. CMV.
Genital tract infection (Bacterial vaginosis).
5. Rh-isoimmunization

Diagnosis:
1. History:
Previous abortions: GA, place & fetal abnormalities.
Medical history: DM, thyroid disorders, PCOS, autoimmune
diseases & thrombophilia.
2. Examination:
General: weight , thyroid & hair distribution
Pelvic: cervix (length & dilatation) & uterine size.
3. Investigations:
For chromosomal disorders:
Parental karyotyping: Parental balanced translocation.
Fetal karyotyping: Fetal chromosomal anomalies.
For anatomical disorders:
TV/US: fibroids, cervical incompetence & PCOS.
Hysteroscopy or HSG: fibroids, cervical incompetence,
uterine anomalies & Asherman's syndrome.

For medical disorders:

Blood grouping & indirect Coombs test in Rh ve women
Endocrinal screening: Blood sugar, TFT & LH /FSH ratio
Immunological screening: Anti anticardiolipine Abs & lupus
inhibitor.
Thrombophilia screening: Protein C & S, antithrombin III
levels, factor V Leiden, APTT & PT.
Infection screening:
High vaginal & cervical swabs
TORCH profile (scientifically is not necessary)

Management:
1. Idiopathic:
Support & good antenatal care, the chance of successful
spontaneous pregnancy is about 60-70%.
Advice: stop smoking & alcohol intake, decrease physical
activity
Tender loving care
Drug therapy
i. Progesterone & HCG: once she gets pregnant, start
from the luteal phase & up to 12 weeks.
ii. Low dose aspirin (75 mg/day) start from the
diagnosis of pregnancy (4th -5th wk) & up to 37wks.
iii. LMWH (low molecular weight heparin) (20-40
mg/day) subcutaneously start from the diagnosis of
fetal heart activity (7th wk) & up to 37 wks
2. Endocrine disorders
Control DM and thyroid disorders before pregnancy.
PCOS: ovulation induction drugs, ovarian drilling or IVF.
Corpus luteum insufficiency: progesterone or hCG.

3. Anti-cardiolipin syndrome:
Low dose aspirin (75 mg/day) & prednisilone (20-30 mg
/day)
Starting when pregnancy is diagnosed till 37 weeks.
4. Thrombophilia:
Low dose aspirin (75 mg/day) starting when pregnancy is
diagnosed and
LMWH (20-40 mg/day) starting when fetal heart activity
diagnosed & to continue both till 37 weeks.
5. Uterine disorders:
Cervical cerclage in cervical incompetence, best time at
14w GA
Myomectomy in submucus fibroid
Excision of uterine septum in septate & subseptate uterus
Adhesolysis in Asherman's syndrome.
6. Infection: treatment of the genital tract infection.
7. Rh-isoimmunization: Repeated intrauterine transfusion
8. Parental balanced translocation
Explain the risk of fetal chromosomal disorders (30%)
Encourage to try again or adoption.

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