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Mujib Ur Rahman

Termination of pregnancy, either spontaneously or intentionally prior to 20 weeks gestation or less than 500-g birth weight The early abortion: occurs before 12w The late abortion: occurs after 12w Abortion occurring without medical or mechanical means to empty the uterus is referred to as spontaneous Another widely used term is miscarriage

Etiology
>80 percent occur in the first 12 weeks AOG At least half result from chromosomal anomalies After the first trimester, both the abortion rate & the incidence of chromosomal anomalies decrease

The risk of spontaneous abortion increases with parity as well as with maternal and paternal age

The frequency of abortion increases from 12 percent in women younger than 20 years to 26 percent in those older than 40 years

If a woman conceives within 3 months following a term birth incidence of abortion

Spontaneous abortion Pathology

Hemorrhage into the decidua basinalis, followed by necrosis of tissues adjacent to the bleeding If early, the ovum detaches, stimulating uterine contractions that result in its ovulation Gestational sac is opened , fluid surrounding a small macerated fetus or alternatively no fetus is visible blighted ovum

In later abortion, the retained fetus may undergo maceration


The skull bones collapse, the abdomen distends with bloodstained fluid, and the internal organs degenerate

The skin softens and peels off in utero or at the slightest tough

When amnionic fluid is absorbed, the fetus may become compressed and desiccated fetal compressus The fetus become so dry and compressed that it resembles parchment - a fetus papyraceous

Spontaneous abortion factors Fetal factors

Abnormal zygotic development


Early spontaneous abortion commonly display a developmental abnormality of the zygote, embryo, early fetus, or placenta

Spontaneous abortion - Fetal factors

Aneuploid abortion - Autosomal trisomy


The most frequently identified chromosomal anomaly associated with first-trimester abortions

Autosomes 13, 16, 18, 21, and 22 most common

Spontaneous abortion - Fetal factors

Monosomy X
The second frequent chromosomal abnormality Usually results in abortion

Triploidy
Associated with hydropic placental (molar) degeneration Incomplete (partial) hydatidiform moles may contain triploidy or trisomy for only chromosome 16

Spontaneous abortion Maternal factors

Infections
Uncommon causes of abortion in human
Listeria monocytogenes Clamydia trachomatis Mycoplasma hominis Ureaplasma urealyticum Toxoplasma gondii

Spontaneous abortion Maternal factors

Chronic debilitating diseases


Celiac sprue

Spontaneous abortion Maternal factors

Endocrine abnormalities
Hypothyroidism

Diabetes mellitus
Progesterone deficiency

Spontaneous abortion Maternal factors

Drug use and environmental factor


Tobacco
Risk for euploid abortion More than 14 cigarettes a day the risk twofold greater

Alcohol Caffeine

Immunological factors alloimmune factors


Allogeneity
Human fetus is allogenic transplant tolerated by mother

Spontaneous abortion Maternal factors

Uterine defects acquired uterine defects


Uterine leiomyoma : Uterine synechiae (Asherman syndrome)

Incompetent cervix
Painless dilatation of cervix in the 2nd or early in the 3rd trimester prolapse & ballooning of membranes into vagina rupture of membrane & expulsion of immature fetus

Spontaneous abortion Paternal factors

Little is known in the genesis of spontaneous abortion Chromosomal translocations in sperm can lead to abortion

Clinical classification /differential's


(1) Threatened abortion (2)Inevitable abortion (3)Incomplete abortion (4)complete abortion (5)Missed abortion (6)Habitual abortion (7)Septic abortion(infect abortion)

Threatened

Inevitable

Imcomplete

Complete

History Bleeding Abdominal pain Tissues are expelled Slight No/slight No

Middlesevera Aggravate No

Slightsevera Decrese Yes(partial)

Slightno No Complete

Gynecologic examination

Cervical os Uterine size

Close Consistent with

Open =/slight small

Open/tissue blochk <

Close =/slight larger

Pregnancy test Treatment principle

+ Protect fetus

+/Curettage

+/Curettage

+/no


INDUCED ABORTION

Induced abortion

The medical or surgical termination of pregnancy before the time of fetal viability Therapeutic abortion
Termination of pregnancy before of fetal viability for the purpose of saving the life of the mother

Induced abortion

Elective (voluntary) abortion


Interruption of pregnancy before viability at the request of the women, but not for reasons of impaired maternal health or fetal disease

Consequences of elective abortion

Septic abortion manifested by fever, malodorous vaginal discharge, pelvic and abdominal pain, and cervical motion tenderness.
Most often associated with criminal abortion Metritis is usual outcome, but parametritis, peritonitis, endocarditis, and septicemia may all occur

Surgical techniques for abortion

Dilatation and curettage


Performed first by dilating the cervix & evacuating the product of conception
Mechanically scraping out of the contents (sharp curettage) Vacuum aspiration (suction curettage) Both

Before 14 weeks, D&C or vacuum aspiration should be performed After 16 weeks, dilatation & evacuation (D&E) is performed
Wide cervical dilatation Mechanical destruction & evacuation of fetal parts

Resumption of ovulation after abortion

Ovulation may resume as early 2 weeks after an abortion Therefore, if pregnancy is to be prevented, effective contraception should be initiated soon after abortion