abortion

Induced

abortion :is accomplished for

therapeutic or elective termination of pregnancy

Spontaneous

abortion

Spontaneous abortion

Definitions
* Spontaneous abortion is defined as a pregnancy terminating before the 20th completed week (139 days) of gestation or the weight is 500g or less . * Early abortion occurs before 12 weeks late abortion between 12 and 20 weeks.

Essentials of diagnosis
Suprapubic pain and uterine cramping Vaginal bleeding Cervical dilatation Extrusion of products of conception Disappearance of symptoms and signs of pregnancy Negative pregnancy test or quantitative HCG that is not properly increasing Adverse ultrasonic findings(eg,empty gestational sac,fetal disorganization,lack of fetal growth)

Incidence
In

the spectrum of reproductive wastage, spontaneous abortion is probably the largest single contributor,with an incidence of 15~20%.
75% of spontaneous abortions occur before 16 weeks and 62 % before 12 weeks.

Approximately

Etiology *1. chromosomal abnormalities

Malformation of the foetus is the commonest single cause of abortions. Nearly 60 percent of early abortions are due to gross malformations of the embryo and feotus. Autosomal trisomy-constitutes half of the chromosomal abnormalities.

Other common abnormalities are: Aneuploidy,triploidy,tetraploidy Monosomy Turner syndrome

such as gross abnormalities lead to nondevelopment the foetus ,aembroynic pregnancy or blighted ovum.

Maternal factor
1.Maternal infection 2.Endocrine disorder:hyperthyroidism,diabetes luteal defect and inadequate progesterone production. 3.Anotomic defects Uterine defects:gross malformation may interfere with the accommodation of the products of conception and cause abortion.

congenital abnormalities that distort or reduce the size of the uterine cavity: unicornuate,bicornuate ,or septate uterus, double uterus.

acquired anomalies:myomas,previous scarring of the uterus,anatomic and functional incompetence of the uterine cervix. 4.Immunologic disorder:Blood group incompatibility due to ABO,Rh 5.Mulnutrition,Emotional disturbance,toxic factor,trauma

Pathology
In spontaneous early abortion,hemorrhage into the decidua basalis often occurs. Necrosis and inflammation appear in the region of implantation. The pregnancy become partially or entirely detached and is, in effect, a foreign body in the uterus.

 Uterine

contractions and dilatation of the cervix result in expulsion of most or all of the products of conception.

Clinical classification
Common types:
Threatened abortion Inevitable abortion Incomplete abortion Complete abortion

 Special

types: Missed abortion Septic abortion Habitual abortion

A. Threatened abortion
Is

bleeding of intrauterine origin occuring before the 20th compeleted week, with or without uterine contraction, without dilatation of the cervix,and without expulsion of the product of conception.The cervix remains closed, although slight bleeding or cramping may be noted.

 Ultrasonography

is helpful in the management of threatened abortion by detecting fetal movement of heart beat.This prognostic sign is most reliable after 7 weeks gestation.

Treatment
Place

the patient at bed rest, interdict intercourse, and observe the patients progress. Drug therapy is generally ineffective in preventing abortion because so many of these uncertain pregnancies are abnormal. Progesterone use is controversial

 The

prognosis in the case of threatened abortion is good when all abnormal signs and symptoms disappear and when resumption of the progress of pregnancy is apparent. D&C may b e necessary if significant bleeding persists or if product of conception are retained.

B.Inevitable abortion
The

process of abortion has become irreversible Is bleeding of intrauterine origin before the 20th completed week,with dilatation of the cervix,and without expulsion of the products of conception. Pain ( uterine cramping ) and bleeding with an open cervix indicate impending abortion; the expulsion of the uterine contents is imminent.

Treatment

Evacuation of the uterus by suction D&C should be promptly performed. The prognosis for the mother is excellent if retained tissue is promptly and completely evacuated.

C.Incomplete abortion
IN

incomplete abortion the products of conception have partially passed from the uterine cavity.Retained tissue is evidenced by continued bleeding, a patulous cervix, and an enlarged, boggy uterus. Bleeding generally is persistent and is often severe enough to constitute frank hemorrhage.

Treatment
D&C should be performed for possible retained tissue. Evacuate the uterus promptly.Suction D&C is most effective. Tissue at the external os should be removed with sponge forceps and examined by a pathologist. If abortion is complicated or has occurred after the first trimester, the patient may require hospitalization.

 Type

and cross-match for possible blood transfusion if bleeding is brisk or if the initial hemoglobin is less than 100g/L. The oxytocin( contracts the uterus, aids in the expulsion of tissue or clots, and limits blood loss.

 The

prognosis for the mother is good if the retained tissue is promptly and completely evacuated. anemia

D.Complete abortion
Is

identified by passage of the entire conceptus. Marked by cessation of pain as well as termination of brisk bleeding.
The

conceptus be very carefully examined for completeness and for trophoblastic disease. prognosis for mother is excellent.

The

The process of the abortion

continue
Threatened abortion Inevitable

Complete

Incomplete

E.Missed abortion
Missed

abortion implies that the foetus dies inside the uterine cavity and the uterus fails to expel it. Manifestion: 1. loss of symptoms of pregnancy 2. repeated vaginal bleeding or brownish vaginal dischargea

3.decrease in uterine size. 4.State of cervix:not dilated .The cervix remains firm and closed,and no adnexal abnormality can be identified.

 Ultrasonograph

is effective for following a pregnancy suspected of being a missed abortion. An embryo or fetus without heart motion Abnormal gestational sac

The

quantitative B_HCG may decline, and urine pregnancy Tests may become negative .

Treatment The uterus being evacuated soon after diagnosis In the first trimester this is usually accomplished by suction curetage In the second trimester evacuation is most frequently accomplished using prostaglandin E suppositories.

Complications
If

evidence of a seriously reduced fibrinogen level,,infection,or anemia exist ,appropirate threapy must be also instituted. Hypofibrinogenemia This complication occurs because of the release of thromboplastins from the dead products of conception (if it retained more than four weeks).

 This

tromboplastins utilize the available fibrinogen ,resulting in a defect in the coagulability of the blood ,which may cause severe bleeding during or after expulsion of products of conception. Treatment: blood infusion, plasma infusion ,fibrinogen,heparin.

G.Septic abortion
by a malodorous ( discharge from the vagina and cervix, pelvic and abdominal pain,marked suprapubic tenderness,signs of peritonitis,tenderness with movement of the uterus or cervix. Fever :37.8-41
Manifested

 The

extent of the infection is usually confirmed by an Elevated white blood count and other systemic signs Of infection. Blood cultures Endometrial biopsy

treatment
Hospitilization Intravenous antibiotic therapy coverage for anaerobic and aerobic bacteria. Individualize antibiotic therapy if a specific organism is suspected or if the patients has a known antibiotic sensitivity.

D$C should be performed to make certain all of the products of conception have been removed. If the patient is bleeding heavily ,the evacuation should be carried out soon after initiation of antibiotic therapy. if the patient is not bleeding ,the Evacuation may be delayed until the sepsis is brought under control with antibiotics.

 Hysterectomy

may have to be performed if the infection does not respond to treatment.

F.Habitual abortion
Defined

as 3 consecutive spontaneous pregnancy losses before 20weeks. Incidence:when there is no previous history is 15% this increases to 25-50% when there are have been 3 or more miscarriages.

Etiology
:Genetic

error:there is a 50-60% incidence of abnormal karyotype in first-trimester spontaneous abortion . anatomic abnormalities is the first reason of habitual abortion,congenital abnormalities ,cervical incompetence, submucous leiomyomas)

 Hormonal

causes: Inadequate hormonal support cause to the abortion. hypothyroidisim, hyperthyroidisim, progesterone insufficiency,uncontrolled diabetes mellitus.progesterone deficiency or luteal phase defect is an important reason of habitual abortion.

Diagonosis and treatment

Genetic

error:Obtain a 3-generation pedigree and karyotype of both parents and any previously aborted material.
abnormalities:diagnosis of anatomic abnormalities is usually accomplished by hysterosalpingography or hysteroscopy .

anatomic

Treatment
If the causative factor is detected the patient should be treated accordingly. Uterine operation:reconstruction of the uterus,myomectomy cervical incompetence: cervical cerclage. cervical cerclage is recommended between 12-14 weeks of gestation.success rate with cerclage are 85-90%.

Horminal factor:Use progesterone,control diabetes Infection:should choose low toxic antibiotics.

differential diagnosis
Ectopic

pregnancy: amenorrhea,menstrual abnormality,unilateral pelvic pain,uterine bleeding ,and a tender adnexal mass. Hydatidiform mole:the uterus may be unusually large.if theca lutein cysts present cause bilateral ovarian enlargement,bloody discharge may contain hydropic villi.

Complications
Severe

or persistent hemorrhage during or following abortion may be life threatening. Sepsis develops most frequently after criminal or self-induced abortion. there are sequelae of infection, eg, salpingitis, infertility Hypofibrinogenemia

 Perforation

of the uterus occur during D and C Injury to the bowel ,bladder,