Abortion -Type and it's Management

INTRODUCTION:
• The causes of bleeding in early pregnancy
are broadly divided into two groups:
Those related to the pregnant state
Those associated with the pregnant state

CONT….
• Those related to the pregnant state: this
group relates to abortion(95%), ectopic
pregnancy, hydatidiform mole and
implantation bleeding.
• Those related with the pregnant state: the
lesions are unrelated to pregnancy-either
pre-existing or aggravated during
pregnancy. cervical lesions such as vascular
erosion, polyp, ruptured varicose veins and
malignancy are important causes.

ABORTION:
• DEFINITION: Abortion is the
expulsion or extraction from its mother
of an embryo or fetus weighing 500 gms
or less when it is not capable of
independent survival (WHO). This 500
gm of fetal develop is attained
approximately at 20 to 22 weeks (154
days) of gestation.

ETIOLOGY:
• The etiology of miscarriage is often
complex and obscure. The following factors
(embryonic or parker important:
• Genetic
• Endocrine and metabolic
• Anatomic
• Infection

CONT….
• Genetic: Chromosomal abnormalities:
majority of at least 50% of early abortions
are due to chromosomal abnormality e.g.
trisomy, monosomy X (XO) and triploidy.

CONT…
• Endocrine causes:
• Luteal phase defect (LPD) results in early
miscarriage. Implantation and placentation
are not supported adequately.
• Deficient Progesterone secretion from
corpus luteum or poor endometrial response
to progesterone is cause abortion between
8-12 weeks.
• Diabetes mellitus
• Hyperthyroidism

CONT…
• Anatomical abnormalities: These are related
mostly to second trimester abortions.
• Cervico uterine factors: cervical
incompetence.
• Congenital uterus malformation in the form
of bicornuate or separate uterus.
• Intrauterine adhesions

CONT….
• Infections:
• Viral: rubella,cytomegalo, variola or HIV.
• Parasitic: toxoplasma, malaria.
• Bacteria: Chlamydia,
• brucella. Spirochaetes causes abortion
before 20th week because of effective
thickness of placental barrier.

• Immunological causes:
• Systemic lupus erythematosus.

• Maternal infections:
• Cyanotic heart disease, cytomegalovirus
and toxoplasmagondii which causes
abortion if there is acute infection early in
pregnancy. Acute fever for whatever the
cause can induce abortion.

• Blood group incompatibility: couple with group ‘A’ husband and
group ‘O’ wife have higher incidences of abortion.
• Premature rupture of membranes
• Parental factor: sperm chromosomal anomaly(translocation)
• Drugs: e.g. quinine, ergots, severe purgatives,
• Environmental causes: cigarette smoking,tobacco, alcohol, arsenic,
lead, formaldehyde, benzene and radiation.
• Trauma: external to the abdomen or during abdominal or pelvic
operations.
• Maternal anoxia and malnutrition.
• Overdistension of the uterus: e.g. acute hydramnios.
• Ageing sperm or ovum
• Nervous, psychological conditions and over fatigue.

Mechanism of Abortion:
• Up to 8 weeks: the ovum surrounded by the
villi with the decidual coverings is expelled
out intact. .
• Sometimes, the external os fails to dilate so
that the entire mass is accommodated in the
dilated cervical canal and is called cervical
abortion.
• The gestational sac tends to be expelled
complete and the decidua is shed thereafter.

• From 8-14 weeks: The decidua capsularis
ruptures and the Embryo is expelled either
entire or after rupture of the amnion.

Cont…
• After 14 weeks: The placenta is completely
formed and the process of abortion is like a
miniature labour.
• It is more common for the foetus to be
expelled but for the placenta to be retained
due to firmer attachment to the uterine
wall.

DEFINITION:
• It is a clinical
entity where the
process of
miscarriage has
started but has not
progress to a state
from which
recovery is
impossible.

CLINICAL FEATURES
• (1) Bleeding per vaginam is usually slight
and may be brownish or bright red in color.
On rare the bleeding may be brisk,
especially in the late second trimester. The
bleeding usually stops spontaneously.

• Pain: Bleeding is usually painless but there
may be mild backache or dull pain in lower
abdomen. Pain appears usually following
hemorrhage.

• Symptoms and signs of pregnancy coincide
with
• 1. its duration.
• 2.Vaginal bleeding slight or mild, bright red
in colour originating from the
choriodecidual interface.
• 3.Pain is absent or slight.
• 4. Cervix is closed.
• 5. Pregnancy test is positive.
• 6. Ultrasonography shows a living foetus.

INVESTIGATIONS:
• Blood - for hemoglobin, haematocrit,
ABO and Rh grouping. Blood transfusion
may be required if abortion becomes
inevitable and anti-D gamma globulin has
to be given in Rh negative non-
immunized women.

Cont…
• Urine for
immunological test of
pregnancy is not helpful
as the test remains
positive for a variable
period even after the
fetal death.

Cont…
• Blighted ovum: there is absence of fetal
pole in a gestational sac with diameter of 3
cm or more. Uterus is to be evacuated once
the diagnosis made
• Ultrasonography: a blighted ovum is
evidenced by loss of the gestation sac,
smaller mean gestational sac diameter,
absent fetal echoes and absent fetal cardiac
movements.

TREATMENT:
• Rest: the patient should
be in bed until one week
after stoppage of bleeding.
• Drugs: Relief of pain may
be ensured by diazepam 5
mg tablet or
phenobarbitone 30
mg.twice daily.

• Treatment of controversy: Progestogens: e.g.
hydroxyprogesteronecaproate (Primulot depot) 250
mg IM twice weekly is given by some if there is
evidence of progesterone deficiency. However, low
plasmaprogesterone level is an indication of
pregnancy failure. Progestogens may cause retention
of the dead ovum leads to missed
abortion.Gonadotrophins may be of benefit in cases
of luteal phase deficiency and those get pregnant
with ovulatory drugs.

MANAGEMENT:
• The patient is advised to preserve
the vulval pads and anything
expelled out per vaginam, for
inspection.
• To report if bleeding and/or pain
becomes aggravated.
• Routine note of pulse, temperature
and vaginal bleeding.

ADVICE ON DISCHARGE:
• The patient should limit her activities for at
least two weeks and avoid heavy work.
• Coitus is contraindication during this
period, as it may disturb pregnancy by the
mechanical effect and the effect of semen
prostaglandins on the uterus.
• She should be re-examine after one month
to assess the growth of fetus.

PROGNOSIS:
• PROGNOSIS:
• The prognosis is very unpredictable whatever
method of treatment is employed either in the
hospital or at home. In isolated spontaneous abortion
the following events may occur. In about 2/3 the
pregnancy continues beyond 28 weeks. In the rest it
terminates either in inevitable or missed abortion. If
pregnancy continues, there is increased frequency of
preterm labor, placenta previa, intra uterine growth
retardation of the fetus and fetal anomalies.

DEFINITION:
• It is the clinical type
of abortion where the
changes have
progressed to a state
from where
continuation of
pregnancy is
impossible.

CLINICAL FEATURES:
• The patient, having the features of threatened miscarriage,
develops the following manifestations.
• Increased vaginal bleeding and may accomplanied with
clots.
• Aggravation of pain in the lower abdomen which may
colicky in nature in the suprapubic region radiating to the
back.
• Internal examination reveals internal os of the cervix is
dilated and products of conception may be felt through it.
• Rupture of membranes between 12-28 weeks is a sign of the
inevitability of abortion.

MANAGEMENT:
• The principles in the management
are:(a) to look after general
condition.(b)to accelerate the process
of expulsion (c) to maintain strict
asepsis

General measures:
• Excessive bleeding should be promptly
controlled by administering methergin 0.2
mg if the cervix is dilated and the size of the
uterus is less than 12 weeks.
• The shock is corrected by intravenous fluid
therapy and blood transfusion

Active Treatment:
Before 12 weeks:
• (1) Dilatation and evacuation followed by
curettage of the uterine cavity by blunt
curette under general anesthesia (2)
Alternatively, suction evacuation followed
by curettage done.

Cont…
• After 12 weeks: (1) The uterine contraction
is accelerated by oxytocin drip (10 units in
500 ml of normal saline) 40-60 drops per
minute. If the fetus is expelled and the
placenta is retained, it is removed by
OVUM forceps, if lying separated.
• If the placenta is not separated, digital
separation followed by its evacuation is
done under G.A.

DEFINITION:
When the products of
conception are expelled
as an masses, it is called
complete miscarriage.

CLINICAL FEATURES:
• There is history of expulsion of a fleshy
mass per vagina followed
(1) Subsidence of abdominal pain.
(2) Vaginal bleeding becomes trace or absent
(3) Internal examinations reveals: (a) Uterus is
smaller than the period of amenorrhea and a
little firmer (b) Cervical os is close (c)
Bleeding is trace.
(4) Examination of the expelled fleshy mass is
found complete.

• The retained products may cause: (a)
profuse bleeding (b) sepsis or (c) placental
polyp. (d) Rarely choriocarcinoma.

MANAGEMENT:
• The effect of blood loss, if any, should be
assessed and treated. If there is doubt about
complete expulsion of product, uterine
curettage should be done.
• Transvaginal sonography is useful to see
that uterine cavity is empty; other
evacuation of uterine curettage should be
done.

Cont….
• A Rh-negative patient without antibody in
her system should be protected Anti-D
gamma globulin-50 microgram or 100
microgram intramuscularly in cases of early
miscarriage or, miscarriage respectively
within 72 hours.
• However, Anti-D may not be required in a
case with complete miscarriage before 12
weeks gestation where no instrumentation
has been done.

DEFINITION:
• When there is entire
products of conception
are not expelled,
instead a part of it is
left inside the uterine
cavity, it is called
incomplete abortion.

CLINICAL FEATURES:
• History of expulsion of a fleshy mass per
vagina followed by :
1. Continuation of pain in lower abdomen,
colicky in nature, although in diminished
magnitude.
2. Persistent vaginal bleeding

3. Examination reveal: uterus
smaller than the period of
amenorrhoea, patulous
cervical os. Often admitting
one finger, expelled mass is
found incomplete.
• She should be resuscitated
before any active treatment
is undertaken.

MANAGEMENT:
• In recent cases – the same principles to be
followed like that of the inevitable. it is
emphasized, patient may be in a state of
shock due to blood loss.
• Early abortion: dilatation and evacuation
under general anesthesia is to be done.
• Late abortion: the uterus is evacuated under
general anesthesia and the products are
removed by ovum forceps or by blunt
curette.

DEFINITION:
• When the fetus is dead and
retained inside the uterus
for a variable period, it is
called missed abortion or
silent miscarriage or early
fetal demise.

CLINICAL FEATURES:
 Persistence of brownish vaginal discharge.
 Subsidence of pregnancy symptoms.
 Retrogression of breast changes.
 Cessation of uterine growth which in fact
becomes smaller in size.
 Non audibility of the fetal heart sound
even with Doppler ultrasound if it had
been audible before.

Cont…
• Cervix feels firm.
• Immunological test for pregnancy becomes
negative.
• Real time Ultrasonography reveals an
empty sac early in the pregnancy or the
absence of fetal motion or fetal cardiac
movements.

COMP LICATIONS:
• The complications of the missed
miscarriage are those mentioned in
intrauterine fetal death.
• Disseminated intravascular coagulation
(DIC) may occur if the dead conceptus is
retained for more than 4 weeks.

INVESTIGATION:
• Pregnancy test becomes negative within two
weeks from the ovum death, but it may
remain positive for a longer period due to
persistent living chorionic villi.
• Ultrasound shows either a collapsed
gestational sac, absent foetal heart
movement or foetal movement.

MANAGEMENT:
• If the uterus size is less than 12 weeks:
Vaginal evacuation can be carried out
without delay. This can be done effectively
done by suction evacuation or slow
dilatation of cervix by laminar tent followed
by D&E of the uterus under general
anesthesia.
• The risk of damage to the uterine walls and
brisk h’age during the operation should be
kept in mind.

Cont…
Induction is done by following methods:
• Oxytocin: to start with 10-20 units of
oxytocin in 500 ml of normal saline at 30
drops/minute.
• Prostaglandins: are more effective than
oxytocin in such cases. The methods used
are :

• Prostaglandin E1 analogue( misoprostol)
200 µg tablet is inserted into the posterior
vaginal fornix every 4.

DEFINITION:
• Any abortion associated
with clinical evidences
of infection of the uterus
and its contents, is called
septic abortion.

Cont….
• Although clinical criteria vary, abortion is
usually considered septic when the:
(l) rise of temperature of at least 100.4°F
(38°C) for 24 hours or more
(2) offensive or purulent vaginal discharge
(3) other evidences of pelvic infection such as
lower abdominal pain and tenderness.

CLINICAL FEATURES:
• Pyrexia is an important clinical
manifestation.
• Pain abdomen of varying degrees is almost
a constant feature.
• A rising pulse rate of 100-120/minute or
more is a significant finding than even
pyrexia. It indicates spread of infection
beyond the uterus.

CLINICAL GRADING:
Grade-I: The infection is localized in the
uterus.
Grade-II: The infection spreads beyond the
uterus to the perimetrium, tubes and ovaries
or pelvic peritoneum.

• Grade-III: Generalized peritonitis and/ or
end toxic shock or jaundice or acute renal
failure.

INVESTIGATION:
• Routine investigation include: cervical or
high vaginal swab is taken prior to internal
examination from culture.
• Sensitivity of micro organisms to
antibiotics
• Smear to gram stain.

Cont…
• Hemoglobin test
• Urine analysis.
• Ultrasonography pelvis and abdomen to
detect intrauterine retained products of
conception

COMPLICATION:
Immediate:
• Hemorrhage related to abortion process.
• Injury may occur to the uterus and also to
the adjacent structures particularly to gut.
• Generalized peritonitis.
• Endotoxic shock
• Acute renal failure
• Thrombophlebitis

Remote:
• Chronic pelvic pain and backache
• Dyspareunia
• Ectopic pregnancy
• Secondary infertility due to tubal blockage
• depression
• Chronic debility

MANAGEMENT:
• Isolate the patient .
• Bed rest .
• An intravenous line is established for
therapy.
• In case of shock a central venous pressure
(CVP) line to aid in the control of fluid and
blood transfusion is added.

• Observation for vital signs: pulse,
temperature and blood pressure as
well as fluid intake and urinary
output.
• A cervico-vaginal swab is taken for
culture (aerobic and anaerobic) and
sensitivity,
• Antibiotic therapy: Ampicillin or
cephalosporin (as a broad spectrum)

Cont…
• Gentamycin (for gram -ve organisms) +
metronidazole (for anaerobic infection)are
given by intravenous route while awaiting
the results of the bacteriological culture.
• Another regimen to cover the different
causative organism is clindamycin +
gentamycin

• Fluid therapy: e.g. glucose
5% normal saline and/or
lactated ringer solutions can
be given as long as there is no
manifestations of acute renal
failure particularly the urinary
output is more than 30
ml/hour.
• Blood transfusion: is given if
CVP is low

• Oxytocin infusion: to control bleeding and
enhances expulsion of the retained products.
• Surgical evacuation of the uterus can be
done after 6 hours of commencing IV
therapy but may be earlier in case of severe
bleeding or deteriorating condition in spite
of the previous therapy.

Cont…
• Surgical evacuation of the uterus can be
done after 6 hours of commencing IV
therapy but may be earlier in case of severe
bleeding or deteriorating condition in spite
of the previous therapy.
• Hysterectomy may be needed in endotoxic
shock not responding to treatment
particularly due to gas gangrene

DEFINITION:
• It is define as a sequence of Three (two by
some authors) or more consecutive
spontaneous abortions before 20 weeks.

ETIOLOGY:
Chromosomal abnormalities:
• Can be detected in Foetus: e.g. autosomal
trisomy, sex chromosome monosomy (X).

Cont…
• Uterine abnormalities: Congenital
anomalies: e.g. bicornuate, septate uterus.
• Intrauterine adhesions (Asherman’s
syndrome).
• Cervical incompetence: whether congenital
or acquired.
• Uterine myomas.

Cont…
• Deficiency of endometrial oestradiol and
progesterone receptors: leads to failure of
implantation or early abortion.
• Divided uterine artery: uterus with two
ascending uterine arteries may fail to
provide adequate blood flow to the
developing placenta and the growing foetus.

MANAGEMENT:
Treatment of the cause as:
• Anemia and malnutrition,
• Diabetes,
• Renal diseases.
• Infections as Chlamydia and mycoplasma
(tetracycline or doxycycline) and
toxoplasma (spiramycin) which may need
another coarse(s) of treatment during
pregnancy.

Abortion -Type and it's Management

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