Abortions

Definition

Termination of a pregnancy before 20 weeks gestation calculated from date of onset of LMP OR

Delivery of fetus with a weight of <500g

Classification
Early

abortion <12W

Late

abortion 12-28W
abortion

Spontaneous

Artificial

abortion

Etiology
Genetic

factors

Maternal

factors

Infection, systemic factors, heart disease, severe anemia, endocrine Reproductive tract abnormality factors

Immunologic

Environmental

factors

Toxin, Radiation, smoking and alcohol

General Pathophysiology

Hemorrhage occurs in the decidua basalis leading to local necrosis and inflammation.

The ovum, partly or wholly detached, acts as a foreign body and irritates uterine contractions. The cervix begins to dilate.

Expulsion complete, The decidua is shed during the next few days in the lochial flow.

Threatened abortion

Uterine bleeding from gestation <20wks without any cervical dilation or effacement bleeding from placental site is not yet severe enough to terminate pregnancy Low abdominal tenderness accompany vaginal bleeding which is slight, but not retro-placental.

Inevitable abortion

Uterine bleeding from gestation of <20 wks accompanied by cervical dilation but without expulsion of any placental or fetal tissue.

Ovum already dead.

Tenderness & ROM

Cervical dilation

Complete abortion

Spontaneous expulsion of all fetal & placental tissue from the uterine cavity before 20wks gestation. Uterine contractions are felt, the cervix dilates and blood loss continues. The fetus and placenta are expelled complete, the uterus contracts and bleeding stops.

Incomplete abortion

Passage of some but not all fetal or placental tissue from the uterine cavity through the cervical canal before 20wks gestation.

In spite of uterine contractions and cervical dilatation, only the fetus and some membranes are expelled. The placenta remains partly attached and bleeding continues.

Missed abortion

Is the retention of a failed intrauterine pregnancy for a extended period, usually defined as more than two menstrual cycles OR

Fetal death before 20wks gestation without expulsion of any fetal or maternal tissue for at least 8wks thereafter.

Recurrent abortion

It is when a patient has had two or more consecutive spontaneous abortions before 20wks gestation

Septic abortion
Any abortion which becomes infected. Causes: -Delay in uterus evacuation, either px delays to seek advice or surgical evacuation is incomplete -Trauma Symptoms Slight bleeding with pyrexia, pelvic tenderness.

History
Age Obstetric history Gynecological history Sexual history Medications Medical history Surgical history Family history Social history

Physical Examination

Vital signs to rule out shock / febrile illness Assessment of hand palm and conjunctiva to rule out anemia. Abdominal examination Pelvic exam to look for sources of bleeding other than uterine and cervical changes to rule out inevitable abortion.

Lab Investigations
-HCG level FBC Blood group Antibody screen Coagulation profile to rule out DIC Ultrasound to assess fetal viability and

Maternal risk factors

Advanced maternal age Previous miscarriage esp. Recurrent Maternal illness-toxoplasma, CMV, listeria Uterine anomalies History of infertility Environmental & occupational stress IUCD presence at conception Chorion villus sampling / amniocentesis Cigarette & alcohol

Treatment
Based on specific clinical scenario. All hemodynamically unstable patients need to be stabilized. Complete abortion can be followed for recurrence of bleeding and signs of infection. If there is concern for retained product of conception, dilation & evacuation is done to ensure completion of abortion.

Heavy bleeding is managed by ergometrine 0.5mg IM.

OR suction curettage in OT followed by ergometrine 0.25mg IV.

Following a complete abortion, or one which has been completed surgically, bleeding usually ceases within 10 days.

Incomplete abortion

by surgery if vitals are stable.

Remove the embryo and placenta(Curettage) ASAP

Negative pressure suction

Missed abortion

Spontaneous expulsion is likely, risk of coagulation defect Notice blood clot function prevent DIC Surgical uterine evacuation is safe if uterus is < 12weeks size Mifepristone (200-600mg) followed by 36-48hrs later by 1g gemeprost vaginally.

Septic abortion

Resuscitation

Fluid crystalloids
IDC, CVP line

Antibiotics: Gentamicin, ampicillin, metronidazole

Curettage Monitor vitals

Follow up
Contraception should be discussed at discharge. Lifestyle advice smoking / alcohol The next pregnancy can be attempted once two periods have occurred. Folic acid intake of 5mg daily prior to and in the first trimester of their next conception