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DEFINITION: Abortion is the process of partial or complete separation of the products of conception from the uterine wall with or without partial or complete expulsion from the uterine cavity before the age of viability. - Annama Jacob

 Abortion may be defined as expulsion from

the uterus of an embryo or fetus prior to the stage of viability, which is 20 weeks gestation, or fetal weight less than 500 gms. -sudha salhan

INCIDENCE:
75%abortions occur before the 16th week and

of these , about 75%occur before the 8th week of pregnancy. 50% have no other children 44% had previous abortion 20% married 20% under 19 years old 6 times more common in unmarried women

Spontaneous 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. -D.C Dutta
Spontaneous abortion is defined as the involuntary loss of the products of conception prior to 28 weeks of gestation, when the fetus weights approximately 1,000 gm or less. -Annamma Jacob

ETIOLOGY: Genetic factors Endocrine and metabolic factors Anatomic factors Infection Immunological Others

Genetic factors:
Majority (50%) of the early miscarriages are due

to chromosomal abnormality in the conceptus. Autosomal trisomy is commonest (50%) cytogenetic abnormality. Polyploidy has been observed in about 22% of abortuses. Monosomy constitutes 20% of abortions.

Endocrine and metabolic factors(10-15%):

Leuteal phase defect (LPD) results in early miscarriage as

implantation and placentation not supported adequately. endometrial response to progesterone is the cause.

deficient progesterone secretion from corpus leuteum or poor

Thyroid abnormalities: overt hypothyroidism or

hyperthyroidism are associated with increased fetal loss. miscarriage.

Diabetes mellitus: when poorly controlled causes increased

Anatomical abnormalities(10-15%): Cervico- uterine factors: like cervical incompetence-either congenital or acquired, congenital malformation of the uterus in the form of bicornuate or separate uterus, uterine fibroid and intra uterine adhesions interfere with the implantation, placentation and fetal growth.

Infections(5%): Trans placental fetal infections occur due to: Viral-rubella, cytomegalo virus, variola vaccinia or HIV Parasitic- toxoplasma, malaria Bacterial-brucella, Chlamydia, ureplasma.

Immunological disorders(5-10%):
Auto immune disease: can cause usually in the second

trimester; these patients form antibodies against their own tissue and the placenta. These antibodies ultimately cause rejection of early pregnancy. the mother invoke a protective blocking antibody response. These blocking antibodies prevent maternal immune cells from recognizing the fetus as a foreign entity. Therefore a fetal allograft containing foreign paternal antigens are not rejected by the mother. Paternal leukocyte antigen (HLA) sharing with the mother leads to diminished fetal maternal immunologic interaction and ultimate fetal rejection (abortion).

Alloimmune disease: paternal antigens which are foreign to

Environmental causes: Cigarette smoking- increases risk due to formation of carboxy hemoglobin and decreased oxygen transfer to the fetus. Alcohol consumption Contraceptive agents- IUDs in situ increases the risk. Drugs- anesthetic gases, arsenic, formaldehyde. Exposure to X- ray radiation.

Unexplained: In spite of the numerous factors mentioned, it is indeed difficult, in the majority, to pinpoint the exact cause of abortion. Too often, more than one factor is present. However risk of abortion increases with increased maternal age. Number of previous abortions and the etiology are also important.

Others: Maternal medical illness: like cyanotic heart disease, haemoglobinopathies are associated with early abortion.
Blood group incompatibility:

Incompatible ABO group matching may be responsible for early pregnancy wastage and often recurrent but Rh incompatibility is a rare cause of death of the fetus before 28th week.
Couple with group A husband and group o wife have got higher

incidence of abortions.

Premature rupture of the membranes: inevitably leads to abortion. Paternal factors: sperm chromosome anomaly can cause abortion.

COMMON CAUSES OF ABORTION: First trimester: Genetic factors Endocrine disorders Immunological disorders Infection Unexplained Second trimester: Anatomical abnormalities Cervical incompetence Maternal medical illness Uterine fibroid Unexplained

Threatened abortion: Definition: It is clinically entity where the process of abortion has started, but has not progressed to a state from which recovery is possible.

Clinical features:
1.Bleeding per vaginam: the bleeding is usually

slight and bright red in color. On rare occasion bleeding may be brisk and sharp, specially in the late second trimester, suggestive of low implantation of placenta. The bleeding is usually stops spontaneously.
pain: bleeding usually painless but maybe mild

backache or dull pain in lower abdomen.

Investigations: Routine investigations include:. Ultrasonography: findings may be -A well formed gestation ring with central echoes from the embryo indicating healthy fetus.
-Observation of fetal cardiac motion A blighted ovum is evidenced by loss of definition of gestation sac, smaller mean gestational

diameter, absent fetal echoes and absent fetal cardiac movements.

 Treatment: Rest: the patient should be in bed for few days

until bleeding stops.

Drugs: sedation and relief of pain may be

ensured by phenobarbitone 30 mg or diazepam 5 mg tablet twice daily.

General measures: 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 contraindicated during this period.
She should be reexamined after one month.

 Prognosis:
In about two third, the pregnancy continues

beyond 28 weeks.
If the pregnancy continues, their is increased

frequency of preterm labor, placenta previa, intra uterine growth retardation of the fetus and fetal anomalies.

INEVITABLE ABORTION:
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

abortion, develops the following manifestation: Increased vaginal bleeding Aggravation of pain in the lower abdomen which may be colicky in nature.

 General condition of the patient is proportionate

to the visible blood loss Internal examination reveals dilated internal OS of the cervix through which the products of conception are left.

Management:
The principles in the management: To take appropriate measures to look after the

general condition To accelerate the process of expulsion To maintain strict asepsis as outline in conduction of labor.

General measures: Excessive bleeding should be promptly controlled by administering methargin 0.2mg 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 week: 1)dilatation and evacuation followed by curettage of the uterine cavity by blunt curette under general anesthesia. 2)alternatively, suction evacuation followed by curettage is done.

After 12 week: 1)the uterine contraction is accelerated by 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 to be done under general anesthesia evacuation of the uterus may have to be done by abdominal hysterectomy.

2) if bleeding is profuse with the cervix closed

Complete abortion:
Definition:

When the products of conception are expelled en mass, is called as complete abortion. The conceptus, placenta and membranes are expelled completely from the uterus.

Clinical features: there is history of expulsion of a fleshy mass per vaginam followed by: Subsidence of abdominal pain Vaginal bleeding becomes trace or absent Internal examination reveals: - uterus is smaller than the period of amenorrhea and a little firmer. -cervical OS is closed -bleeding is trace -examination of the expelled fleshy mass is found intact.

Management: The effect of loss, if any, should be assessed and treated.

If there is doubt about complete expulsion of

the product, uterine curettage should be done.

Trans vaginal sonography is useful to prevent

unnecessary surgical procedure.

 Rh- negative women:

a Rh- negative patient should be protected by anti-D gamma globulin50 micrograms or 100 microgram intramuscularly in cases of early abortion or late abortion respectively within 72 hours.

INCOMPLETE ABORTION: DEFINITION: When the entire products of conception not expelled, instead a part of it is left inside the uterine cavity, it is called abortion. This is the commonest type met amongst women, hospitalized for abortion complications. -D.C Dutta

CLINICAL FEAATURES: History of expulsion of a fleshy mass per vaginam followed by: Continuation of pain lower abdomen, colicky in nature. Persistent of vaginal bleeding Internal examination reveals - uterus smaller than the period of amenorrhea -Patulous cervical OS often admitting tip of finger and -varying amount of bleeding

 On examination the expelled mass is found

incomplete.
Termination: the products left behind may lead

to Profuse bleeding Sepsis Placental polyp rarely choreo -carcinoma

MANAGEMENT: Early abortion: dilation 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.

In late cases, dilatation and curettage operation is

to be done to remove the bits of tissues left behind. The removed materials are subjected to histological examination

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

CLINICAL FEATURES: The patient usually presents with features of threatened abortion followed by: Persistence of brownish vaginal discharge Subsidence of pregnancy symptoms Retrogression of breast changes Cessation of uterine growth which in fact becomes smaller than in size.

 Non audibility of the fetal heart sounds even

with Doppler cardio scope if it had been audible before 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 heart movement later in the pregnancy.

Management: Uterus is less than 12 weeks: vaginal evacuation can be carried out without delay.
Uterus more than 12 weeks: Induction is done

by the following methods; Oxytocin: to start with 10-20 units of oxytocin in 500 ml of normal saline at 30 drops per minute. If fails, escalating dose of oxytocin to maximum of 200 ml/ min, may be used with monitoring.

 Prostaglandins are more effective than

oxytocin in such cases. The methods are: a)prostaglandins E1 anlogue 200 gm tablet is inserted into the posterior vaginal fornix every 4 hours of a maximum of 5 such. b) intramuscular administrated of 15 methyl PGF2 250 gm at three hourly intervals for a maximum of 10 such.