Overview

Abortion
Early pregnancy loss, or
miscarriage, is the loss
of a pregnancy before
20 weeks.
In the first trimester,
embryonic causes of
spontaneous abortion
are the predominant
etiology and account for
80-90% of miscarriages
 Spontaneous abortion/miscarriage
: A pregnancy that ends spontaneously before
the fetus has reached a viable gestational
age. The World Health Organization defines it
as expulsion or extraction of an embryo or fetus
weighing < 500 g (typi-cally corresponds to a
gestational age of <22 weeks).
Threatened abortion
: Bleeding through a closed cervical os during the
first half of pregnancy. The bleeding is often
painless, although it may be accompanied by mild
suprapubic pain. On examination, the uterine size
is appropriate for gesta-tional age, and the cervix
is long and closed. Fetal cardiac activity can be
detectable if the gestation is sufficiently
advanced.
Inevitable abortion
: When abortion is pending, there may be
increased bleeding, intensely painful uterine
cramps, and a dilated cervix. The gestational
tissue can often be felt or visualized through the
internal cervical os.
 Incomplete abortion
: When the fetus is passed, but significant amounts of pla-cental tissue may be retained,
also called an abortion with retained products of conception (RPOC) (commonly
occurs after 12 weeks gestation). On examination, the cervical os is open, gestational
tissue may be observed in the vagina/cervix, and the uterus is smaller than expected for
gestational age but not well contracted. The amount of bleeding varies but can be
severe enough to cause hypovolemic shock. Painful cramps are often present.
Complete abortion
: When an abortion occurs (usually before 12 weeks of gestation) and the entire
contents of the uterus are expelled. More than one-third of all cases are complete
abortions. If a complete abortion has occurred, the uterus is small and well contracted
with a closed cervix; slight vaginal bleeding and mild cramping can be present.
Missed abortion
: Refers to in utero death of the embryo or fetus prior to the 20th week of gestation,
with prolonged retention of the pregnancy (48 weeks). Vaginal bleeding may occur,
and the cervix is usually closed.
 Septic abortion
: An abortion accompanied by fever, chills, malaise,
abdominal pain, vaginal bleeding, and frequently purulent
discharge. Physical examination may reveal tachycardia,
tachypnea, lower abdominal tenderness, and a tender
uterus with dilated cervix. Infection is usually due to
Staphylococcus aureus
, Gram-negative bacilli, or some Gram-positive cocci.
Mixed infections (anaerobic organisms and fungi) can
also be encountered. The infection may spread, leading to
salpingitis, generalized peritonitis, and septicemia.
 In the case of a complete
abortion, pelvic examination may
show some blood on the
perineum or vagina but there is
limited active bleeding. Note the
following:
Cervical motion tenderness does
not exist.
The cervical canal is closed.
The uterus is smaller than
expected for dates, and it is
nontender to mildly tender.
The adnexa are nontender to
mildly tender. Usually, no adnexal
masses exist, unless a corpus
luteum is still palpable.
 Management
Complete abortions
do not require therapy, it is difficult to reliably distinguish
them clinically or sonographically from incomplete
abortions. Although, it is clear that surgery is necessary
for women with excessive bleeding, unstable vital signs,
or obvious signs of infection [41], some clinicians
recommend suction curettage for all patients with
complete abortions. However, if shows an empty uterus
and the bleeding is minimal, it is reasonable to take no
further actions. Serum b-hCG levels should be measured
and followed until they are undetected.
 Management for
Inevitable and Incomplete Abortion, Missed Abortion, Embryonic/Fetal
Demise (Dead Fetus)

Surgical Management
The conventional treatment of first or early second trimester
pregnancy loss is dilatation and curettage (D&C) or dilatation and
evacuation (D&E) to prevent potential hemorrhagic and infectious
complications from the RPOC. The benefits of surgical management
include convenient timing for the patient and high success rates,
ranging from 93 to 100%, with most studies reporting success rates
at or above 98% [19].
Surgical management is appropriate for women with heavy bleeding
or sepsis in whom delaying therapy could be harmful as well as for
women who do not want to wait for spontaneous or medically
induced evacuation of the uterus. Suction curettage is preferable to
sharp curettage, which is associated with greater morbidity [44, 45].
 Medical Treatment
The availability of effective medical therapies for
inducing abortion has created new options for
women who want to avoid surgery or when surgical
intervention needs to be avoided. With medical
management, medications are used to induce
expulsion of the products of conception from the
uterus. Regimens have typically included a
prostaglandin analog (most commonly misoprostol)
or a combination of mifepris-tone or methotrexate
with misoprostol [19].
 Post abortion care
After surgical evacuation or if medical management or
expectant management is planned, women who are
Rh(D)-negative and unsensitized should receive Rh(D)-
immune globulin. A dose of 50 mg is effective through the
12th week of gestation due to the small volume of red
blood cells in the fetoplacental circulation, although the
more readily available 300 mg dose is normally
given.Women are advised to refrain from coitus and the
use of tampons for at least 2 weeks after evacuation of the
uterus
 Plasenta Previa
Placenta previa is an obstetric complication that
classically presents as painless vaginal bleeding in
the third trimester secondary to an abnormal
placentation near or covering the internal cervical
os.
there have been three defined types of placenta
previa: complete, partial, and marginal. More
recently, these definitions have been consolidated
into two definitions: complete and marginal previa.
 A complete previa is defined
as complete coverage of the
cervical os by the placenta.
If the leading edge of the
placenta is less than 2 cm
from the internal os, but
not fully covering, it is
considered a marginal
previa (see the following
image).
 Can we diagnose placenta praevia clinically?
Clinical suspicion should be raised in all women
with vaginal bleeding after 20 weeks of
gestation. A high presenting part, an abnormal
lie and painless or provoked bleeding,
irrespective of previous imaging results, are
more suggestive of a low-lying placenta but
may not be present, and the definitive
diagnosis usually relies on ultrasound imaging
How should we image for placental
localisation?
Transvaginal scans improve the
accuracy of placental localisation
and are safe, so the suspected
diagnosis of placenta praevia at
20 weeks of gestation by
abdominal scan should be
confirmed by transvaginal scan.
In the second trimester transvaginal
sonography (TVS) will reclassify 26
60% of cases where the
abdominal scan diagnosed a low-
lying placenta[46,47] meaning fewer
women will need follow-up. In the
third trimester, TVS changed the
transabdominal scan diagnosis of
placenta praevia in 12.5% of 32 women.
Pathophysiology of Plasenta Previa
Placental implantation is initiated by the embryo (embryonic plate)
adhering in the lower (caudad) uterus. With placental attachment
and growth, the developing placenta may cover the cervical os.
However, it is thought that a defective decidual vascularization
occurs over the cervix, possibly secondary to inflammatory or
atrophic changes.
A leading cause of third-trimester hemorrhage, placenta previa
presents classically as painless bleeding. Bleeding is thought to
occur in association with the development of the lower uterine
segment in the third trimester. Placental attachment is disrupted as
this area gradually thins in preparation for the onset of labor; this
leads to bleeding at the implantation site, because the uterus is
unable to contract adequately and stop the flow of blood from the
open vessels.
 Complication
Maternal complications of placenta previa are
summarized as follows:
Hemorrhage, [11] including rebleeding
(Planning delivery and control of hemorrhage
is critical in cases of placenta previa as well
as placenta accreta, increta, and percreta.)
Higher rates of blood transfusion [11, 12]
Placental abruption
Preterm delivery
Increased incidence of postpartum
endometritis [12]
Mortality rate (2-3%); in the US, the maternal
mortality rate is 0.03%, the great majority of
which is related to uterine bleeding and the
complication of disseminated intravascular
coagulopathy
Complications of placenta previa in the
neonate/infant are summarized as follows:
Congenital malformations
Fetal intrauterine growth retardation (IUGR)
Fetal anemia and Rh isoimmunization
Abnormal fetal presentation
Low birth weight (< 2500 g) [12]
Neonatal respiratory distress syndrome [12]
Jaundice [12]
Admission to the neonatal intensive care unit
(NICU) [12]
Longer hospital stay [12]
Increased risk for infant neurodevelopmental
delay and sudden infant death syndrome
(SIDS) [13]
Neonatal mortality rate
 Post partum Hemorrhage
Postpartum hemorrhage
(PPH) is the leading cause of
maternal mortality. All
women who carry a
pregnancy beyond 20
weeks gestation are at risk
for PPH and its sequelae.
Although maternal
mortality rates have
declined greatly in the
developed world, PPH
remains a leading cause of
maternal mortality
elsewhere.
 The definition of PPH is
somewhat arbitrary and
problematic. PPH is Blood Volume Loss
Blood Pressure
(systolic)
Symptoms and
Signs
Degree of Shock

defined as blood loss of Palpitations,

more than 500 mL 500-1000 mL (10-

15%)
Normal tachycardia,
dizziness
Compensated

following vaginal
delivery or more than 1000-1500 mL (15-
25%)
Slight fall (80-100
mm Hg)
Weakness,
tachycardia,
sweating
Mild

1000 mL following
cesarean delivery. [5, 6] A 1500-2000 mL (25-
35%)
Moderate fall (70-80 Restlessness,
mm Hg) pallor, oliguria
Moderate

loss of these amounts 2000-3000 mL (35-

50%)
Marked fall (50-70
mm Hg)
Collapse, air
hunger, anuria
Severe

within 24 hours .
 Prevention
High-quality evidence suggests
that active management of the
third stage of labor reduces
the incidence and severity of
PPH. [9] Active management is
the combination of (1)
uterotonic administration
(preferably oxytocin)
immediately upon delivery of
the baby, (2) early cord
clamping and cutting, and (3)
gentle cord traction with
uterine countertraction when
the uterus is well contracted
(ie, Brandt-Andrews
maneuver).
 Preeclamsia
Preeclampsia is defined as in addition to the blood
the presence of (1) a pressure criteria,
systolic blood pressure proteinuria of greater than
(SBP) greater than or equal or equal to 0.3 grams in a
to 140 mm Hg or a diastolic 24-hour urine specimen, a
blood pressure (DBP) protein (mg/dL)/creatinine
greater than or equal to 90 (mg/dL) ratio of 0.3 or
mm Hg or higher, on two higher, or a urine dipstick
occasions at least 4 hours protein of 1+
apart in a previously
normotensive patient,
OR (2) an SBP greater than
or equal to 160 mm Hg or a
DBP greater than or equal
to 110 mm Hg or higher
 In a patient with new-onset
hypertension without proteinuria,
the new onset of any of the
following is diagnostic of
preeclampsia:
Platelet count below 100,000/L
Serum creatinine level above 1.1
mg/dL or doubling of serum
creatinine in the absence of other
renal disease
Liver transaminase levels at least
twice the normal concentrations
Pulmonary edema
Cerebral or visual symptoms
Pathophysiology
 Management
The American College of Obstetricians and Gynecologists (ACOG)
and the Society for Maternal-Fetal Medicine (SMFM) continue to
support the short-term (usually <48 hours) use of magnesium
sulfate in obstetric care for conditions and treatment durations that
include the following [66] :
1. For prevention and treatment of seizures in women with
preeclampsia or eclampsia
2. For fetal neuroprotection before anticipated early preterm (<32
weeks of gestation) delivery
3. For short-term prolongation of pregnancy (48 hours) to allow for
the administration of antenatal corticosteroids in pregnant
women who are at risk of preterm delivery within 7 days
 Prevention and prediction
Aspirin
A systematic review of 14 trials
using low-dose aspirin (60-150
mg/d) in women with risk factors
for preeclampsia concluded that
aspirin reduced the risk of
preeclampsia and perinatal
death.
Heparin
The use of lowmolecular weight
heparin in women with
thrombophilia who have a history
of adverse outcome has been
investigated. To date, however, no
data suggest that the use of
heparin prophylaxis lowers the
incidence of preeclampsia.
Screening Test
More recently, a prospective
study demonstrated that an sFlt-
1:PlGF ratio of 38 or lower had a
negative predictive value of
99.3% (95% confidence interval
[CI], 97.9 to 99.9), suggesting an
extremely unlikely development
of preeclampsia or HELLP
(hemolysis, elevated liver
enzyme, low platelets)
syndrome within 1 week, in
women with a clinical suspicion
of preeclampsia or HELLP
syndrome. [
 Eclampsia
Eclampsia, which is
considered a complication
of severe preeclampsia, is
commonly defined as
new onset of grand mal
seizure activity and/or
unexplained coma during
pregnancy or postpartum
in a woman with signs or
symptoms of
preeclampsia. [4, 5]
 Clinical manifestation
The clinical manifestations of
maternal preeclampsia are
hypertension and proteinuria
with or without coexisting
systemic abnormalities involving
the kidneys, liver, or blood.
There is also a fetal manifestation
of preeclampsia involving fetal
growth restriction, reduced
amniotic fluid, and abnormal fetal
oxygenation. [6]
HELLP syndrome is a severe form
of preeclampsia and involves
hemolytic anemia, elevated liver
function tests (LFTs), and low
platelet count.
Eclampsia manifests as 1 seizure
or more, with each seizure
generally lasting 60-75 seconds.
The patients face initially may
become distorted, with
protrusion of the eyes, and
foaming at the mouth may occur.
Respiration ceases for the
duration of the seizure.
Eclamptic seizures may be divided
into 2 phases. Phase 1 lasts 15-20
seconds and begins with facial
twitching. The body becomes
rigid, leading to generalized
muscular contractions.
 Pathophysiology Eclampsia
Inhibition of uterovascular
development
Many uterovascular changes occur
when a woman is pregnant. It is
believed that these changes are due
to the interaction between fetal and
maternal allografts and result in
systemic and local vascular changes.
Hindrance of cerebral blood flow
regulation
It is believed that in eclampsia there
is abnormal cerebral blood flow in
the setting of extreme hypertension.
The regulation of cerebral perfusion
is inhibited, vessels become dilated
with increased permeability, and
cerebral edema occurs, resulting in
ischemia and encephalopathy.
Endothelial dysfunction
1. Factors associated with endothelial
dysfunction have been shown to be
increased in the systemic
circulation of women suffering from
eclampsia. These include the
following [1] :
2. Cellular fibronectin
3. Von Willebrand factor
4. Cell adhesion molecules (ie, P-
selectin, vascular endothelial
adhesion molecule-1 [VCAM-1]
5. Intercellular adhesion molecule-1
[ICAM-1])
6. Cytokines (ie, interleukin-6 [IL-6])
7. Tumor necrosis factor- [TNF-
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