ABORTION

(MISCARRIAGE)

DEFINITON

Abortion is the expulsion or extraction of the product of conception (embryo or fetus) before the age of viability which is 22 weeks (WHO) or fetus weighing 500 or less . Incidence : 10-15% of clinical pregnancy.

CLASSIFICATION

Spontaneous :

Induced:

Sporadic Recurrent

Legal Illegal

Threatened Inevitable Incomplete Complete Missed Septic

Septic

ETIOLOGY

Genetic factors Endocrine & metabolic factors Anatomical abnormalities Infections Immunological disorders Others Unexplained

Genetic factors

50% cases of miscarriage are due to chromosomal abnormalities. eg.

Autosomal
Monosomy

trisomy

Endocrine & metabolic factors

Luteal phase defect (LPD) Deficient progesterone Thyroid abnormalities Poorly controlled diabetes

Anatomical abnormalities

Cervical incompetence Congenital abnormalities of the uterus Fibroid uterus

Infections

TORCH group Bacterial

Ureaplasma Chlamydia Brucella

Immunological disorders

Antinuclear antibodies Antiphospholipid antibodies

Lupus anticoagulants Anticardiolipin antibodies

Others

Maternal medical diseases

Cyanotic heart disease Haemoglobinopathies

Blood group incompatibility (ABO & Rh) Inherited thrombophilia

Definition: It is a clinical condition where the process of abortion has started but may not proceed. Symptoms:

THREATENED ABORTION

Painless bleeding of varying amount, usually mild. Uterus corresponding with the period of amennorhea. Os closed.

PV examination:

Investigations

Ultrasonogram

Fetal cardiac activity present

Serum progesterone HCG

Treatment

Bed rest. Avoid coitus. Progesterone. Advice: to report if bleeding or pain increase. Rh anti-D if the mother is Rh negative. PROGNOSIS:- Unpredictable; two-third cases may continue, one-third may be terminated.

INEVITABLE ABORTION

Definition: It is a type of abortion where the changes has proceed to a state from where continuation of pregnancy is impossible. Symptoms:

Increased vaginal bleeding Increased pain in the lower abdomen General condition is stable Cervical dilatation started and the product is felt through the os.

PV examination:

Management

General measures Active measures:

Before 12 weeks: Dilatation & evacuation. After 12 weeks:

Prostaglandin Oxytocin

COMPLETE ABORTION

Definition: When the products of conception expelled completely, it is called complete abortion. Symptoms:

H/O complete expulsion of fleshy mass. Pain & P/V bleeding subsided. Uterus is smaller than period of amenorrhea. Bleeding is trace.

Signs:

Management

Investigations:

USG reveals empty uterine cavity. Assurance If the mother is Rh negative anti-D given if the gestation is more than 12 weeks.

Treatment:

INCOMPLETE ABORTION

Definition: When a part of product retained with in the uterine cavity it is called incomplete abortion. Symptoms:

H/O of expulsion of fleshy mass. Continuation of pain although in diminished magnitude. P/V bleeding continued.

Signs:

Uterus is smaller than period of amenorrhea. Cervical os open. Product may be felt. P/V bleeding present.

Management:

Same as inevitable abortion.

MISSED ABORTION

Definition: When the fetus is dead but the uterus did not take any attempt to expel it, is called missed abortion. Symptoms:

Features of early pregnancy followed by,

Subsidence of pregnancy symptoms. Regression of breast changes. Uterus small than period of amenorrhea. Fetal heart sound absent. USG revealed missed abortion.

Complications:

Coagulation failure & intrauterine infection. Before 12 weeks: Suction evacuation After 12 weeks:
Prostaglandin Oxytocin

Management:

SEPTIC ABORTION

Definition: Any abortion associated with clinical evidence of infection of uterus and its contents is called septic abortion. Signs/Symptoms:

Increased temperature 104F for 24 hours or more. Offensive vaginal discharge. Lower abdominal pain & tenderness.

Organisms causing infection includes

Anaerobic:

Bacteroides fragilis Anaerobic streptococcus Clostridium welchii Tetanus bacillus E. coli Klebsiella Pseudomonas Haemolytic streptococcus

Aerobic:

Mode of infection

80% are of endogenous origin (vagina) localised to conceptus. 15% - myometrial involvement. 5% - general peritonitis.

Clinical Features

H/O termination of pregnancy. Pyrexia Pain abdomen of varying degree. Rise in pulse rate. P/V examination offensive purulent discharge, very soft and tender uterus, patulous os.

Investigations

Routine inv:

Cervical and high vaginal swab for culture and sensitivity. CBC and blood grouping and typing. Urine analysis. Ultrasonogram Blood culture Serum electrolytes Coagulation profile

Special inv:

Complications

Immediate:

Haemorrhage Injury to the uterus and adjacent structures particularly gut. Spread of infections.
Generalised peritonitis Endotoxic shock Acute renal failure DIC

Remote:

Chronic pelvic pain Secondary infertility Ectopic pregnancy

Prevention

Acceptance of family planning and avoidance of unwanted pregnancy. Strictly follow the practice of safe abortion. To take antiseptic and septic precautions to manage the cases of spontaneous abortion.

Management

Injectable antibiotics broad spectrum antibiotics & metronidazole. Analgesics Evacuation of the uterus with aseptic technique within 24 hours following antibiotic therapy.

RECURRENT MISCARRIAGE

Definition: It is defined as 3 or more consecutive abortions before the age of viability. Etiology