Abortion

DEFINITION: Abortion is the expulsion or extraction from its

mother of an embryo or fetus weighing
500 g or less when it is not capable of independent survival.
INCIDENCE: 10–20% of all clinical pregnancies

CLASSIFICATION OR VARIETIES:

ETIOLOGY
 Genetic  Endocrine and metabolic  Anatomic  Infection 
Immunological  Thrombophilias  Environmental  Others 
Unexplained
THREATENED MISCARRIAGE
DEFINITION: It is a clinical entity where the process of miscarriage
has started but has not progressed
to a state from which recovery is impossible

CLINICAL FEATURES:
(1) Bleeding per vaginam ( brownish or bright red in color).
(2) Pain: Pain appears usually following hemorrhage.
Pelvic examination
(a) Speculum examination reveals—bleeding
(b) Digital examination reveals the closed external os. The uterine size
corresponds to the period of amenorrhea. The uterus and cervix feel soft.
INVESTIGATIONS:
Routine investigations include:
(1) Blood—for hemoglobin, hematocrit, ABO and Rh grouping.Anti-D
gamma globulin has to
be given in Rh-negative nonimmunized women.
Ultrasonography (TVS)
Serum progesterone value of 25 ng/mL or more indicates a viable
pregnancy (95%)
Serial serum hCG level is helpful to assess the fetal well-being.
TREATMENT:
Rest:
Drugs: Relief of pain may be ensured by diazepam 5 mg tablet twice
daily.
treatment with progesterone improves the outcome.

INEVITABLE MISCARRIAGE

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
(1) Increased vaginal bleeding.
(2) Aggravation of pain in the lower abdomen which may be colicky in
nature.
(3) Internal examination reveals dilated internal os of the cervix
through which the products of conception are felt

MANAGEMENT
(a) to accelerate the process of expulsion.
(b) to maintain strict asepsis.
General measures: Excessive bleeding controlled by Methergine 0.2 mg
The blood loss is corrected by intravenous (IV) fluid therapy and
blood transfusion.
Active Treatment:
 Before 12 weeks:
(1) Dilatation and evacuation
(2) Alternatively, suction evacuation.
 After 12 weeks:
(1) oxytocin drip (10 units in 500 mL of normal saline) 40–60 drops per
minute.

COMPLETE MISCARRIAGE

DEFINITION: When the products of conception are expelled en

masse, it is called complete miscarriage.

CLINICAL FEATURES:
There is history of expulsion of a fleshy mass per vaginam followed by:
(1)Subsidence of abdominal pain.
(2) Vaginal bleeding becomes trace or absent.
(3) Internal examination reveals:
(a) Uterus is smaller than the period of amenorrhea and a little firmer.
(b) Cervical os is closed (c) Bleeding is trace.
(4) Examination of the expelled fleshy mass is found complete.
(5) Ultrasonography (TVS): reveals empty uterine cavity.
INCOMPLETE MISCARRIAGE
DEFINITION: When the entire products of conception are not
expelled, instead a part of it is left
inside the uterine cavity, it is called incomplete miscarriage. This is
the commonest type met amongst
women, hospitalized for miscarriage complications.
CLINICAL FEATURES:
History of expulsion of a fleshy mass per vaginam followed by:
(1) Continuation of pain in lower abdomen.
(2) Persistence of vaginal bleeding.
(3) Internal examination reveals—
(a) uterus smaller than the period of amenorrhea (b) patulous cervical os
often admitting tip of the finger and (c) varying amount of bleeding.
(4) on examination, the expelled mass is found incomplete
(5) Ultrasonography—products of conception.

COMPLICATIONS:
(a) profuse bleeding (b) sepsis or (c) placental polyp.

MANAGEMENT:
In recent cases—evacuation of the retained products of conception.
 Early abortion: D&E
 Late abortion: D&C
Medical management Tablet misoprostol 200 μg vaginally every 4
hours. Compared to surgical method, complications (see p. 203) are less
with medical method.

MISSED MISCARRIAGE
DEFINITION: When the fetus is dead and retained inside the uterus
for a variable period, it is called missed miscarriage or early fetal
demise.
PATHOLOGY: The causes of prolonged retention of the dead fetus in the
uterus are not clear. Beyond 12 weeks, the retained fetus becomes
macerated or mummified. The liquor amnii gets absorbed and the
placenta becomes pale, thin and may be adherent. Before 12 weeks, the
pathological process differs when the ovum is more or less completely
surrounded by the chorionic villi.
CARNEOUS MOLE (Syn: blood mole, fleshy mole): It is the pathological
variant of missed miscarriage affecting the fetus before 12 weeks. Small
repeated hemorrhages in the choriodecidual space disrupt the villi from its
attachments. The bleeding is slight, so it does not cause rupture of the
decidua capsularis. The clotted blood with the contained ovum is known
as a blood mole. By this time, the ovum becomes dead and is either
completely absorbed or remains as a rudimentary structure. Gradually,
the fluid portion of the blood surrounding the ovum gets absorbed and the
wall becomes fleshy, hence the term fleshy or carneous mole.

CLINICAL FEATURES:
(1) Persistence of brownish vaginal discharge.
(2) Subsidence of pregnancy symptoms.
(3) Retrogression of breast changes.
(4) Cessation of uterine growth which in fact becomes smaller in size.
(5) Nonaudibility of the fetal heart sound even with Doppler ultrasound if
it had been audible before.
(6) Cervix feels firm.
(7) Immunological test for pregnancy becomes negative.
(8) Realtime ultrasonography reveals an empty sac early in the
pregnancy or the absence of fetal cardiac motion and fetal movements.

COMPLICATIONS: The complications of the missed miscarriage are those

mentioned in intrauterine fetal death. Blood coagulation disorders are
less likely to occur in missed miscarriage.

MANAGEMENT:
 Uterus is less than 12 weeks:
(i) Expectant management—Many women expel the conceptus
spontaneously.
(ii) Medical management: Prostaglandin E1 (misoprostol) 800 mg
vaginally in the posterior fornix is given and repeated after 24 hours if
needed. Expulsion usually occurs within 48 hours.
(iii) Suction evacuation or dilatation and evacuation

 Uterus more than 12 weeks:

Induction is done by:
(a) Prostaglandin E1 analog (misoprostol) 200 μg tablet is inserted
into the posterior vaginal fornix every 4 hours for a maximum of 5 such.
(b) Oxytocin—10–20 units of oxytocin in 500 mL of normal saline at 30
drops/min is started.
(c) surgical evacuation following medical treatment.
(d) Dilatation and evacuation

SEPTIC ABORTION
DEFINITION: Any abortion associated with clinical evidences of
infection of the uterus and its contents is called septic abortion.
abortion is usually considered septic when there are:
(1) rise of temperature of at least 100.4°F (38°C) for 24 hours or more,
(2) offensive or purulent vaginal discharge and
(3) evidences of pelvic infection

INCIDENCE: About 10% of abortions requiring admission to hospital are

septic.
MODE OF INFECTION
The microorganisms are: (a) Anaerobic—Bacteroides group (fragilis),
anaerobic Streptococci, Clostridium welchii and tetanus bacillus. (b)
Aerobic—Escherichia coli (E. coli), Klebsiella, Staphylococcus,
Pseudomonas and group A beta-hemolytic Streptococcus (usually
exogenous), methicillin-resistant Staphylococcus aureus (MRSA).
(1) proper antiseptic and asepsis are not taken,
(2) incomplete evacuation and
(3) inadvertent injury to the genital organs and adjacent structures,
particularly the bowels.

CLINICAL FEATURES:.
Clinical Features of Septic Abortion
„„The woman looks sick and anxious
„„Temperature: >38°C
„„Chills and rigors (suggest-bacteremia)
„„Persistent tachycardia ≥ 90 bpm (spreading infection)
„„Hypothermia (endotoxic shock) < 36°C
„„Abdominal or chest pain

„Tachypnea (RR) > 20/min

„„Impaired mental state
„„Diarrhea and/or vomiting
„„Renal angle tenderness
„„
Pelvic examination: Offensive, purulent vaginal discharge, uterine
tenderness, boggy feel in the POD (pelvic abscess)

CLINICAL GRADING:
Grade I: The infection is localized in the uterus.
Grade II: The infection spreads beyond the uterus pelvic peritoneum.
Grade III: Generalized peritonitis and/or endotoxic shock or jaundice or
acute renal failure.

INVESTIGATIONS:
(1) Cervical or high vaginal swab culture
(2) Blood for hemoglobin estimation, total WBC, ABO and Rhgrouping.
(3) Urine analysis including culture.
Special investigations—
(1) Ultrasonography
(2) Blood
(3) Plain X-ray

COMPLICATIONS:
 Hemorrhage  Injury  Generalized Endotoxic shock, Acute
renal failure, Thrombophlebitis.
Remote: (a) chronic debility, (b) chronic pelvic pain and backache,
(c) dyspareunia, (d) ectopic pregnancy, (e) secondary infertility due to
tubal blockage and (f ) emotional depression.

PREVENTION:
(1) To boost up family planning acceptance in order to curb the unwanted
pregnancies.
(2) Rigid enforcement of legalized abortion in practice and to curb the
prevalence of unsafe abortions.

MANAGEMENT
GENERAL MANAGEMENT:
 Hospitalization
 To take high vaginal or cervical swab
 Vaginal examination
 Overall assessment of the case
 Investigation protocols

Drugs:
(1) Antibiotics
(2) Prophylactic antigas gangrene serum
(3) Analgesics and sedatives
Antimicrobial therapy
(a) Piperacillin-tazobactam and carbapenems:
(b) Vancomycin
(c) Clindamycin:
(d) Gentamycin
(e) Co-amaxiclav—
(f ) Metronidazole—.
Blood transfusion
Surgery:
(1) Evacuation of the uterus
(2) Posterior colpotomy

RECURRENT MISCARRIAGE

DEFINITION: Recurrent miscarriage is defined as a sequence of three

or more consecutive spontaneous abortion before 20 weeks. Some,
however, consider two or more as a standard. It may be primary or
secondary (having previous viable birth). A woman procuring three
consecutive induced abortions is not a habitual aborter.

INCIDENCE: This distressing problem is affecting approximately 1% of all

women of reproductive age. The risk increases with each successive
abortion reaching over 30% after three consecutive losses.
ETIOLOGY
 Genetic factors
 Endocrine and metabolic:
 Infection
 Inherited
 Immune factors
 Unexplained
Anatomic abnormalities
Dica
tINVESTIGATIONS
medical, surgical and obstetric history clinical examination
Diagnostic tests:
(1) Blood-glucose (fasting and postprandial), VDRL, thyroid function test,
ABO and Rh grouping (husband and wife), toxoplasma antibodies IgG and
IgM.
(2) Autoimmune screening
(3) Serum LH on D2/D3 of the cycle.
(4) Ultrasonography.
(5) Hysterosalpingography
(6) This is supported by hysteroscopy and/or laparoscopy.
(7) Karyotyping (husband and wife).
(8) Endocervical swab

TREATMENT
INTERCONCEPTIONAL PERIOD:
 To alleviate anxiety and to improve the psychology—
 Hysteroscopic resection
 Chromosomal anomalies—genetic counseling is undertaken.
 Women with PCOS are best treated .
 Endocrine dysfunction: may be treated.
 Genital tract infections are treated