SPONTANEOUS ABORTION Signs and symptoms

Fetal cause • Low back pain or abdominal pain that is dull, sharp, or cramping
- Most common cause of early spontaneous abortion is abnormal • Vaginal bleeding, with or without abdominal cramps
development of the zygote, embryo or fetus. These abnormalities are
incompatible with life • Tissue or clot-like material that passes from the vagina

- Also known MISCARRIAGE

Early miscarriage occurs before 16 weeks’ AOG
Late miscarriage occurs between 16 and 20 weeks’ AOG

1. For the 1st 6 weeks (between 1st and 2nd month) of pregnancy,
the developing placenta is tentatively attached to the decidua of
the uterus
2. During weeks 6 to 12 (2nd to 3rd month) of pregnancy, the
placenta is moderately attached
3. After week 12, the attachment is penetrating and deep
Bleeding before week 6 is rarely severe
Bleeding after week 12 can be profuse because the placenta is
implanted so deeply
Types of Spontaneous Abortion

• Threatened abortion - Possible loss of product of conception

• Inevitable abortion- The loss of the products of conception
cannot be prevented
• Complete abortion - Spontaneous expulsion of the products of
conception after the fetus has died in utero
• Incomplete abortion- Expulsion of some parts and retention of
the other parts of conceptus in utero
• Missed abortion - Retention of all products of conception after
the death of fetus in the uterus
• Habitual abortion - Abortion occurring in 3 or more successive
pregnancies
• Septic abortion - Abortion complicated by infection
 Complications of Abortion

HEMORRHAGE
• Nx care: • Flat on bed and massage fundus to aid in contraction (not
possible in early pregnancy because the small uterus isn’t palpable
above the symphysis pubis)
• D&C to empty the uterus of material from preventing it form
contracting • Blood transfusion
• Rule of thumb: more than 1 sanitary pad/hour is excessive • Large
clots – indicative of excessive bleeding
• Methergine to aid in contraction
INFECTION

ISOIMMUNIZATION
• Production of antibodies against Rh-positive blood
• Antibodies would attempt to destroy RBC of the next infant (if Rh-
positive) during the months that infant is in utero
• After a miscarriage, women should receive Rh immune globulin to
prevent the buildup of antibodies
ECTOPIC PREGNANCY Ectopic Pregnancy: S/SX

-Implantation occurs outside the uterus
Ampulla of the fallopian tube – most common site
-Second most frequent cause of bleeding in early pregnancy
Incidence
• Pelvic Inflammatory Disease d/t tubal scarring
• Smokers
• IUD – slows down transport of zygote
-Unilateral lower abdominal pain on the side of the affected tube
when the tube is not yet ruptured
- Sudden severe and knife like pain is the most common
symptom when the tube ruptures. After tubal rupture, pain radiating
to the neck and shoulder d/t phrenic nerve irritation by blood in the
peritoneal cavity
-Occurs at 6 – 12 weeks of pregnancy when the zygote grows and
rupture the fallopian tube
-Spotting or bleeding. Amount of bleeding may not reflect the
actual amount of blood loss, as blood tends to collect in the peritoneal
cavity. Blood is usually dark brown.
Signs of hemorrhage when tube ruptures: •
1. Cullen’s sign: Bluish discoloration of the
umbilicus d/t the presence of blood in the peritoneal
cavity
2. Hard or rigid abdomen d/t peritoneal irritation
3. Signs of shock: cyanosis, pallor, cold clammy skin,
rapid pulsem
4. BP decreases and PR increases

Ruptured Ectopic Pregnancy

-Salpingectomy is indicated in uncontrollable hemorrhage and
severely damaged tube. Many physicians choose to remove a ruptured
tube because the presence of a scar if tube is repaired and left
increases the risk of subsequent tubal pregnancy.

Ectopic Pregnancy: Mgt

Unruptured Ectopic pregnancy

• Medical Management
-Methotrexate to induce abortion when ectopic pregnancy is less than
3 cm and no FHT is present yet.
-IM leucovorin is given to reduce side effects of methotrexate •
Surgical Management
Salpingostomy – performing a linear incision over ectopic
pregnancy to remove manually
Salpingotomy – longitudinal incision to removed conceptus with
forceps or by suction
 SECOND TRIMESTER BLEEDING • Sperm – lifespan of 48 – 72 hours, meaning that it is capable of
fertilizing an ovum within this time only.
1. Hydatidiform mole/H-mole/Gestational trophoblastic
disease/Molar pregnancy Fertilization
-a benign disorder characterized by degeneration of the chorion and • Fertilization occurs in the ampulla
death of the embryo
• After fertilization, the first cell formed is called zygote
-The chorionic villi rapidly proliferates and become grapelike vesicles
• The zygote travels for 3 days from fallopian tube to uterine cavity
that produce large amounts of HCG
• At this time it undergoes mitotic cell division. The daughter cells
2. Incompetent Cervix
from these cell division are called blastomeres. When there are at
-Mechanical defect of the cervix that causes painless cervical dilatation
least 16 blastomeres formed, the zygote is called a morula.
in the second trimester or early in the third trimester, followed by
prolapse and ballooning of the membranes in the vagina and then,
rupture of membranes and expulsion of the fetus.
- This abnormality, which may be congenital or acquired
-is the most common cause of habitual abortion.

Review: Fetal Development

Human gametes
• Ovum – lifespan of 24 hours, meaning, it can be fertilized only
within this time
Blastocyst
• When the morula (zygote) reaches the uterine cavity, it is referred to
as blastocyst
• The blastocyst is composed of
1. Trophoblast cells on its surface that gives rise to the placenta,
umbilical cord and amniotic membrane, and that differentiate in two
layers, namely
Cytotrophoblast/Langhan’s layer that protects the fetus from
syphilis until the second trimester
Synctiotrophoblast that produce the hormones of pregnancy
Implantation
- Upon reaching the uterus, the zygote remains floating for 3-4 days
more before it implants
-Implantation occurs around 6-7 days after fertilization at the upper
posterior fundal portion of the uterus
- Blastocyst release enzymes that digest blood vessels in the
endometrium resulting in blood vessel rupture and bleeding – This is
responsible for some spotting experienced by some women, and called
implantation bleeding.

-Human placental lactogen (HPL) which renders insulin less

effective and is the main diabetogenic hormone of pregnancy

-Human chorionic gonadotrophin (HCG) which functions

primarily to prolong the life of corpus luteum, responsible
for positive test, and stimulates testosterone secretion in
male fetus
2. Inner cell mass (embryoblast)
3.Blastocele (blastocyst cavity Decidua
– after implantation the endometrium is referred to as decidua
1. Decidua parietalis – located under decidua basalis
2. Decidua basalis – site of implantation and later forms the maternal
side of the placenta
3. Decidua capsularis – enclose the blastocyst. At 4 months, fuses with
decidua parietalis to become one layer called decidua vera
Developmental stages
• Pre-embryonic or ovum stage: fertilization to 3 weeks which covers
formation of primary germ layers and implantation
• Embryonic stage: from 4 to 8 weeks which is the period of
organogenesis. This is the time when the newly formed human is most
susceptible to teratogenic agents that can cause congenital anomalies.
Has assumed a human form at the end of embryonic period
• Fetal stage: from 8 weeks to birth which is characterized by rapid
development of different body organs .
• Fetal membranes
1. Amnion: innermost lining of the membrane that produces amniotic
fluid
2. Chorion: outermost lining of the membrane that forms from
trophoblasts; chorionic villi develop into the placenta