Abortion

(miscarriage)

Departemen Obsteri & Ginekologi

FK – USU / RS. H. ADAM MALIK
Definition
The termination of pregnancy before the 20th week,
when the fetus weight is less than 500 grams.

Early abortion: <12th week of pregnancy

Late abortion: 12th-20 th week of pregnancy

Spontaneous abortion
Artificial abortion
Etiology
Genetic factors:
chromosomal abnormal accounts 50～60%
of the early abortions
• Numeral abnormalities:
polyploidy, triploidy, monosomy
• Structural abnormalities:
break, translocation, deletion
Etiology
Extrinsic factors
• Chemical: mercury, lead, cadmium,
smoking,
• Physical: video display terminals,
radioactive materials, noise,
hyperthermia
Etiology
Maternal factors
• General diseases:
infection, heart diseases, hypertension, anemia
• Reproductive organic diseases:
congenital uterine malformation, pelvic tumor,
cervical incompetence
• Endocrine disorders:
LPD, hypothyroidism
• Injuries
Etiology
Defects in the developing placenta

Immunologic factors: paternal histo-

compatibility antigen , maternal cellular
immunity regular disorder, deficiency of
maternal blocking antibody
Pathology

The death of the embryo or rudimentary analog

Hemorrhage into the decidua basalis

Uterine contraction, dilation of the cervix

Expulsion of the products conception

Pathology
Before the 8th week of the pregnancy, the
abortus can be expelled completely

During the 8th-12th week of the pregnancy,

retention of the tissue is common

After the 12th week of the pregnancy, the

abortus may be expelled totally
 Normal US Findings

Normal gestational sac at arrow,

Yolk sac (at curved arrow) with
endometrial cavity at curved arrow
embryo (between X’s)
“Double decidual sac” sign

GS=gestational sac, DP=decidua

parietalis, * = endometrial cavity,
arrow=decidua capsularis
 Normal US Findings

Embryo (black arrow); amnion (small arrow) does not fuse

with chorion (large arrow) until 12-16wks gestation.
Clinical subgroups
of abortion
Theatened miscarriage

Inevitable miscarriage

Incomplete miscarriage

Complete miscarriage
Abortion
 Complet Abortion
► Presentation: Varies greatly
depending on type of
abortion, but often presents
with vaginal bleeding and
uterine cramps or back pain.
► β-hCG: Falling or rising
abnormally slow
► US findings vary depending
on classification and
cause of abortion
Anembryonic pregnancy: large (>18mm)
gestational sac without embryo
 Abnormal US Findings: Spontaneous
Abortion

Abortion in progress: low-lying gestational Missed abortion: embryo (at arrow) is

sac (thick arrow), decidual reaction and relatively small compared to large
hemorrhage (mixed hyper- and hypo-echoic gestational sac. No cardiac activity was
material between arrowheads) present.
 Abnormal US Findings: Spontaneous
Abortion

Patient presented with continued vaginal Abnormally shaped gestational sac at 5

bleeding after spontaneous abortion. US wks. Patient later had a complete
shows retained products of conception. spontaneous abortion.
 The developing processes
of the abortion

Threatened miscarriage

Normal pregnancy Inevitable miscarriage

Complete miscarriage Incomplete miscarriage

 Classifications and
characteristics
conceptus Vaginal abdominal Cervix os Uterine
Subgroups expulsion bleeding pain dilation enlargement

Threatened no ＋ －＋ － compatible
miscarriage

Inevitable no ＋＋ ＋＋ ＋－ compatible
or miscarriage smaller

Incomplete part ＋＋＋ ＋ ＋－ smaller

miscarriage

Complete all ＋－ － － normal

miscarriage
Alternative
classification

• Blighted ovum

• Missed miscarriage

• Live miscarriage
 Classification of miscarriage

Blighted
Normal pregnancy
ovum

Missed
miscarriage

Threatened Inevitable
miscarriage miscarriage

Continuing Incomplete Complete

pregnancy miscarriage miscarriage
 Special subgroups:

Missed Miscarriage
Expulsion of the conceptus does not occur
despite a prolonged period after embryonic
death.
Symptoms of pregnancy regress
Pregnancy test becomes negative
No fetal heart motion is detected
Uterine enlargement ceases
 Special subgroups:

Recurrent miscarriage
(Habitual abortion)
Three or more consecutive spontaneous losses
of pregnancy
First-trimester: LPD, hypothyroidism,
chromosomal abnormalities, immunologic
factors
Second-trimester: uterine malformations,
cervical incompetence, myomas
 Special subgroups:

Septic miscarriage
Any type of spontaneous miscarriage is
complicated by infection
Endometritis, parametritis, peritonitis
Fever, abdominal tenderness, uterine pain
Septicemia, septic shock
 Diagnosis
• History: amenorrhea, symptoms of
pregnancy, vaginal bleeding……
• Examination: general and pelvic
• Ultrasounograph
• Pregnancy test, ß-HCG
• Others:
Differential diagnosis
• Ectopic pregnancy
• Molar pregnancy
• Dysfunctional uterine bleeding (DUB)
• Pelvic infective diseases (PID)
• Acute appendicitis
Ectopic Pregnancy

• 95% are in the

fallopian tube (70%
ampulla, 12% isthmus,
11% fimbria, 2%
interstitial/cornual)
• Ovarian occurs about
3% of the time,
abdominal 1% of the
time and cervical <1%
of the time
 Abnormal US Findings: Ectopic

Gestational sac (between arrowheads) Pseudogestational sac of ectopic

and embryo (between calipers) outside pregnancy. Note central location and
of the uterus. Normal ovary is seen at absence of double decidual sign.
arrow.
 Anembryonic gestation

• No yolk sac or fetal

pole
• Mean gestational sac
diameter of 20 mm
Management

Threatened miscarriage:
rest, follow-up
Inevitable & incomplete miscarriage:
Evacuation of the uterus,vacuum or suction
curettage, oxytocin iv, antibiotics
Complete miscarriage:
no further therapy is necessary.
 Management
Missed miscarriage
First- trimester:
suction curettage
The second-trimester:
D&E(dilation and evacuation)
D&C(dilation and curettage)
Induction of labor with intravaginal
prostaglandin E2 or misoprostol
 Management
Recurrent miscarriage

A workup for possible causes of recurrent

pregnancy loss (RPL): anatomic,
hormonal,genetic,and autoimmune factors
(underlying maternal factors)
Incompetent cervix: cerclage designed to
reinforce the cervix at the level of the internal os
at the end of the first trimester, the suture is
removed after 37 weeks’ gestation
 Management
Septic miscarriage
• Evacuation of the uterus within a few
hours after antibiotics iv
• High-dose, broad-spectrum coverage
antibiotics, aggressive use before, during,
and after removal of necrotic tissue by
curettage
• hysterectomy
Summary points

• The most frequent etiology of

miscarriage is a chromosomal
abnormality of the conceptus and most of
the abortions occur in the first-trimester.
• The processes of the pathology decide
the characteristics of the subgroups.
• Ultrasound is helpful in diagnosis.
 Take-home Points
►Along with β-hCG, ultrasound is the mainstay
in determining the cause of first-trimester
vaginal bleeding
►Important causes of bleeding include: Ectopic
pregnancy, spontaneous abortion,
hydatidaform mole, subchorionic hematoma,
and uterine AVM.
►It is vital to determine the cause of bleeding in
order to select appropriate treatment
Problem-based learning (3)
• On examination you find no abnormality
on abdominal palpation and in particular,
no tenderness. On vaginal examination,
however, you find blood clot in the vagina
and products of conception are present in
the cervix, which is dilated. What is the
diagnosis and how would you manage the
situation?
The End