1. Definition
•It is expulsion or extraction of products of conception
before fetal viability i.e. before 24 weeks of gestation.
Incidence :
•Is the commenest gynaecological & obstetric disorder
• About 15% of clinically recognized pregnancies end
in abortion (this rise to 30% if unrecognized
pregnancies are included).
•Most abortions occur between 8 and 12 weeks of
pregnancy.
Miscarriage ( Abortion )
2. Etiology
A. First trimester abortion :
1. Fetal chromosomal abnormalities - particularly
trisomy , triploidy & monosomy
• is the commonest cause of abortion
• 50– 70 % of the first trimester abortions are due to
chromosomal abnormalities
• the incidence of these abnormalities increased with
the increase in the maternal age
2. Anembryonic pregnancy - Blighted ovum
3. Multiple pregnancy
4. Etiology
A. First trimester abortion :
8. Thrombophilia: Congenital deficiency of
protein C & S, & anti-thrombin III
9. Immunological disorders : Anticardiolipin
syndrome and SLE
10. Cigarette smoking , anaesthetic agents &
chemical agents .
11. Psychological disorders
5. Etiology
B. Second trimester abortion :
1. Multiple pregnancy
2. Cervical incompetence (congenital & acquired )
3. Uterine anomalies and submucous fibroid
4. Genital tract infection and PROM
7. Threatened abortion
(Features)
1. History Mild vaginal bleeding.
No abdominal pain or mild
abdominal pain
2. Examination Good general condition.
The cervix is closed
The uterus is usually the
correct size for date
3. U/S which is essential for the diagnosis Showed
the presence of fetal heart activity
8. Threatened abortion
(Management)
1. Reassurance If fetal heart activity is present, > 90% of
cases will be progressed satisfactorily
2. Advice: Decrease physical activity (bed rest is of no
therapeutic value) avoid intercourse
3. Hormones i.e. Progesterone & hCG Which are used in the
first trimester to support pregnancy, (but they are of no
proven value)
4. Anti- D: An adequate dose of anti-D should be given to all
Rh –ve,non-immunised patients, whose husbands are Rh +ve
5. ANC as high risk patients
Because those patients are liable to late pregnancy
complications such as APH and preterm labour .
9. Inevitable and incomplete abortions
(Features)
1. History
Heavy vaginal bleeding.
with no passage of products conception
(inevitable)
with the passage of products of conception
(incomplete abortion)
Severe lower abdominal pain which follows the
bleeding
10. Inevitable and incomplete abortions
(Features)
2. Examinations
Poor general condition.
The cervix is dilating and products of
conception may be passing trough the os
The uterus may be the correct size for date
(inevitable abortion) or small for date
(incomplete abortion)
3. U/S Fetal heart activity may or may not present
in inevitable abortion or retained products of
conception ( RPOC ) in incomplete abortion
11. Inevitable and incomplete abortions
(management)
1. CBC , blood grouping , XM 2 units of
blood
2. Resuscitation large IV line, fluids & blood
transfusion
3. Oxytoxic drugs Ergometrine 0.5 mg IM +
Oxytocin infusion (20-40 units in 500 cc saline)
4. Evacuation & curettage.
5. Post-abortion management.
12. Complete abortion
(Features)
1. History
Heavy vaginal bleeding which has been
stopped.
lower abdominal pain which follows the bleeding
which has been stopped.
2. Examination
The cervix is closed
3. U/S
showed empty uterine cavity or PROP
14. Missed abortion
(Features)
1. Most of missed abortions are diagnosed
accidentally during routine U/S in early
pregnancy .
In some cases there may be a history of :
Episodes of mild vaginal bleeding
Regression of early symptoms of pregnancy .
Stop of fetal movements after 20 weeks gestation.
2. Examination
The uterus may be small for date
15. Missed abortion
(Features)
3. U/S (which is essential for diagnosis )
diagnosed if two ultrasound ( T/V or T/A) at
least 7days apart showed an embryo of > 7
weeks gestation ( CRL > 6mm in diameter and
gestational sac > 20 mm in diameter ) with no
evidence of heart activity .
16. 1. CBC , blood grouping , XM 2 units of blood
2. Platelets count, – to exclude the risk of DIC
NB : DIC does not occur before 5 weeks of
missed abortion or IUFD and if occurred will
be of mild grade
Missed abortion
(Management)
17. 3.Options of treatment
Conservative treatment: if left alone spontaneous
expulsion will occur
Surgical evacuation of the uterus; by D & C:
Indicated in 1st
trimester missed abortion
Medical termination of pregnancy: by Misoprostol (PGE1)
Cytotec: Indicated in 1st
& 2nd
trimesters missed abortions.
Cytotec vaginal ( is the best) or oral tab. 200 μg, 2 tab/ 3 hrs/
up to 5 doses daily, which can be repeated next day if there is
no response in the first day
Subsequent surgical evacuation is needed in cases of RPOC
The main side effects of cytotec are nausea, vomiting and
fever.
4.Post-abortion management.
Missed abortion
(Management)
18. It is due to an early death and resorption of the
embryo with the persistence of the placental
tissue
It is diagnosed if two ultrasound ( T/V or T/A)
at least 7 days apart showed after 7 weeks of
gestation i.e. gestational sac > 20mm , an empty
gestational sac with no fetal echoes seen .
It is treated in a similar way to missed
abortion .
Anembryonic pregnancy
(Blighted ovum)
19. Definition :
It is an incomplete abortion which complicated by infection
of the uterine contents .
This may be due to criminal interference
Features : Poor general condition
Include the features of incomplete abortion ie severe
vaginal bleeding with passage of product of conception,
with or without history of evacuation.
Features of pelvic infection i.e pyrexia , tachycardia ,
general malaise , lower abdominal pain , pelvic tenderness
& purulent vaginal discharge .
Septic abortion
20. Bacteriology : Mixed infection
The commonest organisms are :
1. Gram -ve : E.coli , strepto & staphylococcu
2. Anaerobics : Bacteroides
Rarely Cl. tetani , which is potentially lethal if
not treated adequately .
Types :
Mild the infection is confined to decidua : 80%
Moderate the infection extended to myometrium15%
Severe the infection extended to pelvis + Endotoxic
shock + DIC 5%
Septic abortion
21. Management :
1. Investigations :
CBC , blood grouping , XM 2 units of blood .
Cervical swabs (not vaginal) for culture and sensivity
Coagulation profile , serum electrolytes & blood culture if
pyrexia > 38.5
2. Antibiotics : Cephalosporin I.V + Metronidazole I.V
3. Surgical evacuation of uterus usually 12 hrs after
antibiotic therapy ( until a reasonable tissue levels of
antibiotics have been achieved )
4. Post-abortion management.
Septic abortion
22. 1. Haemorrhage .
2. Complication related to surgical evacuation ie E&C and D&C.
– Uterine perforation- which may lead to rupture uterus in the
subsequent pregnancy.
– Cervical tear & excessive cervical dilatation – which may lead
to cervical incompetence.
– Infection – which may lead to infertility & Asherman's
syndrome.
– Excessive curettage – which may lead to Adenomyosis
3. Rh- iso immunisation if the anti –D is not given or if the
dose is inadequate .
4. Psychological trauma .
Complications of abortion
23. Post - abortion management
In cases of incomplete, inevitable, complete, missed
& septic abortions
1.Support: from the husband, family& obstetric
staff
2.Anti D – to all Rh –ve, nonimmunised patients,
whose husbands are Rh+ve
3. Counseling & explanation:
A.Contraception (Hormonal, IUCD, Barrier)
Should start immediately after abortion if the patient
choose to wait , because ovulation can occur 14 days after
abortion and so pregnancy can occur before the expected
next period .
24. Post - abortion management
3. Counseling & explanation:
B.When can try again :
Best to wait for 3 months before trying again . This
time allow to regulate cycles and to know the LMP, to give
folic acid, and to allow the patient to be in the best shape
(physically and emotionally) for the next pregnancy
C.Why has it happened
In the fiIn the majority of cases there is no obvious
cause
In the first trimester abortion , the most common cause
is fetal chromosomal abnormality
25. Post - abortion management
3. Counseling & explanation:
D. Can it happen again
As the commonest cause is the fetal chromosomal
abnormality which is not a recurrent cause , so the chance of
successful pregnancy next time in the absence of obvious
cause is very high even after 2 or 3 abortions
E. Not to feel guilty as it is extremely unlikely that
anything the patient did can cause abortion
No evidence that intercourse in early pregnancy is
harmful
No evidence that bed rest will prevent it ..
26. Recurrent abortion
Definition :
Is defined as 3 or more consecutive spontaneous abortions
It may presented clinically as any of other types of abortions .
Types :
Primary : All pregnancies have ended in loss
Secondary : One pregnancy or more has proceeded to
viability(>24 weeks gestation) with all others ending in loss
Incidence :
occurs in about 1% of women of reproductive age .
27. Recurrent abortion
Causes
• Idiopathic recurrent abortion, in about 50%, in which no
cause can be found .
• The known causes include the followings :
1. Chromosomal disorders:
Fetal chromosomal abnormalities & structural
abnormalities
Parental balanced translocation
2. Anatomical disorders:
Cervical incompetence: →congenital and aquired
Uterine causes: → submucous fibroids, uterine anomalies &
Asherman’s syndrome
28. Recurrent abortion
Causes
3. Medical disorders:
Endocrine disorders : diabetes , thyroid disorders , PCOS &
corpus luteum insufficiency .
Immunological disorders : Anticardiolipin syndrome & SLE.
Thrombophilia: congenital deficiency of Protein C&S and
antithrombin III, & presence of factor V leiden.
Infections
ToRCH - CMV may be a cause of recurrent abortion, but
ToRH are not causes of recurrent abortion.
Genital tract infection e.g Bacterial vaginosis
Rh – isoimmunization
29. Recurrent abortion
Diagnosis :
1. History :
Previous abortions : gestational age and place of
abortions & fetal abnormalities.
Medical history : DM , thyroid disorders, PCOS,
autoimmune diseases & thrombophilia.
2. Examination :
General : weight , thyroid & hair distribution
Pelvic: cervix ( length & dilatation ) and uterine size.
30. Recurrent abortion
Diagnosis :
3. investigations :
A. Investigations for medical disorders:
Blood grouping & indirect Coomb’s test in Rh –ve women
Endocrinal screening: Blood sugar , TFT & LH /FSH ratio
Immunological screening: Anti anticardiolipine antibodies & lupus
inhibitor.
Thrombophilia screening: Protein C & S, antithrombin III levels,
factor V leiden, APTT and PT.
Infection screening
High vaginal & cervical swabs
ToRCH profile ( which scientifically is not
necessary )
31. Recurrent abortion
Diagnosis :
3. investigations :
B. Investigations for anatomical disorders:
TV/US: fibroids, cervical incompetence & PCOS.
Hystroscopy or HSG, fibroids, cervical incompetence, uterine
anomalies & Asherman's syndrome
C. Investigations for chromosomal disorders:
Parental karyotyping: Parental balanced translocation.
Fetal karyotyping: Fetal chromosomal anomalies.
32. Recurrent abortion
Management:
3. in idiopathic recurrent abortion.
With support and good antenatal care , the chance of successful
spontaneous pregnancy is about 60-70%
Support : from husband, family & obstetric staff.
Advice : stop smoking & alcohol intake, decrease physical activity
Tender loving care
Drug therapy
• Progesterone & hCG: start from the luteal phase & up to 12 weeks.
•Low dose aspirin ( 75 mg/day ) start from the diagnosis of pregnancy & up to 37 weeks
•LMWH (20-40 mg/day) start from the diagnosis of fetal heart activity & up to 37 ws
33. Recurrent abortion
Management:
3. In the presence of a cause treatment is directed to control
the cause
Endocrine disorders
• Control DM and thyroid disorders before pregnancy
• Ovulation induction drugs , ovarian drilling or IVF in PCOS.
• Progesterone or hCG in corpus luteum insufficiency .
:In anti-cardiolipin syndrome:
• Low dose aspirin ( 75 mg/day ) & prednisilone ( 20-30 mg / day),
starting when pregnancy is diagnosed till 37 weeks.
• These drugs are not teratogenic.
34. Recurrent abortion
Management:
In thrombophilia:
• Low dose aspirin ( 75 mg/day) starting when pregnancy is
diagnosed and low molecular weight heparin ie LMWH
( 20-40 mg/day) starting when fetal heart activity diagnosed
& to continue both till 37 weeks .
In uterine disorders
• Cervical cerclage in cervical incompetence, best time at the 14 weeks of
pregnancy.
• Myomectomy in submucus fibroid, excision of uterine septum in
septate & subseptate uterus & adhesolysis in Asherman's syndrome.
35. Recurrent abortion
Management:
In infection:: treatment of the genital tract infection.
In Rh isoimmunization: Repeated intrauterine transfusion
In parental balanced translocation
• Explain the risk of fetal chromosomal disorders ( about 30% )
• Encourage to try again or adoption.
