TYPES OF ABORTION

FEATURES
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

THREATENED
ABORTION

1.

INEVITABLE
ABORTION

1. History
Heavy vaginal bleeding.
with no passage of products conception (inevitable)
with passage of products of conception (incomplete
abortion)
Severe lower abdominal pain which follows the
bleeding
2. Examinations
Poor general condition.
The cervix is dilating and products of conception may
pass thru 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
1. History
Heavy vaginal bleeding which has been stopped.
Lower abdominal pain which follows the bleeding
which has been stopped.

INCOMPLETE
ABORTION

COMPLETE
ABORTION

MANAGEMENT
1. Reassurance If fetal heart activity is
present, > 90% of cases will be
progressed satisfactorily
2. Advice: Decrease physical activity, avoid
intercourse
3. Hormones i.e. Progesterone & hCG to
support pregnancy, (no proven value)
4. Anti- D: 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
Coz liable to late pregnancy complications
such as APH and preterm labour.
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.

1. Evacuation & curettage in the presence of

RPOC.
2. Post-abortion management.

MISSED
ABORTION

ANEMBRYONI
C
PREGNANCY
(BLIGHTED
OVUM)

2. Examination: The cervix is closed

3. U/S : Showed empty uterine cavity or PROP
1. Most are diagnosed accidentally
1. CBC , blood grouping, XM 2 units of blood
during routine U/S in early pregnancy. 2. Platelets count: to exclude the risk of DIC
In some cases there may be a history
NB : DIC does not occur before 5 weeks of missed abortion or
of:
IUFD and if occurred will be of mild grade
Episodes of mild vaginal bleeding 3. Options of treatment
Conservative treatment: if left alone spontaneous
Regression of early symptoms of
expulsion will occur
pregnancy.

Surgical evacuation of the uterus; by D & C: Indicated in 1 st

Stop of fetal movements after 20
trimester missed abortion
weeks gestation.
Medical termination of pregnancy: by Misoprostol (PGE1)
2. Examination: The uterus may be
small for date
Cytotec: Indicated in 1st & 2nd trimesters missed abortions.
3. U/S (essential for dx) diagnosed if
Cytotec vaginal ( is the best) or oral tab. 200 g, 2 tab/ 3
two ultrasound (T/V or T/A) at least
hrs/ up to 5 doses daily, which can be repeated next day if
7days apart showed an embryo of >7
there is no response in the first day
wks gestation (CRL >6mm in
Subsequent surgical evacuation is needed in cases of
diameter and gestational sac >20
RPOC
mm in diameter) with no evidence of
Main side effects of cytotec: Nausea, vomit & fever.
heart activity.
3. Post-abortion management.
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.

SEPTIC
ABORTION

Def: Incomplete abortion complicated by infection of the uterine

contents. May be due to criminal interference.
Features : Poor general condition
Features of incomplete abortion: Severe vaginal bleeding with
passage of product of conception, with/without hx of evacuation.
Features of pelvic infection: Pyrexia , tachycardia , general malaise
, lower ab pain, pelvic tenderness & purulent vaginal discharge.
Bacteriology : Mixed infection
The commonest organisms are :
1. Gram -ve: E.coli , strep & staph
2. Anaerobics: Bacteroides
Rarely Cl. tetani - 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%

1. Investigations :
CBC, blood grouping, XM 2
units of blood.
Cervical swabs (not vaginal)
for culture and sensitivity
Coagulation profile , serum
electrolytes & blood culture
if pyrexia > 38.5
2. Antibiotics: IV Cephalosporin +
IV Metronidazole
3. Surgical evacuation of uterus
usually 12 hrs after
antibiotic therapy (until
reasonable tissue levels of
antibiotics achieved)
4. Post-abortion management.

RECURREN
T
ABORTION

Definition: 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 .
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 & Ashermans syndrome
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

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.
3. investigations :
A. Investigations for medical disorders:
Blood grouping & indirect Coombs test in
Rh ve women
Endocrinal screening: Blood sugar , TFT &
LH /FSH ratio
Immunological screening: Anti
anticardiolipin 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
unnecessary)
B. Investigations for anatomical disorders:
TV/US: fibroids, cervical incompetence &
PCOS.
Hysteroscopy or HSG, fibroids, cervical
incompetence, uterine anomalies &
Asherman's syndrome
C. Investigations for chromosomal disorders:
Parental karyotyping: Parental balanced

abortion, but ToRH are not causes of

recurrent abortion.
Genital tract infection e.g Bacterial
vaginosis
Rh isoimmunization

translocation.
Fetal karyotyping: Fetal chromosomal
anomalies.

Management
Idiopathic Recurrent Abortion
In the Presence of Cause
With support and good antenatal care , the chance of Treat the cause
successful spontaneous pregnancy is about 60-70%
Endocrine disorders
Support : from husband, family & obstetric
Control DM and thyroid disorders before
staff.
pregnancy
Advice : stop smoking & alcohol intake,

Ovulation induction drugs , ovarian drilling

or IVF in PCOS.
decrease physical activity

Progesterone or hCG in corpus luteum

Tender loving care
insufficiency
.
Drug therapy

In
anti-cardiolipin
syndrome:

Progesterone & hCG: start from the luteal

Low dose aspirin ( 75 mg/day ) & prednisilone
phase & up to 12 weeks.
( 20-30 mg / day), starting when pregnancy is
Low dose aspirin ( 75 mg/day ) start from
diagnosed till 37 weeks.
the diagnosis of pregnancy & up to 37
These drugs are not teratogenic.
weeks
In thrombophilia:
LMWH (20-40 mg/day) start from the
Low dose aspirin ( 75 mg/day) starting when
diagnosis of fetal heart activity & up to 37
pregnancy is diagnosed and low molecular weight
ws
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.
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.

COMPLICATIONS OF ABORTION
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 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.

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 .
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.
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 ..

MISCARRIAGE
(ABORTION)
Def: Expulsion or extraction of products of conception before fetal viability i.e. before 24 weeks of gestation.
Incidence :
Is the commonest 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.
ETIOLOGY
1st Trimester Abortion
2nd Trimester Abortion
1. Fetal chromosomal abnormalities - particularly trisomy, triploidy & monosomy
1. Multiple pregnancy
- is the commonest cause of abortion
2. Cervical incompetence (congenital &
- 50 70 % of the first trimester abortions are due to chromosomal abnormalities
acquired )
- the incidence of these abnormalities increased with the increase in the maternal 3. Uterine anomalies and submucous
age
fibroid
2. Anembryonic pregnancy - Blighted ovum
4. Genital tract infection and PROM
3. Multiple pregnancy
4. Parental balanced translocation
5. Infections: genital tract infection , systemic infection with pyrexia & ToRCH
syndrome
6. Endocrine disorders : Diabetes, thyroid disorders , PCOS & corpus luteum
insufficiency
7. Uterine disorders: Uterine anomalies , submucus fibroid & Ashermans
syndrome
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