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  1. 1. AbortionAbortionDr. Fakher ShatnawiDr. Fakher ShatnawiAl-Bashir HospitalAl-Bashir Hospital
  2. 2. Bleeding from the genital tract before viability due to:-Abortion-Ectopic pregnancy-vesicular mole-Local conditions (cervical erosion , polyps, ca……)-Hartman bleeding : bleeding at the time of expectedmenses before 12 weeks( due to shedding of part of the decidua
  3. 3. Definition of abortion:Spontaneous or artificial termination of pregnancybefore viability of the fetus.Viability: reasonable chance of the fetus for extrauterine survival*Was before 28 weeks*Now before 24 weeks*In some countries before 22 weeks
  4. 4. Incidence of abortion:Clinical (10-15%) 12%Preclinical (25-30%)The overall incidence of AB. Is 45%Even more
  5. 5. * 75-80% of abortion occurs before 12 weeks gestation* pts who have no live born and have hx of one abortion theincidence of abortion in the next pregnancy is 20%* Same pts but with hx of 2 abortions the incidence ofabortion in the next pregnancy is 35%* Same pts with hx of 3 abortions the incidence increase to45%
  6. 6. *Habitual abortion ( Recurrent ) : if 3 or more successivespontaneous abortion*Abortion:Early abortions which occurs before 12 weeksLate abortion which occur between 13-24 weeks gestation…Most of early abortions are unembryonicabortionsBlighted ovum*Usually early abortions due to fetal causes but Lateabortions usually due to maternal causes
  7. 7. #Important points :-abortions increase after the age of 30s-abortioins increase more after the age of 35 yearsThis increase is about 9 times than pts aged between 20-29years-the risk of abortion increases with increased gravidity.(parity)-the risk of abortion increases with increasesd maternal andpaternal age (mostly the maternal one)
  8. 8. Ethiology of abortion:1.Fetal couses (occur in early abortions)--chr. abnormalities (50-60%)The most common are *trisomies the commonest is trisomy16(21,22)This frequently seen in blighted ova*triploidy : 69 chr. (15-20%) of chr.abnormalities seen in abortions molar pregnancy*monosomies : (45x)1:15 of all monosomies will not abort TURNER SYNDROMtoxoplasmosieslysteria monocytogenes--infections : rubellacytomegalovirusherpes simplexsyphilisinfictions are not considered as frequent couses of recurrentabortions , because they couse abortions only during there acute attacks
  9. 9. 2.Maternal causes:Usually lead to abortion in late pregnancy (13-24) weeks*local causes in the uterus1.Uterine anomalies -spetate uterus-bicornuate uterus-hypoplastic uterus-unicornuate uterusthe cause of abortion is:--decreased uterine blood supply--decreased uterine cavity2.Uterine synechia (Asher man syndrome)3.Submucous fibroidsdecrease of blood supplyweek decidualization4.Cervical incompetence:-congenital-iatrogenic*chronic maternal diseases:(A).chr. Nephritis(B). Renal failure(C). Uncontrolled D.M.
  10. 10. *Endocrine causes:1. Luteal phase defect…. (progesterone deficiency) due to weekcorpus luteum2. Hypothyroidism (increase prolactin hormone)3. Immunological causes:-Anticardiolipins Abds.Antiphopholipids Abds.-Lupus anticoagulantThese Abds. Lead to Thrombosis in placental vaseles withprolonged PTT at the same time.The antiphospholipd syndr. Leads to sever and early preclampsia< 20 wksIf pregnancy continue I.U.G.R*Other causes:1.Acute fever ( by activation of P.G.)2.Acute hydramnios ( occurs early before 24 wks. While chr. Hydramniosoccurs late > 24 wks. Gestation )3.Direct trauma to the abdomen4.Radiation-ergots (Methergin , Syntometrine)5.Drugs -Prostaglandins ( cytotec)-Kenins
  11. 11. Types of Abortion:-Threatened Ab.-Missed Ab.-Complete Ab.-Incomplete Ab.-Inevitable Ab.-Septic Ab. May be with any type ofmentioned Abs.Abortions-Medical Ab.-Criminal Ab.septic Abs. mainly occurs with criminal one**Threatened AB.mild separation of the products of conception.Symptoms :-That of early pregnancy still present-Mild-moderate vaginal bleeding-Mild lower abdominal pain#.vaginal ex.:-uterine size coresponds with gestational age-Cx. Is closed
  12. 12. #.Ultrasound alive fetus#.Treatment:-bed rest-No sexual intercourse-Sedation ( mental rest )-Treat the cause ( progesterone if luteal phaseinsufficiency …..etc).**Missed AB.The fetus is dead and retained in uterus.#.symptoms :-cessation of fetal movements if already present(>18 wks)-sometimes brownish vaginal discharge#.Vaginal ex. :-uterus is smaller than expected gestational age-Cx. Is closed…US: No F.H.B. could be seenif pregnancy is >10 wks and if the fetal death is >4 wks we must ROD.I.C. by doing the coagulation profile:-PT , PTT-S.Fibrinogen-Plat.count-D.dimer
  13. 13. If coagulation profile is normal , D&C is the treatment for missedAb. If gestation Age is less than 12 wks. (But) if gestational age is >12 wks and bony elements are Present by ultrasound ex. ( of thefetus ) , then medical evacuation of the uterus is The best treatment byusing :-cytotectab.-R.U.486-P.G.N.B: Hypofibrinogenemia occurs if the death of the fetus is > 4wks. , due to release of Thromboplasin material from fetal tissue tomaternal ciculation**Inevitable AB.:marked separation of the products of conception-Sever bleeding (with clots).- -Sever lower abdominal painEx.: the Cx is usually dilated. Pts may have signs of hypovolemic shock ifbleeding is sever.after 12 wks. Gestation ruptured of membranes indicates inevitable
  14. 14. **Complete & incomplete Ab.:**Complete Ab:all products of conception are expelled from uterinecavityThe bleeding and the pain are not present( stopped)The Cx is closedultrasound ex. Empty uterus**Incomplete Ab.:Parts of the products of conception are still inside theuteruspts still have vaginal bleedingpts still have lower abdominal painCx-openedultrasound : uterus bulky with products ofconception
  15. 15. **Septic AB.infection superimposed on any type of mentioned Ab.The causative organisms:-streptococci β hemolytic (the commonest organismisolated)-Staphylococci-clostridium Welchii-other organism = gr.+ve-veThe route of infection :-exogenous-endogenousSeptic Ab. Is mostly seen in criminal Abs.…Symptomes and signs:-That of abortion-fever-Lower Abd pain-tachycardia-lower Abdominal tenderness
  16. 16. **Treatment:*-isolation of the pt.*-exclude septic shock (hypothermia)*-start Antibiotics as rules to cover both gr. +ve & gr.-ve and tocover anaerobes as well as aerobes. ( Ampcillins + Gentamycins +metronidazol)until the results of the culture is ready.If clostridium Welchii is isolated Give Anti-gas gangrene +Penicilin (Ampicilin)*-Evacuation of the uterus ( drainage) within 24 hrs afterantibioticsif gestation <12 wks better by digital evacuation or suctioncurettage, and if >12 wks gestation by prostaglandins.Hysterectomy : is rarely needed if infection by clostridiumproducing gangrene to the uterine tissue.
  17. 17. Cx - Incompletence:1. Congenital type usually is associated with otheruterine anomalies2.Iatrogenic type :-after D&C-cervical injury:A. Conisation (cone biopsy) C.I.N.B.After delivery (cervical tears)C.Deep cautary ( incompetence or stenosis)This type of Cx ( incompetent one) leads to Ab. Inthe second trimestre (>12-24 wks)usually it is painless Ab.(or little pain)By ultrasound Funyl shape of the internal os
  18. 18. Diagnosis :*-ultrasound (T.Y.V.U) (vaginal ultrasound)*-Heigger test*-HistoryTreatment:*cervical circalage-shrudkar stich-Mc.Donalled stichthe stich is inserted > 12 wks but check fetalviability before insertion the stich ( by ultrasound)
  19. 19. Recurrent Ab.:If 3 or more succesive abortionsthis usually increase the risk of ectopic pregnancy.*Remember:**give Anti-D if pts. Blood group is –ve ( her husbands group is +ve). After all types ofabortion.**after cervical stich ( cervical incompetence) No need to give Anti-D if pts bloodgroup is -ve