4. SpontaneousAbortion
Defined as the involuntary loss of the
products of conception prior to 24 weeks
gestation
It is thought that 15% of conceptions result in
miscarriage
Majority occur within first trimester
6. SpontaneousAbortion
Causes
Maldevelopment of the conceptus
Most common cause
Chromosomal abnormalities account for 70% of
defective conceptions
Spontaneous mutations may still arise
Defective Implantation
Hydatidiform Mole
Fibroids
7. SpontaneousAbortion
Causes
Maternal Infection
Due to high temperature relating to general
metabolic effect of fever
Result of transplacental passage of viruses, e.g.
Influenza
Rubella
Pneumonia
Toxoplasmosis
Cytomegalovirus
Listeriosis
Syphilis
Brucellosis
Appendicitis
9. SpontaneousAbortion
Causes
Endocrine Abnormalities
Poor development of the corpus luteum
Inadequate secretory endometrium
Low serum progesterone levels
UterineAbnormalities
Structural abnormalities implicated in 15% of early
pregnancy losses e.g.
Double uterus
Unicornuate, bicornuate, septate or subseptate uterus
Failure of uterus to develop to adult size,
remaining infantile
10. SpontaneousAbortion
Causes
Retroversion of the Uterus
Does not itself cause abortion
As uterus fails to enlarge into abdomen, vaginal and
abdominal manipulation to correct the retroversion
causes abortion
CervicalWeakness
Caused by laceration of cervix or undue stretching of
internal os as a result of previous medical abortion or
childbirth
Membranes bulge through cervical canal and rupture
Characterised by recurrent late pregnancy losses
11. SpontaneousAbortion
Causes
Environmental Factors
Environment teratogens such as lead and
radiation
Ingested teratogenetic substances such as drugs
(namely cocaine) and alcohol
Smoking
Maternal Age
Women in late 30’s and older at higher risk,
irrespective of previous obstetric history
12. SpontaneousAbortion
Causes
Stress and Anxiety
Severe emotional upset may disrupt hypothalmic
and pituitary functions
Paternal Factors
Poor sperm quality
Source of chromosomal abnormalities
Immunologocial Factors
Maternal lymphocytes with natural killer cell
activity may affect trophoblast development
Autoimmune diseases such as antiphospholipid
syndrome
14. SpontaneousAbortion
ThreatenedMiscarriage
Signs and Symptoms
Pain: Variable, possibly slight lower
abdominal pain or backache
Bleeding: Scant, during first 3 months
Cervical Os: Closed, no dilation
Uterus: If palpable, soft and not tender
15. SpontaneousAbortion
ThreatenedMiscarriage
No vaginal assessment as may provoke uterine
activity
No evidence that bedrest is effective
Woman should be referred for medical
attention straight away
A pregnancy test is carried out and ultrasound
performed to assess viability
Heavy or increased amount of bleeding in an
ominous sign and may precede inevitable
abortion
17. SpontaneousAbortion
InevitableMiscarriage
As name indicates, it is unavoidable pregnancy
loss
Gestational sac separates from uterine wall
and uterus contracts to expel the contents of
conception
Midwife should attend at once when called as
woman may collapse from blood loss
Speculum examination in hospital, input from
obstetrician or gynaecologist
Oxytocic drug may be given after products
expelled
19. SpontaneousAbortion
IncompleteMiscarriage
Gestational sac is incompletely expelled, with
usually the placental tissue retained
Static or slowly falling HCG levels
Evacuation of retained products of conception
from the uterus carried out
Medical management possible using
prostaglandin analogues such as misoprostol
If surgical evacuation required, woman should
be screened for chlamydial infection
Transfusion may be given if blood loss
excessive
21. SpontaneousAbortion
CompleteMiscarriage
Gestational sac completely expelled
History of abdominal pain, bleeding with
passing of clots and tissue
Once miscarriage is complete, pain and
bleeding subside, cervix closes
Ultrasound shows empty uterus coupled with
falling HCG levels
23. SpontaneousAbortion
MissedMiscarriage
Also known as delayed or silent abortion
Usually follows threatened abortion
Bleeding occurs between uterine wall and
gestational sac and embryo dies
Layers of blood clots form and later become
organised
Retainment of fetus inhibits menses
Other signs of pregnancy diminish
Confirmed by ultrasound
Surgical evacuation or expectant management
possible
25. SpontaneousAbortion
MissedMiscarriage–GestationalTrophoblasticDisease
Clinical presentation of Hydatidiform Mole
Exaggerated signs of pregnancy, appearing by 6-8
weeks due to high levels of HCG
Bleeding or a blood stained vaginal discharge after
period of amenorrhoea
Ruptured vesicles, resulting in light pink or brown
vaginal discharge, or detached vesicles, which may be
passed vaginally
Anaemia as a result of the gradual loss of blood
Early-onset pre-eclampsia
On examination, uterine size exceeding that expected
for gestation
On palpation, a uterus that feels ‘doughy’ or elastic
26. SpontaneousAbortion
MissedMiscarriage–GestationalTrophoblasticDisease
Hydatidiform Mole
Gross malformation of trophoblast
Chorionic villi proliferate and become avascular
Found in cavity of uterus and rarely within uterine
tube
Can lead to development of cancer, therefore
accurate and rapid diagnosis, treatment and follow-
up paramount
Two forms of mole
Complete hydatidiform mole (risk of choriocarcinoma)
Partial mole
27. SpontaneousAbortion
MissedMiscarriage–GestationalTrophoblasticDisease
Treatment of Hydatidiform Mole
Treatment is to remove all trophoblastic tissue
In some cases, mole will abort spontaneously
If this does not occur, vacuum aspiration or D and C
necessary
Spontaneous abortion carries less risk of malignant
change
Pregnancy to be avoided in follow up period
IUCDs contraindicated and hormonal methods of
contraception to be avoided until HCG levels normal
28. SpontaneousAbortion
MissedMiscarriage–GestationalTrophoblasticDisease
Choriocarcinoma
Malignant disease of trophoblastic tissue
HCG levels will rise and test will become strongly
positive again
May occur in next pregnancy following evacuation
of mole
Condition rapidly fatal unless treated
Disease spreads by local invasion and via
bloodstream
Metastases my occur in lungs, liver or brain
29. SpontaneousAbortion
MissedMiscarriage–GestationalTrophoblasticDisease
Treatment of Choriocarcinoma
Responds extremely well to chemotherapy
Cytotoxic drugs are used singly or in combination
with other therapy
Nearly always completely successful
Pregnancy should be avoided for at least one year
on completion of treatment
Subsequent pregnancy will require close HCG
monitoring as there is a risk of recurrance
31. SpontaneousAbortion
SepticMiscarriage
May occur after spontaneous or induced abortion,
more likely after incomplete miscarriage
Causitive organisms include Staphyloccus aureus,
Clostridium welchii, Escherichia coli, Klebsiella,
Serratia and Bacteroides species, and group B
haemolytic streptococci
Woman will feel acutely ill with fever, tachycardia,
headache, nausea and general malaise
High vaginal swab and blood cultures should be
taken
Antibiotics before any surgical intervention
Risks include septicaemia, endotoxic shock, DIC,
liver and renal damage, salpingitis and infertility
32. SpontaneousAbortion
MidwiferyAssessments
Blood loss
Amount?
Nature?
When did it start?
What were you doing
at the time?
Pain
Menstrual History
Confirm LMP
Symptoms of Pregnancy
Still present?
Have they changed?
Obstetric History
Gynaecological History
Cervical infections
Cervical operations
Contraceptive History
Blood Group and Rhesus
Status
33. SpontaneousAbortion
MidwiferyResponsibilities
Referral
Support groups
Recurrent miscarriage clinic
GP/gynaecologist-obstetrician
Advice
Expect a grief reaction
Dependent on gestation, lactation may occur
Understand it takes weeks – months to recover from a miscarriage
physically and even longer emotionally
Menstruation may return four to six weeks later
Await the next normal period before trying to conceive
Expect bleeding for up to two weeks
No intercourse, swimming, tampons for two weeks or duration of
bleeding
Support
Remember the partner too
35. ImplantationBleeding
As the trophoblast erodes the endometrial
endothelium and the blastocyst implants, a
small vaginal loss may be apparent
Occurs at approximately 10-12 days post
conception, around the same time as
expected menses and may be mistaken for a
woman’s period, although abnormal (usually
bright red and lighter)
It is significant when calculating LMP for
estimation of due date
37. Decidual Bleeding
Occasionally there is bleeding from the decidua
during the first 10 weeks, usually at around the
time menses is expected
Caused by menstrual hormones
Especially common in the early stages of
pregnancy, before the lining has completely
attached to the placenta
Not thought to be a health threat to mother
or fetus
May affect calculation of EDD
39. EctopicPregnancy
Occurs when a fertilised ovum implants itself
outside the uterine cavity
Sites can include the uterine tube, an ovary,
the cervix or the abdomen
95% implant in the uterine tube (tubal
pregnancy), of which 64% are implanted in
the ampulla of the fallopian tube (where
fertilisation takes place)
40. EctopicPregnancy
RiskFactors
Any alterations of the normal function of the uterine
tube in transporting gametes contributes to the risk of
ectopic pregnancy:
Previous ectopic pregnancy
Previous surgery on the uterine tube, pelvic or abdominal
surgery which may cause adhesions
Exposure to diethylstillboestrol in utero (postcoital
contraception)
Congenital abnormalities of the tube
Endometriosis
Previous infection including chlamydia, gonorrhoea and pelvic
inflammatory disease
Use of intrauterine contraceptive devices
Assisted reproductive technology
Delayed childbearing (>35 years)
42. EctopicPregnancy
ClinicalPresentation
Pelvic pain can be very severe
Acute symptoms are the result of tubal rupture (more
likely to occur between 5-7 weeks gestation) and relate
to the degree of haemorrhage there has been
Ultrasound enables an accurate diagnosis of tubal
pregnancy, making management more proactive
Vaginal ultrasound, combined with the use of sensitive
blood and urine tests which detect the presence of
HCG, helps to ensure diagnosis is made earlier
If the tube ruptures, shock may ensue; therefore
resuscitation, followed by laparotomy, is needed
The mother should be offered follow-up support and
information regarding subsequent pregnancies
43. EctopicPregnancy
Diagnosis
The woman will give a history of early pregnancy signs
The uterus will have enlarged and feel soft
Abdominal pain may occur as the tube distends and
uterine bleeding may be present
Abdomen may be tender and distended
Shoulder tip pain due to referred pain
Woman may appear pale, complain of nausea and
collapse
Severe pain felt during pelvic exam
A mass may be felt on one side of the uterus
Hormonal assay will find progesterone levels low and
hCG levels falling
USS may show fluid or and mass in pelvic cavity and
absence of intrauterine pregnancy
45. EctopicPregnancy
Treatment
Common perception is that everyone with an
ectopic needs an operation to deal with it
However, a number of treatment options are
available including expectant management if
no bleeding, pain or shock
If there is evidence of pain and bleeding
producing shock, immediate treatment is
essential, as it is a life-threatening condition
This is a surgical emergency and in most
cases a laparotomy is performed
46. EctopicPregnancy
SurgicalTreatment
Salpingectomy
Salpingectomy (tubal removal) is the principle
treatment especially where there is tubal rupture
Salpingotomy
Conservative surgical management may be
employed when the ectopic has not ruptured and
where the tube appears normal
This is called salpingotomy, where the ectopic is
removed and the tube allowed to heal
47. EctopicPregnancy
ExpectantTreatment
Used when pain is less and indicators are that the
ectopic is a small one or it is not bleeding too much
Expectant approach involves close follow up with hCG
tests every 2-7 days until levels have returned to
normal
Is successful in 90% of selected patients
Methotrexate – a drug that destroys actively growing
tissues such as the placental tissues that support the
pregnancy is used as an injection in selected cases to
avoid surgery (in non ruptured ectopic)
Side effects include abdominal pain for 3 – 7 days in
50% of cases and mild symptoms of nausea, mouth
dryness and soreness and diarrhoea
49. AntepartumHaemorrhage
Defined as bleeding from the genital tract
after the 24th week of gestation and before
the onset of labour
Bleeding during labour is referred to as
Intrapartum Haemorrhage
Bleeding usually due to placental separation,
but can also be due to incidental causes from
extraplacental sites in the birth canal, such as
cervical polyps or some other local lesion
50. AntepartumHaemorrhage
EffectsontheFetus
Mortality and Morbidity increased as a result
of severe vaginal bleeding in pregnancy
Stillbirth or neonatal death may occur
Premature separation of the placenta and
subsequent hypoxia may result in severe
neurological damage in the baby
51. AntepartumHaemorrhage
EffectsontheMother
If bleeding is severe, it may be accompanied by
shock and disseminated intravascular
coagulation (DIC)
The mother may die or be left with permanent
ill health
APH is unpredictable and the woman’s
condition can deteriorate rapidly at any time
Rapid decisions about the urgency of need for
medical or paramedic presence, or both, must
be made often at the same time as observing
and talking to the woman and her partner
53. AntepartumHaemorrhage
InitialAssessmentofPhysicalCondition
Take a detailed history from the woman
Take observations: Temperature, Pulse,
Respiratory Rate, Blood Pressure
Observe for any pallor or breathlessness
Assess the amount of blood loss
Perform a gentle abdominal examination,
observing signs that the woman is going into
labour
54. AntepartumHaemorrhage
InitialAssessmentofPhysicalCondition
Ask the mother is the baby has been moving as
much as normal
Attempt to auscaltate the fetal heart
Insert large bore canula, take bloods for FBC,
Cross match, LFTs, Clotting times, Kleihaur if
necessary
Obstetric referral
Anti-D administration if applicable
Steroids if <34 weeks gestation
56. DifferentialDiagnosis
Pain
Did the pain precede bleeding and is it continuous or
intermittent?
Onset of bleeding
Was this associate with any event such as coitus?
Amount of blood loss visible
Is there any reason to suspect that some blood has been
retained in utero?
Colour of the blood
Is it bright red or darker in colour?
Degree of shock
Is this commensurate with the amount of blood visible or
more severe?
57. DifferentialDiagnosis
Consistency of the abdomen
Is it soft or tense and board-like?
Tenderness of the abdomen
Does the mother resent abdominal palpation?
Lie, presentation and engagement
Are any of these abnormal when account is taken of parity and
gestation?
Audibility of the fetal heart
Is the fetal heart heard?
Ultrasound scan
Does a scan suggest that the placenta is in the lower uterine
segment?
58. AntenatalHaemorrhage
SupportiveTreatment
Provide woman and partner with emotional
reassurance
Give rapid fluid replacement (warmed) with a
plasma expander, and later with whole blood if
necessary
Give analgesia
If at home, arrange transfer to hospital
Subsequent management depends on the
definite diagnosis
61. PlacentalAbruption
Premature separation of a normally situated
placenta, occurring after the 24th week of
pregnancy
Aetiology is not always clear, some predisposing
factors are:
Pregnancy-induced hypertension or pre-eclampsia
A sudden reduction in uterine size, e.g. SRM with
polyhydramnios or after the birth of a first twin
Short umbilical cord
Direct trauma to the abdomen (risk remains for 2 days
following trauma)
High parity
Previous caesarean section
Cigarette smoking or illicit drug use (esp. Cocaine)
62. PlacentalAbruption
Blood loss may be:
Revealed
Concealed
Mixed
Separation may be:
Mild
Moderate
Severe
Complications of Placental Abruption:
Disseminated Intravascular Coagulation
Postpartum Haemorrhage
Renal Failure
Pituitary Necrosis
63. PlacentalAbruption
MildSeparationofthePlacenta
Separation and the haemorrhage are minimal
Mother and fetus are in a stable condition
No indication of maternal shock
Fetus is alive, with normal heart sounds
Consistency of uterus is normal
No tenderness on abdominal palpation
64. PlacentalAbruption
ManagementofMildSeparationofthePlacenta
Ultrasound scan
Determine placental location
Identify any degree of concealed bleeding
Monitoring of fetal heart rate
Frequently to assess fetal condition whilst bleeding
persists
CTG should be carried out once or twice daily
Admission to hospital
Women who are not yet 37 weeks gestation may be
cared for in an antenatal ward for a few days
May be discharged if there is no further bleeding and
placenta has been found to be in the upper uterine
segment
65. PlacentalAbruption
ManagementofMildSeparationofthePlacenta
Induction of Labour
May be offered for woman who have passed the 37th
week of pregnancy
Especially if there has been more than one episode of
mild bleeding
Further management
Heavy bleeding or evidence of fetal distress may
indicate that a caesarean section is necessary
66. PlacentalAbruption
ModerateSeparationofthePlacenta
Separation of about one-quarter
Considerable amount of blood may be lost, some
of which will escape from the vagina and some
will be retained as a retroplacental clot or an
extravasation into the uterine muscle
Mother will be shocked, with tachycardia and
hypotension
Degree of uterine tenderness with abdominal
guarding
Fetus may be alive, although hypoxic and
intrauterine death is also a possibility
68. PlacentalAbruption
ManagementofModerateSeparationofthePlacenta
If fetus is alive or has already died, vaginal birth
may be contemplated
Such a birth is advantageous because it enables
the uterus to contract and control the bleeding
Spontaneous labour frequently accompanies
moderately severe abruption, but if it does not,
then amniotomy is usually sufficient to induce
labour
Syntocinon may be used with great care, if
necessary
Delivery is often quite sudden, after a short labour
Drugs to attempt to cease labour is usually
inappropriate
69. PlacentalAbruption
SevereSeparationofthePlacenta
Acute obstetric emergency
Two-thirds of the placenta has become
detached
2000 mls of blood or more are lost from the
maternal circulation
Most or all of the blood can be concealed
behind the placenta
Woman will be severely shocked, perhaps to a
degree far beyond what might be expected
from the amount of blood loss visible
70. PlacentalAbruption
SevereSeparationofthePlacenta
Woman will have severe abdominal pain with
excruciating tenderness; the uterus has a
board like consistency
Hypotensive, however woman may be
normotensive owing to preceding
hypertension
The fetus will almost certainly be dead
Features associated with severe haemorrhage:
Coagulation defects (e.g. DIC)
Renal failure
Pituitary failure
71. PlacentalAbruption
ManagementofSevereSeparationofthePlacenta
Treatment is same as for moderate separation
Whole bloods transfused rapidly and subsequent amounts
calculated in accordance with the woman’s central venous
pressure
Labour may begin spontaneously in advance of amniotomy
and the midwife should be alert for signs of uterine
contraction causing periodic intensifying of abdominal pain
However, if bleeding continues of a compromised fetal heart
rate is present, caesarean section may be required as soon as
the woman is adequately stable
The woman requires constant explanation and psychological
support, despite the fact that her shocked condition may
mean she is not fully conscious
Pain relief must be considered
Don’t forget the partner!
73. PlacentaPraevia
Placenta partially or wholly implanted in the
lower uterine segment on either the anterior
or posterior wall
Lower segment of uterus grows and stretches
progressively after the 12th week of
pregnancy
In later weeks, this may cause the placenta to
separate and severe bleeding can occur
74. PlacentaPraevia
DegreeofPlacentaPraevia
Type 1 Placenta Praevia
Majority of placenta is in the upper uterine segment
Blood loss is usually mild
Mother and fetus remain in good condition
Vaginal birth is possible
Type 2 Placenta Praevia
Placenta is partially located in the lower segment near
the internal cervical os
Blood loss is usually moderate
Condition of mother and fetus can vary
Vaginal birth is possible, particularly if placenta is
anterior
75. PlacentaPraevia
DegreeofPlacentaPraevia
Type 3 Placenta Praevia
Placenta is located over the internal cervical os but not
centrally
Bleeding is likely to be severe
Vaginal birth is inappropriate
Type 4 Placenta Praevia
The placenta is located centrally over the internal
cervical os
Torrential haemorrhage is very likely
Caesarean section is essential
76. Indicationsof PlacentaPraevia
Bleeding from vagina is the only sign, and it is
painless
Uterus is not tender or tense
Presence of placenta preavia should be
considered when:
Fetal head is not engaged in a primigravida (after 36
weeks gestation)
There is a malpresentation, especially breech
The lie is oblique or transverse
The lie is unstable, usually in a multigravida
Location of the placenta under USS will confirm
the existence and extent of placenta praevia
77. Managementof PlacentaPraevia
Management of placenta praevia depends
on:
The amount of bleeding
The condition of mother and fetus
The location of the placenta
The stage of pregnancy
