2. SPONTANEOUS ABORTION OR
MISCARRIAGE
◦ Abortion/ miscarriage is termination of pregnancy < 20 weeks of gestation or fetus weight < 500 gms.
◦ About 15 % of all conceptions end in miscarriage.
◦ TYPES OF SPONTANEOUS ABORTIONS:
Threatened abortion
Inevitable abortion
Incomplete abortion
Complete abortion
Blighted ovum
Missed abortion
Septic abortion
Recurrent abortion/ miscarriage ( 3 or more consecutive abortions)
3. COMMON CAUSES OF ABORTION
◦ FIRST TRIMESTER:
1) Chromosomal anomalies
2) Immunological causes (esp.
antiphospholipid syndrome)
3) Endocrinal causes (luteal phase
defect, thyroid disorders, diabetes)
4) Genitourinary and systemic
infections
5) Unexplained causes
o SECOND TRIMESTER:
1) Anatomical (cervical insufficiency, uterine
malformations, asherman’s syndrome,
leiomyoma)
2) Autoimmune causes
3) Medical diseases (SLE, renal disease,
diabetes)
4) Maternal infections (syphilis,
toxoplasmosis)
5) Unexplained causes
4. PATHOPHYSIOLOGY OF ABORTION
◦ BEFORE 8 WEEKS- complete and intact gestational sac (ovum surrounded by villi and decidual covering)
is usually passed
◦ BETWEEN 8- 14 WEEKS – expulsion of fetus occurs; placenta and membranes left attached to uterine
wall causing bleeding; may need surgical evacuation.
◦ BEYOND 14 WEEKS- passage of fetus followed by placenta; complete abortion like a miniature labor.
◦ In threatened abortion, cervix is closed while it is open in inevitable and incomplete abortion.
5. THREATENED MISCARRIAGE
(ABORTION)
o Process of abortion has started but further progression can be averted and pregnancy can be continued.
o COMPLAINTS OF:
• Amenorrhea
• Bleeding per vaginum
• Pain (may or may not be there)
o PER VAGINUM: external os is closed.
o MANAGEMENT: conservative; bed rest, Progesterones; reassess patient after one month to assess the growth of fetus by
ultrasound.
6. INEVITABLE MISCARRIAGE
(ABORTION)
◦ Abortion has progressed to the extent that expulsion of products of conception is inevitable; pregnancy can’t be continued.
◦ CLINICAL FEATURES:
Amenorrhea followed by excessive vaginal bleeding
Excessive colicky pain in lower abdomen or pelvis
GENERAL CONDITION: patient is bleeding profusely, may be in shock; may have tachycardia and/or hypotension.
PER SPECULUM: cervix is open; clots and products can be seen protruding through the cervix along with bleeding.
7. ◦ PELVIC EXAMINATION: internal and external os are open, products of conception felt.
◦ MANAGEMENT:
◦ Correct patient’s general condition and hypovolemia (use of crystalloids, colloids and blood transfusion)
◦ Injection TT 0.5 ml im given.
◦ Take up evacuation in operation theatre after taking consent.
< 12 weeks: D&E, suction evacuation or Manual Vacuum Aspiration (MVA)
>12 weeks:
Oxytocin drip
Tablet misoprostol 400 mcg orally or vaginally
o After fetus and placenta are expelled, perform USG to confirm that the uterine cavity is empty.
8. INCOMPLETE (MISCARRIAGE)
ABORTION
◦ Products of conception are partly expelled.
◦ CLINICAL FEATURES:
Anemia and shock
History of passage of products and blood clots.
Continual vaginal bleeding.
Colicky lower abdominal pain and pelvic pain.
o INTERNAL EXAMINATION:
Size of uterus < gestational age
Open cervix admitting tip of finger with products felt in uterus.
9. ◦ ULTRASONOGRAPHY FINDINGS:
Uterine cavity shows products of conception.
Cardiac activity not localized.
Fetus not seen.
o SURGICAL PROCEDURE:
Dilatation & Evacuation and suction evacuation or Manual Vacuum Aspiration (MVA)
If patient is stable: T. Misoprostol 400 mcg vaginally amd repeated after 4-6 hours.
10. COMPLETE ABORTION
(MISCARRIAGE)
◦ Patient has bleeding per vaginum and expulsion of all products of conception from uterus.
◦ Cavity is completely empty when patient presents in hospital.
◦ GENERAL CONDITION: stable.
◦ PER SPECULUM: bleeding may or may not be observed; external os is closed.
◦ PELVIC EXAMINATION: size of uterus is normal/ bulky but size < period of amenorrhea. The consistency of uterus is firm.
◦ MANAGEMENT: no treatment; only reassurance required.
11. MISSED ABORTION (SILENT
MISCARRIAGE)
◦ Death of fetus before 20 weeks of gestation with retention of all products of conception.
◦ CLINICAL FEATURES:
History of amenorrhea and signs & symptoms of pregnancy.
Brownish or dark coloured vaginal discharge.
o GENERAL PHYSICAL EXAMINATION: stable
o COMPLICATIONS:
Infection
Disseminated intravascular coagulation (DIC)
12. ◦ ULTRASONOGRAHY is mandatory for making diagnosis.
Absent cardiac activity.
Evidence of collapse of fetal skeletal system or a collapsed fetal skull if pregnancy > 16 weeks duration.
o MANAGEMENT:
< 12 weeks: suction evacuation, dilatation and evacuation or manual vacuum aspiration (MVA); medical management with T.
misoprostol.
> 12 weeks:
Misoprostol 200 mcg vaginally every 4 hours (max. 5 doses).
Carboprost 250 mcg im 3 hourly.
Oxytocin drip in increasing dose.
Dilatation and evacuation.
13. RECURRENT MISCARRIAGE/
RECURRENT PREGNANCY LOSS
◦ Recurrent miscarriage: occurrence of three of more consecutive (sequential) spontaneous abortions before 20 weeks of gestation.
◦ INCIDENCE:
1% women.
Risk increases by 10 % with each abortion
Risk being 24 % after two clinically recognized losses
30 % after three losses
40-50 % after four losses
14. FIRST TRIMESTER RECURRENT MISCARRIAGE:
1) CHROMOSOMAL ANOMALIES (3-5 %):
i. Parental chromosomal anomalies
ii. Most common chromosomal anomaly: balanced translocation (risk = 25%)
2 ) ENDOCRINE & METABOLIC CAUSES:
i. Uncontrolled diabetes mellitus
ii. Thyroid disorders
iii. Luteal phase defect (LPD): decreased progesterone levels
iv. Hypersecretion of LH (as in PCOS)
v. Prolactin disorders (hyperprolactinemia)
15. 3) INFECTIONS (RARE CAUSE)
4) INHERITED THROMBOPHILIA:
i. Protein C resistance (Factor V Leiden mutation)
ii. Hyperhomocystinemia
iii. Antithrombin III deficiency
iv. Prothrombin gene mutation
5) IMMUNOLOGICAL CAUSES:
i. Autoimmune factors (immunity against self):
High levels of antiphospholipid antibodies (APLA), lupus anticoagulant and anticardiolipin antibodies lead to repeated
miscarriages.
Frequency of miscarriage in untreated group with this condition is 85- 90%.
Majority of losses ~ 2nd trimester.
16. ii. Antinuclear antibodies (ANA)
iii. Alloimmune (immunity against other person- fetus and father) factors
• Detected by: cytotoxic antibodies to paternal leucocytes and testing for blocking factors for maternal-paternal mixed lymphocytic
reactions.
• Deficient production of serum blocking factors by mother due to sharing of human leucocyte antigen (HLA) with her husband.
• Altered natural killer cell activity and raised lymphocytotoxic antibodies in maternal serum can also be responsible.
6) UNKNOWN CAUSE (majority)
17. SECOND TRIMESTER RECURRENT MISCARRIAGE:
1) ANATOMICAL ABNORMALITIES: (10-15 %)
i. Congenital abnormalities: congenital mullerian duct anomalies (like unicornuate, uterus didelphys, bicornuate uterus,
septate or subseptate uterus); Congenital cervical insufficiency.
ii. Acquired anomalies: intrauterine adhesions (Asherman’s syndrome), previous cervical surgery or tears, uterine fibroids
and cervical incompetence.
2) AUTOIMMUNE FACTORS: anti-phospholipid antibody (APLA) syndrome
3) MATERNAL MEDICAL DISORDERS (sle, renal diseases, uncontrolled diabetes)
4) MATERNAL INFECTIONS (syphilis and toxoplasma)
18. HISTORY TAKING: Medical, surgical, obstetric, family history should be taken.
EXAMINATION:
1) GENERAL OBSERVATION of patient for health and nutritional status such as height, weight, body mass index, pulse,
BP, respiratory rate. Look for anemia, galactorrhea, thyroid or lymph node swelling. Look for position of breasts,
distribution of hair.
2) SYSTEMIC EXAMINATION: per abdomen examination: look for any mass, scar of surgery, free fluid and hernial sites.
3) PER SPECULUM EXAMINATION: exclude any vaginal infection and Mullerian duct anomalies.
4) VAGINAL EXAMINATION: to assess size of uterus, consistency of cervix, Mullerian anomaly.
19. INVESTIGATIONS:
1) BASELINE INVESTIGATIONS IN NON-PREGNANT STATE:
◦ Glucose tolerance test with 75 gm glucose
◦ VDRL
◦ Blood group and Rh typing
2) SPECIAL TESTS:
◦ Thyroid profile
◦ Glycosylated hemoglobin level
◦ Serum insulin (fasting)
◦ Anti cardiolipin antibodies, anti-phospholipid antibodies, lupus anticoagulant antibody
◦ Hormone profile (FSH, LH, PROLACTIN)
20. ◦ Karyotype
◦ Ultrasonography of pelvis
◦ Hysterosalpingography (HSG)
◦ Hysteroscopy
◦ Magnetic resonance imaging (MRI) for anatomical defects of uterus or cervix
PROGNOSIS: Good irrespective of treatment.
TREATMENT:
1) GENETIC CAUSES: genetic counselling.
2) ENDOCRINE CAUSES:
i) Thyroid dysfunction: diagnosis by thyroid function tests and thyroid antibodies. Treated by treating hypo or hyper thyroidism.
21. ii) Diabetes:
Diagnosis: fasting and post prandial blood sugar
Treatment: insulin
iii) Inadequate luteal phase:
Diagnosis: luteal phase < 10 days, progesterone levels < 15 nmol/ L on 21 day in five consecutive cycles; Endometrial biopsy.
Treatment: Clomiphene, low dose FSH
iv) Polycystic ovarian disease (rare cause):
Diagnosis: elevated serum LH and free testosterone.
Treatment: Laparoscopic diathermy to ovaries in selected resistant cases
22. 3) ANATOMICAL CAUSES:
i) Fibroids:
Diagnosis: USG or HSG
Treatment: Myomectomy in selected cases.
ii) Uterine anomalies:
Diagnosis: transvaginal scan or HSG
Treatment: resection of septum in hysteroscopy/ laparotomy
iii) Asherman’s syndrome:
Diagnosis: hysteroscopy
Treatment: synechiolysis (resection of synechiae)
23. iv) Cervical insufficiency or incompetence:
Diagnosis: HSG or transvaginal ultrasound
Treatment: cervical cerclage (McDonald or Shirodkar suture) during pregnancy
4) IMMUNOLOGICAL CAUSES:
i) Anti-phospholipid antibody (APLA):
Treatment: low dose aspirin 75 mg daily and injection heparin 5000 units subcutaneously twice daily or low molecular weight
heparin 40 mg/ IM daily from time of appearance of fetal heart activity upto 34 weeks.
