Abortion is the expulsion or extraction from its mother of an embryo or fetus weighing 500g or less when it is not capable of independent survival . there are many types of abortion. for this yo u read this ppt and also be ready to watch its next part. so read it and get information about miscarriage. it is an important topic in obstetrics. stay tuned.

1. ABORTION
( PART- 1)
PIYUSH PARASHAR

2. DEFINITION
 An abortion is a procedure to end a pregnancy.
 It uses medicine or surgery to remove the embryo or
fetus and placenta from the uterus

4. SPONTANEOUS
ABORTION
( MISCARRIAGE)

5. DEFINITION
 Abortion is the expulsion or extraction from its mother
of an embryo or fetus weighing 500g or less when it is
not capable of independent survival.
 The expelled embryo or fetus is called abortus.
 The word abortion is the recommended terminology for
spontaneous miscarriage.

6. INCIDENCE
 The incidence of abortion is difficult to
work out but probably 10-20% of all
clinical pregnancies end in miscarriage
and another optimistic figure of 10% are
induced or deliberate.
 About 75% miscarriage occur before the
16th week and of these about 80% occur
before the 12th week of pregnancy.

7. ETIOLOGY
 The etiology of miscarriage is often complex and
obscure.The following factors ( embryonic or parental)
are important:
o GENETIC
o ANATOMIC
o IMMUNOLOGICAL
o ENVIRONMENTAL
o UNEXPLAINED
o ENDOCRINE AND METABOLIC
o INFECTION
o THROMBOPHILIAS
o OTHERS

8. GENETIC
FACTORS
 Autosomy trisomy is the most common cytogenic
abnormality .The most common trisomy is trisomy 16.
 Polyploidy has been observed in about 22% of abortus.
 Monosomy X is the single most common chromosomal
abnormality in miscarriage.
 Structural chromosomal rearrangements are observed
in 2-4% of abortus.
 these include translocation, deletion, inversion and ring
formation.
 Other chromosomal abnormalities are mosaic, double
trisomy, etc. are found in about 4% of abortus.

9. ENDOCRINE AND
METABOLIC
FACTORS
 Luteal phase defect (LPD) results in early miscarriage
as implantation and placentation are not supported
adequately.
 Deficient progesterone secretion from corpus luteum or
poor endometrial response to progesterone is the
cause.
 Thyroid abnormalities: Overt hypothyroidism or
hyperthyroidism is associated with increased fetal loss.
 Thyroid autoantibodies are often increased.
 Diabetes mellitus when poorly controlled causes
increased miscarriage.

10. ANATOMICAL
ABNORMALITIES
 These are related mostly to the second trimester abortions.
1. CERVICAL INCOMPETENCE: either congenital or acquired is one of
the most common cause of midtrimester and recurrent abortion.
2. CONGENITAL MALFORMATION OF UTERUS in the form of
bicornuate or septate uterus may be responsible for midtrimester
recurrent miscarriages.Causes of fetal loss are:
i. Reduced intrauterine volume
ii. Reduced expansile property of the uterus
iii. Reduced placental vascularity when implanted on septum
iv. Increased uterine irritability and contractility.
CERVICOUTERINE FACTORS

11. ANATOMICAL
ABNORMALITIES
 UTERINE ( FIBROIDS) especially of the submucous
variety might be responsible not only for infertility but
also for abortion.
 Other causes are: decreased vascularity at the
implantation site, red degeneration of of fibroid and
increased uterine irritability.
 INTRAUTERINE ADHESIONS ( SYNECHIAE): interfere
with implantation, placentation and fetal growth.
 Depending on the severity of adhesions, e.g. total ,
corporal or cervicoisthmic, patient suffers from
amenorrhea, hypomenorrhea, infertility or recurrent
abortion.
CERVICOUTERINE FACTORS

12. INFECTIONS
 They are the accepted causes of late as well as early
abortions.
 Transplacental fetal infections occur with most micro-
organisms and fetal loss could be caused by any.
 Infections could be:
a) VIRAL: Rubella, cytomegalovirus, variola, vaccinia or
HIV
b) PARASITIC:Toxoplasma, malaria.
c) Bacterial: Ureaplasma,chlamydia, brucella.
Spirochetes hardly cause abortion before 20th week
because of effective thickness of placental barrier.

13. IMMUNOLOGICAL
DISORDERS
 It is due to the presence of antiphospholipid antibodies.
These are: lupus anticoagulant (LAC), anticardiolipin
antibodies and β- glycoprotein 1 antibodies. Mechanism of
pregnancy loss in women with APAS are:
a. Inhibition of trophoblast function and differentiation.
b. Activation of complement pathway
c. Release of local inflammatory mediators (cytokines,
interleukins)
d. Thrombosis of uteroplacental vascular bed. Ultimate
pathology is fetal hypoxia.
ANTIPHOSPHOLIPID ANTIBODY
SYNDROME ( APAS)

14. IMMUNOLOGICAL
DISORDERS
 Cytokines are immune molecules.
 Cytokine response may be either T- helper 1 type or T-
helper 2 type.
 Th 1 response is the production of proinflammatory
cytokines (interleukin -2, interferon and tumor necrosis
factor).
 Th 2 response is the production of anti- inflammatory
cytokines.
 Successful pregnancy is the result of predominantly Th2
cytokine response.
 Women with recurrent miscarriage have more Th1
response.
Immune factors

15. IMMUNOLOGICAL
DISORDERS
 Natural killer cells present in peripheral blood and that
in the uterus are different functionally.
 There is no relationship between uterine natural killer
cells number and future pregnancy outcome though
Unk cells help trophoblast invasion, proliferation and
angiogenesis.
 Human leukocyte antigen incompatibility between
couples or absence of maternal blocking antibodies is
not considered as the cause of recurrent miscarriage.
AUTOIMMUNITY

16. MATERNAL
MEDICAL
ILLNESS
 Cyanotic heart disease, hemoglobinopathies are
associated with early miscarriage.

17. PREMATURE
RUPTUREOFTHE
MEMBRANE
 PATERNAL FACTORS: Sperm chromosomal anomaly ca
cause miscarriage. Some women who miscarry
recurrently may have normal pregnancies following
marriage with different man.
 THROMBOPHILIAS: Inherited thrombophilia causes
both early and late miscarriage due to intravascular
coagulation and thrombosis.
 Protein C resistance is the most common cause.
 Other conditions are: Protein C deficiency and
hyperomocysteinemia antithrombin III or prothrombin
gene mutation.

18. ENVIRONMENTAL
FACTORS
 CIGARETTE SMOKING: increase the risk due to formation of
carboxyhemoglobin and decreased oxygen transfer to the
fetus. Alcohol consumption should be avoided or minimized
during pregnancy.
 X- irradiation and anti- neoplastic drugs are known to cause
abortion. X- ray exposure up to 10 rad is of little risk.
 CONTRACEPTIVE AGENTS: IUD in situ increases the risk
whereas oral pills do not.
 DRUGS, CHEMICALS, NOXIOUS AGENTS: Anesthetic gases,
arsenic, aniline, lead formaldehyde increase the risk.
 MISCELLANEOUS:Exposure to electromagnetic radiation
from video display terminals does not increase the risk.
Women can use hair dyes, watch television and fly in airlines
during pregnancy.

19. UNEXPLAINED
 In spite of the numerous factors mentioned, it is indeed
difficult, in the majority, to pinpoint the exact cause of
miscarriage.
 Too often, more than one factor is present.
 However, risk of abortion increases with increased
maternal age.

20. COMMONCAUSES
OFMISCARRIAGE
A. Genetic factors (50%)
B. Endocrine disorders ( LPD,Thyroid abnormalities,
diabetes.)
C. immunological disorders( autoimmune and
alloimmune)
D. Infection
E. unexplained
FIRST TRIMESTER

21. COMMONCAUSES
OFMISCARRIAGE
 ANATOMIC ABNORMALITIES:
a. Cervical incompetence ( congenital or acquired)
b. Mullerian fusion defects ( bicornuate uterus, septate
uterus)
c. Uterine synechiae
d. Uterine fibroid
 Maternal medical illness.
 Unexplained
SECOND TRIMESTER

22. MECHANISM
OF
MISCARRIAGE
 In the early weeks, death of the ovum occurs first, followed by its
expulsion.
 In the later weeks, maternal environmental factors are involved
leading to expulsion of the fetus which may have signs of life but is
too small to survive.
o BEFORE 8 WEEKS:The ovum, surrounded by the villi with the
decidual coverings, is expelled out intact. Sometimes the external os
fails to dilate so that the entire mass is accommodated in the dilated
cervical canal and is called cervical miscarriage.
o BETWEEN 8 AND 14 WEEKS: Expulsion of the fetus commonly
occurs leaving behind the placenta and the membranes. A part of it
may be partially separated with brisk hemorrhage or remains totally
attached to the uterine wall.
o BEYOND 14TH WEEK:The process of expulsion is similar to that of a ‘
mini labor’.The fetus is expelled first followed by expulsion of the
placenta after a varying interval.

23. THREATENED
MISCARRIAGE

24. DEFINITION
It is a clinical entity where
the process of miscarriage
has started but has not
progressed to a state from
which recovery is
impossible.

25. CLINICAL
FEATURES
 BLEEDING PER VAGINUM: It is usually slight and may be brownish
or bright red in color.The bleeding may be brisk, especially in the
late second trimester.The bleeding usually stops spontaneously.
 PAIN: Bleeding is usually painless but there may be mild backache
or dull pain in lower abdomen. Pain appears usually following
hemorrhage.
 PELVIC EXAMINATION: It should be done as gently as possible.
a) Speculum examination reveals- bleeding if any, escapes through
the external os. Differential diagnosis includes cervical ectopy,
polyps or carcinoma, ectopic pregnancy and molar pregnancy.
b) DIGITAL EXAMINATION: reveals the closed external os.The
uterine size corresponds to the period of amenorrhea.The uterus
and cervix feel soft.
pelvic examination is avoided when ultrasonography is available.

26. INVESTIGATIONS
 Routine investigations include:
1. BLOOD: for hemoglobin, hematocrit, ABO and Rh
grouping. Blood transfusion may be required if
abortion becomes inevitable and anti- D gamma
globulin has to be given in Rh- negative non
immunized women.
2. URINE: for immunological test of pregnancy is not
helpful as the test remains positive for a variable
period even after fetal death.

27. ULTRASONOGRAPHY
 Findings may be:
1) A well- formed gestation sac, yolk sac with central echoes
from the embryo indicating healthy fetus.
2) Observation of fetal cardiac motion.With there is 98%
chance of continuation of pregnancy.
3) Anembryonic sac is diagnosed when the mean gestational
sac diameter (MSD) is >= 25mm and no embryo is seen on
TVS. It suggests early pregnancy failure.
Serum progesterone value of 25ng/mL or more generally
indicates a viable pregnancy in about 95% of cases.
Serial serum hCG level is helpful to assess the fetal well-
being.
Ectopic pregnancy must be ruled out during investigations.

28. TREATMENT
 REST:The patient should be in bed for few days until
bleeding stops. Prolonged restriction of activity has got
no therapeutic value.
 DRUGS: Relief of pain may be ensured by diazepam
5mg tablet twice daily.
There is some evidence that treatment with
progesterone improves the outcome.
Progesterone induces immunomodulation to shift the Th1
to Th2.
Use of hCG is not preferred.

29. ADVICEON
DISCHARGE
 The patient should limit her activities for at least 2
weeks and avoid heavy work.
 Coitus is avoided during this period.
 She should be followed up with repeat sonography at
10- 14 days’ time.
 The following indicates unfavourable outcome :
a. Falling serum β- hCG,
b. Decreasing size of the fetus
c. Irregular shape of the gestational sac or presence of fetal
bradycardia.

30. PROGNOSIS
 The prognosis is very unpredictable.
 In isolated spontaneous threatened miscarriage, the following
events may occur:
1. In about two-thirds, the pregnancy continues beyond 28 weeks.
2. In the rest, it terminates either as inevitable or missed
miscarriage.
If the pregnancy continues, there is increased frequency of preterm
labor, placenta previa, intrauterine growth restriction of the fetus and
fetal anomalies.
Anembryonic sac: It is a sonographic diagnosis.There is absence of
fetal pole in a gestational sac with diameter of 25mm or more.
uterus is to be evacuated once the diagnosis made.

31. INEVITABLE
MISCARRIAGE

32. DEFINITION
 It is the clinical type of abortion where
the changes have progressed to a state
from where continuation of pregnancy
is impossible.

33. CLINICAL
FEATURES
 The patient, having the features of threatened
miscarriage, develops the following manifestations:
1) Increased vaginal bleeding
2) Aggravation of pain in the lower abdomen which may
be colicky in nature.
3) Internal examination reveals dilated internal os of the
cervix through which the products of conception are
felt.

34. MANAGEMENT
AIMS
 To accelerate the process of expulsion.
 To maintain strict asepsis.
GENERAL MEASURES
 Excessive bleeding should be promptly controlled by
administering Methergine 0.2mg if the cervix is dilated
and the size of the uterus is less than 12 weeks.
 The blood loss is corrected by intravenous (iv) fluid
therapy and blood transfusion.

35. ACTIVE
TREATMENT
BEFORE 12 WEEKS
 Dilatation and evacuation followed by curettage of the
uterine cavity by blunt curette using analgesia or under
general anesthesia.
 Alternatively, suction evacuation followed by curettage is
done.
AFTER 12 WEEKS
 The uterine contraction is accelerated by oxytocin drip (10
units in 500mL of normal saline) 40- 60 drops pr minute.
 If the fetus is expelled and the placenta is retained, it is
removed by dilatation and evacuation under general
anesthesia.

36. COMPLETE
MISCARRIAGE

37. DEFINITION
 When the products of conception are expelled en
masse, it is called complete miscarriage.

38. CLINICAL
FEATURES
 There is history of expulsion of a fleshy mass per vaginum
followed by:
 1) Subsidence of abdominal pain
 2) vaginal bleeding becomes trace or absent
 3) internal examination reveals:
a. Uterus is smaller than the period of amenorrhea and a little
firmer,
b. Cervical os is closed
c. Bleeding is trace
4) Examination of expelled fleshy mass is found complete
5) Ultrasonography (TVS): reveals empty uterine cavity.

39. MANAGEMENT
 Transvaginal sonography is useful to see that uterine
cavity is empty, otherwise evacuation of uterine
curettage should be done.
RH – NEGATIVE WOMEN
 A Rh- negative patient without antibody in her system
should be protected by anti- D gamma globulin 50μg or
100μg intramuscularly in cases of early miscarriage or late
miscarriage respectively within 72 hours.
 However, anti- D may not be required in a case with complete
miscarriage before 12 weeks of gestation where no
instrumentation has been done.

40. INCOMPLETE
MISCARRIAGE

41. DEFINITION
 When the entire products of conception are not
expelled, instead a part of it is left inside the uterine
cavity, it is called incomplete miscarriage.
 this is the most common type met amongst women,
hospitalized for miscarriage complications.

42. CLINICAL
FEATURES
1) Continuation of pain in lower abdomen
2) Persistence of vaginal bleeding.
3) Internal examination reveals:
I. Uterus smaller than the period of amenorrhea
II. Patulous cervical os often admitting tip of the finger
III. Varying amount of bleeding
4) On examination, the expelled mass is found incomplete
5) Ultrasonography- reveals echogenic material withion
the cavity.

43. COMPLICATIONS
 The retained products may cause :
a. Profuse bleeding
b. Sepsis
c. Placental polyp

44. MANAGEMENT
 In recent cases- evacuation of the retained products of
conception ( ERPC) is done. She should be resuscitated
before any active treatment is under taken.
 EARLY ABORTION: Dilatation and evacuation under analgesia
or general anesthesia is to be done. Evacuation of the uterus
may be done using MVA also.
 LATE ABORTION:The uterus is evacuated under general
anesthesia and the products are removed by ovum forceps or
by blunt curette. In late cases, dilatation and curettage
operation is to be done to remove the bits of tissues left
behind.
 The removed materials are subjected to a histological
examination.
 Medical management of incomplete miscarriage may be
done.Tablet misoprostol 200μg is used vaginally every 4 hours.

45. MISSED
ABORTION

46. DEFINITION
 When the fetus is dead and retained inside the uterus
for a variable period, it is called missed miscarriage or
early fetal demise.

47. PATHOLOGY
 The causes of prolonged retention of the dead fetus in
the uterus is not clear.
 Beyond 12 weeks, the retained fetus becomes
macerated or mummified.
 The liquor amnii gets absorbed and the placenta
becomes pale, thin and may be adherent.
 Before 12 weeks, the pathological process differs when
the ovum is more or less completely surrounded by the
chorionic villi.

48. CLINICAL
FEATURES
1. Persistence of brownish vaginal discharge
2. Subsidence of pregnancy symptoms
3. Retrogression of breast changes
4. Cessation of uterine growth which in fact becomes
smaller in size.
5. Nonaudibility of the fetal heart sound even with
Doppler ultrasound.
6. Cervix feels firm.
7. Immunological test for pregnancy becomes negative.
8. Real – time ultra sonography reveals an empty sac
early in the pregnancy or the absence of fetal cardiac
motion and fetal movements.

49. MANAGEMENT
 EXPECTANT
 MEDICAL
 SURGICAL

50. MANAGEMENT
 EXPECTANT MANAGEMENT: Many women expel the
conceptus spontaneously
 MEDICAL MANAGEMENT: Prostaglandin E1 800μg
vaginally in the posterior fornix is given and repeated after
24 hours. Expulsion usually occurs within 48 hours.
 SUCTION EVACUATION or dilatation and evacuation is done
either as a definitive treatment or it can be done when the
medical methods fails.
UTERUS IS LESS THAN 12 WEEKS

51. MANAGEMENT
 The same principle of the management as advocated in the
intrauterine fetal death are to be followed. Induction is done
by the following methods:
Prostaglandin E1 analog (misoprostol) 200μg tablet is inserted
into the posterior vaginal fornix every 4 hours for a maximum of 5
such.
OXYTOCIN: 10-20 units of oxytocin in 500mL or normal saline at
30 drops/min is started. If fails, escalating dose of oxytocin to the
maximum of 200 m IU/ min may be used with monitoring.
Many patients need surgical evacuation following medical
treatment. Following medical treatment, ultrasonography should
be done to document empty uterine cavity.
Dilatation and evacuation is done once the cervix becomes soft
with the use of 𝑃𝐺𝐸1. Otherwise cervical canal is dilated using
the mechanical dilators or by luminaria tent.
Evacuation of the uterine cavity is done thereafter slowly.
UTERUS MORE THAN 12 WEEKS