This simple presentation describes about decidualization reaction and types of abortion - as a basic orientation of MBBS undergraduate students

1. DECIDUALIZATION

3. Fertilization
 Fertilization
• The process of union of
male & female gamate
• Site-ampullary region
 Aim of fertilization
• Restoration of diploid
number chromosome
• Determination of sex
• Initiation of clevage
Fig: Fertilization to implantation

18. Period of Viability
• Viability is the capability of fetus to survive outside
the uterus at the earlier gestational age
• Survival depends on
Maturity of fetal central nervous system
Maturity of lungs
• PERIOD OF VIABILITY – varies in different countries
 WHO – 22weeks and 500gms
 UK – 24 weeks
 India – 28 weeks

20. Spontaneous abortion

21. Definition
• Clinically recognised pregnancy loss before 20th
week of gestation
• Expulsion or extraction of an embryo or fetus
weighing 500gm or less(WHO)
• Synonymous with MISCARRIAGE
• Latin :aboriri: to miscarry

22. Incidence
• MC early pregnancy complication
• Frequency decreases with increasing gestational age
• Incidence:8-20%(clinically recognised pregnancies)
• 80% spontaneous abortion :< 12 wks

23. Risk factors
• Advanced maternal age
• Previous spontaneous abortion
• Medications & substances (smoking)
• Mechanisms responsible for abortion: not
apparent
• Death of fetus precedes spont. expulsion,
finding cause involves ascertaining the cause
of fetal death

24. Maternal age
• Most important risk factor in healthy women
• 30yrs:9-17%
• 35yrs:20%
• 40yrs:40%
• 45yrs: 80%

25. Previous spontaneous abortion
• Previous successful pregnancy: 5% risk
• 1 miscarriage: 20%
• 2 consecutive miscarriages:28%
• ≥3 consecutive miscarriages:43%

26. Medications or substances
• Heavy smoking(>10 cigarettes/day) : vasoconstrictive &
antimetabolic effects of tobacco smoke
• Moderate to high alcohol consumption(>3 drinks/week)
• NSAIDS use(acetaminophen) :abnormal implantation &
pregnancy failure due to antiprostaglandin effect

27. Other factors
• Low plasma folate levels(≤2.19ng/ml): no
specific evidence to support
• Extremes of maternal weight: prepregnancy
BMI<18.5 OR >25kg/m2
• Maternal fever:100°F(37.8°C), no evidence to
support

28. Etiology
• Fetal
• Maternal
• unexplained

29. Etiology
• Foetal factors
– Chromosomal abnormalities(50% ),
• aneuplodies ,monosomy X,Triploidy
• Trisomy 16 : mc autosomal trisomy,lethal
• Abnormalities arise de novo
– Congenital anomalies
– Trauma: invasive prenatal diagnostic procedures

31. Aetiology :Maternal factors
– Maternal endocrinopathies:
hypothyroidism, insulin
dependant diabetes
– Congenital or acquired uterine
abnormalities: interfere with
implantation & growth
– Maternal diseases: acute maternal
infection (listeria, toxo, parvo
B19,rubella,CMV) : inconclusive
– Radiation in therapeutic doses
– Hypercoagulable
state(thrombophillias) : RPL

32. Clinical presentation
• Vaginal bleeding
– Scant brown spotting to heavy vaginal
bleeding
– Amount /pattern does not predict
outcome
– May be accompanied by passage of
fetal tissue
• Pelvic pain
– Crampy /dull in character
– Constant/intermittent
• Incidental finding on pelvic
ultrasound in asymptomatic patient

33. Diagnostic evaluation
• History
– Period of amenorrhea ,LMP/USG
• Physical examination: Complete pelvic
examination:
– P/S,:source, amount of bleeding, dilated cervix,
POC visible at Os/in vagina
– P/V: uterine size(consistent with GA)
• Pelvic ultrasound

34. Pelvic ultrasound
• Most useful test in diagnostic
evaluation of women with
suspected spontaneous
abortion
• Foetal cardiac activity: most
important (5.5-6wks)
• Foetal heart rate
• Size & contour of G.sac
• Presence of yolk sac
• Best evaluated ,transvaginal
approach(TVS)

35. Differential diagnosis
• Physiologic: placental sign
• Ectopic pregnancy
• Gestational trophoblastic disease
• Cervical/vaginal/uterine pathology
• Physical examination
• Transvaginal sonography(TVS)
• Serial quantitative ßhCG

36. Post diagnostic classification
• Based upon the location of POC
• Degree of cervical dilatation(pelvic exam)
• Pelvic ultrasound
• Categorization impacts clinical management
– Threatened
– Inevitable
– Incomplete/complete
– Missed

39. Threatened abortion
• Vaginal bleeding has occurred
• The cervical os is closed
• Managed expectantly: until symptoms resolve
or progresses

40. Threatened abortion:
• Expectant
• Progestin treatment: most promising, efficacy
not established
• Bed rest
• Avoid vigorous activity
• Avoid heavy lifting
• Avoid sexual intercourse

41. Threatened abortion :
• Counsel about risk of miscarriage
• Return to hospital in case of additional vaginal
bleeding, pelvic cramping or passage of tissue from
vagina
• Repeat pelvic USG until a viable pregnancy is
confirmed or excluded
• Viable pregnancy, resolved symptoms: prenatal care
• If symptoms continue: monitor for progression to
inevitable, incomplete, or complete abortion

42. Inevitable abortion
• Vaginal bleeding, typically accompanied by
crampy pelvic pain
• Dilated cervix( internal os)
• Products of conception felt or visualised
through the internal os

43. Incomplete abortion
• Vaginal bleeding and/or pain present
• Cervix is dilated
• Products of conception partially expelled out
• Uterine size less than period of amenorrhea

44. Missed abortion
• Non viable intrauterine pregnancy
• Cervical os is closed
• POC not expelled

45. Complete abortion
• POC expelled completely from uterus &
cervix
• Cervical os is closed
• Uterus small in size (GA)
• Resolved or minimal vaginal bleeding & pain
• Aim of t/t: ensure that bleeding is not
excessive & all POC have expelled
• Theoretically does not need treatment

46. Management
• Complete evacuation of uterine contents(POC)
• Surgical methods: suction evacuation/suction
curettage/dilation & evacuation
• Medical methods: Misoprostol,mifepristone
• All have similar efficacy

48. Abortion : complications
• Hemorrhage
• Uterine perforation
• Retained products of conception
• Endometritis
• Septic abortion: abortion accompanying
intrauterine infection

49. Prevention of spont.abortion
• Preconception & prenatal counseling
• Routine screening & optimal disease
control(diabetes, thyroid, thrombophilia)
• Correction of uterine structural
anomalies(septum, submucosal myoma,
intrauterine adhesions) prior to pregnancy
• Avoiding exposure to teratogen or infections
• Modifiable risk factors

50. • Clinically recognised pregnany losses <20 wks
gestation
• Most common complication of early
pregnancy
• Advanced maternal age, previous
spontaneous abortion, maternal smoking: risk
factors
• Mostly due to fetal structural/chromosomal
abnormalities

51. • Present with menstrual delay, vaginal
bleeding& pelvic pain
• D/D: uterine or other genital tract bleeding in
viable pregnancy, ectopic,& GTD
• Pelvic examination & pelvic ultrasound: key
elements for diagnosis
• Spontaneous abortion diagnosed based on
USG criteria
• Categorised as threatened/incomplete/missed

52. • Preconceptual & prenatal counseling & care
regarding modifiable aetiologies ,risk factors
are most imp intervention
• Normal menstrual cycle resumes in 4-6 weeks
• hCG returns to normal 2-4wks

53. Thank you for your patient listening !