Threatened abortion refers to when the abortion process has started but recovery is still possible. Symptoms include mild pain and bleeding. Inevitable abortion means recovery is no longer possible and symptoms are more severe. Incomplete abortion occurs when some products of conception remain after partial expulsion. Septic abortion is complicated by infection. Recurrent pregnancy losses are defined as 3 or more consecutive losses before 20 weeks and can be caused by genetic, anatomical, endocrine, infectious, thrombotic or immunological factors. Evaluation includes history, exam, labs and testing depending on suspected etiology.

1. ABORTIONS
By
Lt Col J L Soko

2. Definitions:
• Termination of pregnancy before
20 weeks gestation calculated
from date of onset of last
menses
– Early Abortion: before 12 weeks
– Late Abortion: from 12-20 weeks
• Delivery of a fetus of weight less
than 1000 grams

3. Classification
• Spontaneous Abortion
- most common complication of
pregnancy
• Induced Abortion
- Medically/legal
- Criminal

4. TYPES
1. Threatened
2. Inevitable
3. Incomplete
4. Complete
5. Septic
6. Missed
7. Recurrent
TYPES

5. Threatened abortion
It is a clinical entity where the process of
abortion has started but has not
progressed to a state from which
recovery is impossible.
Symptoms
– Minimal or no lower abdominal pain or
cramps with/without PV bleeding
– Slight abd pain
– Significant draining of liqour

6. Signs of threatened abortion
– Stable general condition
– Fundal height corresponds to GA
– Cervix closed

7. Management of threatened abortion
1. Bed rest
– Avoid strenuous exercises
2. GA > 16/40 :
• Tocolytics

8. Inevitable abortion
Refers to a stage in the abortion when it is not
possible for the pregnancy to continue.
Symptoms
– Moderate to severe vaginal bleeding
– Severe abd pain
– Significant draining of liquor
Signs
– Dilatation of cervix with evidence of imminent
expulsion of the PoC
– Fundal height corresponds to GA
– Presence of contractions

9. Management of Inevitable abortion
1. Resuscitation
– IV fluids: RL, NS
2. Blood grouping & Cross matching
3. Evacuation
• MVA with GA < 12/40
• Augment if the GA > 12/40
 Oxytocin
 If some PoC remain after abortion, manage
like incomplete abortion.

10. Incomplete abortion
• Some PoC have been expelled from the uterine cavity
and retained, and open cervix.
Symptoms
– Moderate to severe vaginal bleeding
– Cramping/severe abd pain
– Partial expulsion of POC
Signs
– Uterus smaller than dates
– Cervix is dilated

11. Management of Incomplete abortion
1. Resuscitation
• IV fluids: RL, NS
2. Blood grouping & Cross matching
3. Evacuation
– MVA for GA < 12/40
– Augment if the GA > 12/40
• Oxytocin
• If some PoC remain after abortion manage like incomplete
abortion.
4. Antibiotics: ampicilin, metronidazole
5. Analgesics
6. BT if indicated

12. Septic abortion
An abortion complicated by infection
Symptoms
– Abdominal pain
– Fever
– Vaginal discharge (foul smelling)
Signs
– Sick looking, febrile or jaundiced
– Tender uterus
– Offensive vaginal discharge or bleeding
– Cervix is usu. soft and may be dilated
– Trauma to the cervix or upper vagina may be recognized if
there has been a criminal

13. Complications of septic abortions
Immediate cpx
– Haemorrhage
– Peritonitis
– Pelvic abscess, endometritis,
– Septicemia,
– Septic/haemorrhagic shock
Late cpx
– PID
– Pelvic adhesions
– 2° Infertility
– Chronic LAP

14. Management
1. Resuscitation
– IV fluids: RL, NS
2. Insert urethral catheter
– Monitor Input/output
3. Blood grouping & Cross matching
4. Antibiotics:
• Preferably cephalosporins, if not available
ampicilin and metronidazole
5. Evacuation
6. Haematenics

15. Recurrent Pregnancy Losses
• RPL defined as 3 or more consecutive
pregnancy losses before 20wks gestatn.
• However,Clinical investigation
should be initiated after 2
consecutive losses.

16. Other names:
•habitual abortions
•habitual miscarriage
•recurrent abortions
•recurrent miscarriages.

17. epidemiology
• Affects 0.5-3% of all women
• Risk of subsequent loss - 24% after 2
30% after 3
40% after 4

18. Statistics
• Early pregnancy loss: loss < 20 wks or <
500gms
• 15% of all recognized pregnancies 4-20 wks
end in SAB.
• 50% of all pregnancies end in SAB since 2-4
wk pregnancies will often go unnoticed.
• 30% lost between implantation and the 6th wk.
• 70% of first trimester losses due to
chromosomal abnormalities

19. TYPES OF RPL
• ‘Primary recurrent pregnancy
loss’
– Refers to couples that have
never had a live birth
• ‘Secondary RPL’s
– Refers to those who have had
repetitive losses following a
successful pregnancy

20. Aetiology of RPL
• Genetic Factors
• Environmental
• Endocrine
Factors
• Anatomic
Causes
• Infectious
causes
• Thrombophilias
• Immunologic
problems
• Can be established in only 30%

21. I. Genetics
• Chromosomal abnormalities are implicated for
– 70% 1st trimester losses,
– 30% of 2nd,
– 3% of 3rd trimester losses
– 60% of sporadic miscarriage
• Chromosomal anomalies includes
– Translocation and nondisjunction.
– Autosomal trisomy (13, 16, 18 21, 22)
– 2nd most common 45x followed by polyploidies

22. Genetics
Diagnosis
Karyotyping
– Both parents (peripheral blood)
– Abortus (fetal/placental chromosome)
– Amniocentesis
– Chorionic villus biopsy
Treatment: No treatment
1. Gamete donation
2. Genetic counseling to alleviate stress

23. Karyotyping

24. II. Environmental
• Smoking, alcohol, heavy coffee,
anesthetic gases,
Tetrachloroethylene (used in dry
cleaning), Accutane

25. III. Endocrine Factors
1. D.M. & thyroid disease
– Well controlled D.M. is not a risk
factor for RPL, nor treated thyroid
dysfunction.
– Routine screening for occult D.M &
thyroid disease should not be
performed in asymptomatic women
with RPL.

26. Endocrine Factors
2. Inadequate luteal phase
Is associated with RPL, but treatment with progesterone
or it’s metabolites has failed to show statistical
significance in the treatment of RPL.
• DX of LPD: 2 consecutive assays of progesterone in
luteal pase
• Although luteal phase progesterone is always checked
with RPL, studies have NOT proven it’s efficacy

27. Endocrine Factors
• As with infertility, treatment of RPL with
clomid, progesterone or dopamine agonist (if
elevated prolactin) has shown some benefit if
luteal phase is less than 11 days.
• HCG has been used as a Tx to stimulate the
corpus luteum, statistical significance has not
been proven.
• Some have suggested empiric treatment with
clomid if no other cause of RPL can be found.

28. IV. Anatomical
Congenital anomalies of the
uterus;
– Incidence: 10 % of RPL
Septate uterus-
Asherman’s Syndrome-
Uterine Fibroids- esp. sub
mucous
Primary endometrial defects

29. Septate uterus
Types
– Septate uterus: The most frequent
abnormality associated
with RPL.
– Others: Bicornuate, didelphic,
unicornuate uterus

30. Cont. anatomical
• Mechanism:
Impaired vascularization of
pregnancy & limited space for the
fetus.
– However the vascular density of uterine septa is
similar to that of the normal uterine wall

31. Mullerian anomalies

32. Diagnosis
• USS
• Hysteroscopy
• MRI
• HSG ???
Treatment
1. Hysteroscopic division of the septum
Reduces miscarriage rate from 85% to 10%
2. Prophylactic cerclage
May be worthwhile ; e.g. in patients with late losses & mullerian
anomalies e.g bicornuate uterus or unicornuate uterus

33. Cervical incompetence
• Common cause of 2nd trimester abortion.
• Diagnosis is mainly based on characteristic history.
• Commonly over-diagnosed:
– ?Why, no reliable diagnostic tests
• Features
– Spontaneous rupture of membranes
– Painless cervical dilatation
– Live abortus sometimes with other PoC
• Treatment: Cervical cerclage

34. V. Infectious Causes
• No hard evidence that bacterial or viral infections cause except
the Ureaplasma ureolyticum
• Others that have been implicated but not substintiated
include:
– Chlamydia, Mycoplasma, Listeria monoctygenes,
Toxoplasma gondii, rubella, HSV, CMV,
coxackievirus
– These have been associated with SAB’s.
• Antichlamydial Ab has been found in women with
RPL, but chlamydia is NOT associated with RPL.

35. Cont. infectious
• Routine screening for these
infections is not recommended.
• Treatment
– Tx of Ureaplasma and Mycoplasma
with Abx has been beneficial
• Doxycycline 100mg b.i.d. x 14 days
add erythromycin after conception

36. VI. Thrombophilia
• Is associated with late losses and
increased risk of thromboembolism.
• Hypercoaguable conditions:
– Antithrombin III deficiency
– Protein C deficiency or mutation,
– Protein S deficiency or mutation
– Factor V Leiden mutation, Prothrombin
gene G20210A mutation,
– Antiphospholipid syndrome

37. Thrombophilias
• Elevated homocysteine levels have
been associated with thrombosis and
early RPL, but results are not clear
cut at this time.

38. Thrombophilias
• Thrombophilia screening:
Antithrombin III, Protein C and S, Activated
protein C resistance ratio, PT, PTT,
Anticardiolipin Ab, Lupus anticoagulant,
Fibrinogen, Prothrombin G mutation,
Homocystine level, CBC
Screening
Indicated for unexplained RPL especially if
PMH or FH of thromboembolism.
Treatment: Heparin

39. VI. Immunologic
Factors suggesting immunologic
cause;
– Many SAB’s
– No recent full term pregnancies
– Less than 35 years
– SAB with normal karyotype
– One loss after 1st trimester

40. Autoimmunity
Antiphospholipid antibodies syndrome:
Presence of Lupus anticoagulant and/or
anticardiolipin Ab (IgG, IgM), on 2 occasions 6 wks
apart.
Mechanisms
Ab are directed against platelets and endothelium and
inhibit prostacyclin formation leading to unbalanced
thromboxane activity ultimately leads to
vasoconstriction and thrombosis.
Ultimate outcome: miscarriage, IUFD, IUGR.
Treatment:
Low dose ASA and low dose heparin 1st trimester

41. Autoimmunity
• Autoantibodies to Thyroid antigens
– Inconclusive association with RPL
• Antinuclear antibodies
– 15% of women with RPL, but no
association with RPL is proven.
– Tx with ASA and Prednisone did NOT
improve pregnancy outcomes.

42. b. Alloimune disorders
These are foreign antigens
Include:
– Rhesus and non-rhesus blood
groups fetal haemolytic diseases
– Fetal alloimune thrombocytopenia
– Dysregulation of the maternal-fetal
immune mechanisms

43. 부산백병원 산부인과
Preconception Evaluation
• Hystory
• Physical examination
• Laboratory

44. 부산백병원 산부인과
• Hystory
– Pattern, trimester, characteristics of
prior pregnancy losses
– History of subfertility or infertility
– Menstrual history
– Prior or current gynecologic or obstetric
infections
– Signs or symptoms of thyroid, prolactin,
glucose tolerance, hyperandrogenic
disorders (PCOS)
– Personal or familial thrombotic history
– Features associated with the
antiphospholipid syndrome (thrombosis,
false-positive test results for syphilis)

45. 부산백병원 산부인과
– Other automimune disorder
– Medication
– Environmental exposures, illicit and
common drug use (particularly
caffeine, alcohol, cigarettes, in utero
DES exposure)
– Genetic relationship between
reproductive partners
– Family history of recurrent
spontaneous abortion, obstetric
complications, or any syndrome
associated with embryonic or fetal
losses
– Previous diagnostic tests and
treatments

46. 부산백병원 산부인과
• Physical examination
- obesity
- hirsuitism and acanthosis
- thyroid examination
- breast examination and
galactorrhea
- pelvic examination
anatomy
infection
trauma
estrogenization

47. 부산백병원 산부인과
• Laboratory
– parental peripheral blood
karyotype
– HSG, followed by hysteroscopy
or laparoscopy, if indicated
– Luteal-phase endometrial biopsy
– Anticardiolipin antibody level
– Thyroid-stimulating hormone level,
serum prolactin level, if indicated
– Lupus anticoagulant
– Complete blood count with
platelets

48. Summary

49. Conclusion and Counseling
• These patients require an understanding,
sympathetic and supportive doctor.
• Multiple visits during the first trimester.
• 60-70% of pts with 1st trimester RPL will have a
successful pregnancy.
• Pts with 2nd trimester losses have a poorer
prognosis.

51. Questions?