This document defines abortion and provides a classification. It discusses the causes of abortion including fetal and maternal causes. The types of abortion are defined including threatened, inevitable, incomplete, complete, missed and septic abortions. Recurrent abortion is defined. Investigations, differential diagnosis and treatment options for various abortion types are outlined. Induced abortion methods including medical and surgical are also summarized.

1. ABORTION
MR CHIBUYE
MPH,BsCM ,Dip CM & Post Graduate
Dip-in Teaching Methodology
Chreso University

2. Introduction
Objectives
 Definition
Classification
Causes
Types
Symptoms/features
Investigations
Management

3. Definition
Definition:
 Abortion is any fetal loss from conception
until the time of fetal viability at 24 weeks
gestation(WHO).
OR:
The Expulsion of a fetus or an embryo
weighing 500 g or less.

4. Classification of Abortion
1. Spontaneous:
- Occurs without medical or mechanical means.
2. Induced abortion
- Occurs due to either medical or mechanical
interventions.

5. Causes of Abortion
The causes of abortion are classified as;
1. Fetal causes and
2. Maternal causes

6. Causes of Abortion
1. Fetal causes
 Chromosome Abnormality: -50% of spontaneous losses are
associated with fetal chromosome abnormalities;
- Autosomal trisomy (nondisjunction/balanced translocation):
is the single largest category of abnormality and →
recurrence.
- Monosomy (45, X; turner):occurs in 7% of spontaneous
abortions and it is caused by loss of the paternal sex
chromosome.
- Triploids: found in 8 to 9% of spontaneous abortions. it is the
consequence of either dispermy or failure of extrusion of the
second polar body.

7. Causes of Abortion
2. Maternal causes
 Endocrine : Poorly controlled Diabetes (type 1/type 2). -
hypothyroidism and hyperthyroidism.
 Luteal Phase Defect (LPD): A situation in which the
endometrium is poorly or improperly hormonally prepared
for implantation and is therefore inhospitable for
implantation. as in PCO (questionable).
 Infections (maternal/fetal): As TORCH infections, Ureaplasma
urealyticum, listeria,BV
 Environmental toxins: Alcohol, smoking, drug abuse, ionizing
radiation

8. Other potential causes
 No demonstrable cause –this is the commonest
 isolated non recurring in 60%
 An embryonic pregnancies(blighted ovum),an abnormality of
placental development
 Multiple pregnancy
 Uterine anomaly e.g. cervical incompetence(classically occur
in mid-trimester)
 Corpus luteum failure as seen in PCO
 Induced usually criminally

9. Other potential causes
 Second trimester abortion
causes
 Cervical incompetence
 Cone biopsy
 Congenital weakness
Presentation
 Feeling of something giving way
 Painless
Management
 Treated with cervical cerclage at 14 week and remove it at
37-38 weeks

10. Types abortion
1. Threatened abortion.
2. Inevitable abortion.
3. Incomplete abortion.
4. Complete abortion.
5. Missed abortion
6. Septic abortion: Any type of abortion, which is
complicated by infection
7. Recurrent abortion: 3 or more successive
spontaneous abortions
8. Blighted ovum(an embronic pregnancy)

11. THREATEN ABORTION
• Threatened abortion consists of any vaginal bleeding during
early pregnancy without cervical dilatation or change in
cervical consistency.
• Hx of amenorrhea
• Usually, no significant pain exists, although mild cramps may
occur.
O/E
• Cervix OS is closed
• No fetal tissue or membranes have passed.
• Uterine size correct for dates
• The ultrasound shows a continuing intrauterine pregnancy
• Bed rest has no role in management

12. Investigations
• Ultrasound-will show if fetus is in uterus and is viable-if doubt
repeat a week later
• HCG beta unit-doubles by 50% in 48 hours in normal
pregnancy
• FBC for Hb
• Rhesus group should be checked

13. Inevitable abortion
• Inevitable abortion is an early pregnancy with vaginal bleeding and
dilatation of the cervix.
• Hx of amenorrhea
• Vaginal bleeding is worse than with a threatened abortion, and more
cramping is present.
• No tissue has passed yet.
• Cervical Os is open
• On ultrasound, the products of conception are located in the lower uterine
segment or the cervical canal.
• Uterus may be small, large or correct size for dates

14. Incomplete abortion
• Incomplete abortion is a pregnancy that is associated with vaginal
bleeding, dilatation of the cervical canal, and passage of products of
conception.
• Hx of amenorrhea
• Usually, the cramps are intense, and the vaginal bleeding is heavy.
• Patients may describe passage of tissue, or the examiner may observe
evidence of tissue passage within the vagina.
• Cervical Os is open and some product of conception maybe felt during EV
• Ultrasound may show that some of the products of conception are still
present in the uterus.

15. Complete abortion
• Complete abortion is a completed miscarriage.
• Typically, a history of vaginal bleeding, abdominal pain,
and passage of tissue exists.
• After the tissue passes, the patient notes that the pain
subsides and the vaginal bleeding significantly
diminishes.
• The examination reveals some blood in the vaginal vault;
a closed cervical os; and no tenderness of the cervix,
uterus, adnexa, or abdomen.
• The ultrasound demonstrates an empty uterus.

16. Missed abortion
• A missed abortion is a nonviable intrauterine pregnancy that
has been retained within the uterus without spontaneous
abortion.
• Typically, no symptoms exist besides amenorrhea.
• An ultrasound usually confirms the diagnosis.
• No vaginal bleeding, abdominal pain, passage of tissue, or
cervical changes are present
• Uterus small for dates ,cervix os closed

17. Septic Abortion
• Septic abortion occurs when RPOC gets infected
• Patient may present with features of sepsis like fever and
tachycardia, general malaise ,abdominal pain, marked pelvic
tenderness and purulent vaginal discharge
• Examination reveals an open cervical os with infected foul
smelling retained products of conception.
• Common organisms are; E.coli and other gram negatives,
strep (hemolytic and anaerobic),other anaerobes (e.g.
bacteroides) and staphylococcus
• Cl.perfringes and cl.tetani rare but lethal

18. Anembryonic pregnancy(blighted
ovum)
• A gestation sac develops in the absence of an embryo
• Diagnosis made on ultrasound
• Manage as for missed abortion

19. Recurrent miscarriage
• Defn: A recurrent miscarriage is 3 or more consecutive,
spontaneous pregnancy losses, under 20 week gestation from
the last menstrual period , by the same partner.
• May be primary recurrent or secondary
• Incidence is 1% of women of reproductive age
• Primary recurrent pregnancy loss" refers to couples that have
never had a live birth,
• secondary Recurrent Pregnancy Loss, refers to those who
have had repetitive losses following a successful pregnancy
• a woman who had a miscarriage, instead of getting sympathy
and support, is made to feel that it is somehow her fault • It is
all too common to find recurrent miscarriges leading to
divorce

20. Causes of Recurrent miscarriage
• Polycystic ovarian syndrome with LH hypersecretion
• Autoimmune e.g. SLE and antiphospolipid syndrome
• Anatomical factors such as fibroids, congenital defects,
cervical incompetence
• Chromosomal defects-4%
 Investigation of recurrent miscarriage
• Pelvic ultrasound and urinary LH
• Lupus anticoagulant and anticardiolipin antibodies
• Hysteroscopy
• Random glucose and thyroid function • Karyotyping of both
parents

21. Differential diagnosis
• Ectopic pregnancy
• Acute appendicitis
• Cervical polyps, ectropion, or malignancy
• Ovarian torsion
• Pregnancy,
• Molar pregnancy
• Pregnancy, subchorionic hemorrhage
• Cervical cancer

22. investigations
• Complete blood count- look for anemia and
infections
• Ultrasound to confirm pregnancy, location of
pregnancy. More useful in threatened
abortions and ectopic pregnancies
• Blood type- Rh- women may need anti D,
• Possible DIC profile

23. Treatment
• A complete abortion usually needs no further treatment, medically
or surgically
• Threatened abortions are treated conservatively without any
interventions
• Missed abortions can managed by surgical evacuation or
conservatively and await spontaneous expulsion. Disadvantages of
risk of DIC and psychological morbidity.
• Septic abortions ; Antibiotics; Metronidazole,X –pen and
gentamycin IV thereafter are surgically evacuation of the product
of conception
• Incomplete are treated surgically
• Surgical methods include suction Dilation and Curettage ( D&C),
Manual Vacuum Aspiration (MVA)
• Medical methods with misoprostol have also been used as an
alternative.

24. Induced abortion
• Criminal
• Medical
 Methods
• Suction curretage up to 12 completed weeks
• Prostaglandins induction after 12 weeks+/-oxytocin
• Antiprogesterone -up to 9 weeks gestation mifepristone can be
used and may be combined with prostaglandins

25. Induced abortion
 Abortion is legal in Zambia
 2 doctors must agree to patient’s request
 When compared with abortion, continuation of pregnancy must:
1. Endanger the life of woman
2. Endanger the physical or mental health of woman
3. Endanger mental or physical health of siblings
4. Involve a risk that the fetus would be handicapped
 Refer to standards and guidelines on mx of abortion 2009