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1. EARLY PREGNANCY
BLEEDINGS
3. Abortion/Miscarriage

2. Introduction
• Abortion is one of the leading
cause of maternal mortality it
accounts
• 13% world wide
• 4% in Africa

3. Definition
 Abortion is expulsion of the products
of conception prior to viability of the
fetus (before 28 weeks of gestation) or
less than 1000gm weight
 WHO gest. age<20 weeks or weight
less than 500 gm.

4. ABORTIONS CAN BE classified as:
• Spontaneous or induced
• First trimester or second trimester
Induced abortion can be legal or
criminal.
Most criminal abortions are unsafe.

5. Types of abortion
• Spontaneous
• Induced
Spontaneous abortion defined as the
loss of a fetus during pregnancy due to
natural causes…before fetal
development has reached 28 weeks…the
term spontaneous abortion refers to
naturally occurring events, not elective
or therapeutic abortion procedures…”

6. Types of abortion…..
• Unsafe abortion :-is characterized by lack or
inadequate of skill of provider, hazardous
technique and unsanitary facilities or both
• Therapeutic abortion :-termination of
pregnancy before the time of fetal viability for
the purpose of saving the life of the mother

7. Etiology of spontaneous abortions
Could be classified into fetal and maternal
factors
A) Fetal anomaly
– Chromosomal
– Structural
– Genetic
B) Maternal disease
- pyrexia
- Diabetes mellitus
- Thyroid disease

8. Etiology …
C) Endocrine disorder
- early luteal phase defect
D) Uterine abnormalities
- fibroids, especially sub mucous
- congenital uterine anomalies
- intrauterine adhesions
- low implantation of the placenta

9. Etiology …
E) Infections
1. malaria
2. pyelonephritis
3. TORCHES
-Toxoplasmosis
-Rubella
-Cytomegalovirus infection
-Herpes viruses
-Ebsten Barr virus
-Syphylis

10. Etiology …
F) Autoimmune disease
- SLE
- Antiphospholipid antibodies
G) Immunological
- Rhesus iso immunization
H) Trauma
- Amniocentesis
-CVS
- Pelvic surgery

11. Clinical Classification Of Abortion
1. Threatened
2. Inevitable
3. Incomplete
4. Complete
5. Missed
6. Recurrent
7. Septic

12. Cont..
• Septic abortion:-when any of the stage of
abortion complicated by pelvic infection
• Recurrent abortion:-three or more
consecutive spontaneous termination of
pregnancies

13. Clinical stages of abortion
Threatened abortion
oslight intermittent bleeding with or without cramping
o The cervix remains closed and no cervical effacement
oAt least 20–30% of pregnant women have some first-
trimester bleeding.
oIn most cases, this is thought to represent an
implantation bleed.
oMore than 50-80% go to term

15. Inevitable abortion
 The cervix has dilated, but the products
of conception have not been expelled
 Abdominal or back pain and mild to
severe vaginal bleeding
 cervical effacement, cervical dilatation,
and/or rupture of the membranes is
noted.
 It is Irreversible

16. Incomplete abortion
• Some, but not all, of the products of
conception have been passed; retained
products may be part of the fetus,
placenta, or membranes
• In gestations of less than 10 weeks'
duration, the fetus and placenta are usually
passed together. After 10 weeks, they may
be passed separately, with a portion of the
products retained in the uterine cavity.

17. Sign and symptoms
• Cramps are usually present
• Profuse persistent bleeding
• HX of passing concepts tissue
• Some times visible or palpable concepts
tissue through the opening cervix
Complications
Anemia, hemorrhage and infection

18. Missed abortion
Def. a pregnancy in which there is a fetal
demise (usually for a number of weeks) but
no uterine activity to expel the products of
conception
 Regress sx/s of pregnancy , Uterine size
decreased, cervix closed, Brownish vaginal
discharge
Complications
Infection, DIC, AF embolism

19. Complete abortion
• All products of conception have been passed
without need for surgical or medical
intervention.
• Slight bleeding may continue for a short time
• pain usually ceases after pregnancy has
traversed the cervix.

20. Differential diagnosis
• Idiopathic bleeding in a viable pregnancy
• Ectopic pregnancy
• Molar pregnancy
• Infection of the vagina or cervix
• Cervical abnormalities
–Malignancy, polyps, trauma
• Vaginal trauma

21. Diagnosis
Laboratory
-HCG levels
-Progesterone levels
Ultrasound
-Status of the pregnancy
- Intrauterine? Ectopic?
Vaginal Exam: dilated cervix ~> inevitable
abortion

22. Abortion ?or not?
Progesterone HCG Ultrasound Abortion?
>25 ng per mL
Increases
(48 hours)
Normal No
<5 ng per mL
Plateau or
decrease
Nonviable
pregnancy
Yes

23. Complications
• Severe or persistent hemorrhage life
threatening.
• Sepsis develops most frequently after self-
induced abortion.
• Intra abdominal injury
- Perforation of the uterine wall may
- injury to the bowel and bladder
• Asherman’s syndrome, also known as intrauterine
adhesions, is a condition where the cavity of the
uterus develops scar tissue (adhesions)

24. Cont..
. Sheehan syndrome, also known as Simmond syndrome,
postpartum hypopituitarism or postpartum pituitary
gland necrosis, is hypopituitarism (decreased
functioning of the pituitary gland), caused by ischemic
necrosis due to blood loss and hypovolemic
shockduring and after childbirth.
• Multiple pregnancy with the loss of 1 fetus and
retention of another ("vanishing twin").
• Other complications of abortion
Anemia
Renal failure
Infertility(if hysterectomy done
due to complication)

25. Prevention
• Early obstetric care
• Treatment maternal disorders like
diabetes and hypertension
• Protection of pregnant women from
environmental hazards and exposure
to infectious diseases.

26. Laboratory investigations
• Blood type and RH factor
• Complete blood count
• HCG to confirm pregnancy
• WBC and differential to rule out
infection

27. General management
first-trimester loss
MVA ,E&D or D&C
After the first trimester
• hospitalization should be considered
• Oxytocics are helpful in contracting the
uterus, limiting blood loss, and aiding in
expulsion of clots and tissue.

28. Cont..
• Anti D for RH negative
• Surgical evacuation
-Patient is unstable:-Heavy bleeding
-Septic abortion
-Patient choice
• Medical therapy
 Missed spontaneous abortion
• Expectant management
• Completed spontaneous abortion
• Incomplete spontaneous abortion??

29. Treatment
For treated abortion
Bed rest and pelvic rest
Avoid coitus, douching and strenuous
exercise
• Prognosis is good when bleeding
and/or cramping resolve.

30. For inevitable abortion
• According to gestational age
<14 weeks MVA
>14weeks oxytocin infusion and
E/C with pethdine or sedative

31. For incomplete abortion
• Evacuation based on gestational age
• Uterotonic agents
• Blood and fluid replacement
• Antibiotic
• The prognosis for the mother is excellent
if the retained tissue is promptly and
completely evacuated.

32. For complete abortion
• observed for further bleeding.
• The products of conception should be
examined.
• prognosis for the mother is excellent

33. For missed abortion
Expectant management
-3-4 weeks follow up
-Clotting profile
>14weeks
-Prostaglandin or balloon catheter to dilate
cervix
-Pitocin
<14 weeks :-MVA or D/c

34. Treatment of complication
Managed accordingly
• laparotomy are indicated to determine
the extent of laceration or bowel injury
• Broad spectrum antibiotics for sepsis

35. Recurrent spontaneous abortion
• Defined as 3 or more consecutive, spontaneous
pregnancy losses before 28 weeks of gestation from
the last menstrual period , by the same partner ,
each with a fetus weighing less than 1000 g.
• Approximately 1% of women are habitual aborters.
• The risk of having a spontaneous abortion for the
first time is about 15%, and this risk is at least
doubled in women experiencing recurrent abortion

36. Etiology
Three generally accepted etiologies of
recurrent miscarriages are:-
• Chromosomal abnormalities
• uterine malformations
- bicornuate or septate uterus
- cervical incompetence
• Immunologic Factors
-Antiphospholipid antibodies

37. Others etiology
• sub mucous myomas
• Hormonal causes like hyper and
hypothyroidism
• Infection
• Maternal system disease e.g. diabetes
• Chronic malnutrition

38. Treatments
• Pre implantation diagnosis, or prenatal
testing on subsequent conceptions.
• Uterine operation: hysteroscopy resection
• Cervical cerclage
• myomectomy.
• Appropriate antibiotics

39. Induced abortion
Induced abortion is the medical or surgical
termination of pregnancy before the time of fetal
viability. it can be legal or illegal, therapeutic
(safe) or un safe( septic )
septic or Unsafe abortion defined by WHO:
“. . .any procedure for terminating an unwanted
pregnancy (carried out) either by persons
lacking the necessary skills or in an environment
lacking minimal medical standards, or both . . .”

40. Pathogenesis
• Instrument by illegal abortion or
ascending infection from the vaginal
cavity to normal sterile uterus

41. Sign and symptoms
• fever, shivering
• malodorous vaginal discharge
• pelvic and abdominal pain
• Rebound tenderness
• cervical motion tenderness.
• Peritonitis and sepsis

42. Investigations
• A complete blood count
• Hct ,blood group and cross match
• Urine culture and sensitivity
• endometrial cultures
• abdominal x-ray to rule out uterine
perforation should be obtained
• Ultrasound may be helpful in ruling out
retained products of conception.

43. Management
• Hospitalization and intravenous antibiotic therapy
• Broad spectrum antibiotic (ciprofloxacin+ gentamycin)
• Monitor v/s
• Blood transfusion if Hgb is low
• Remove focus of infection
• T.A.T to prevent tetanus
• Anti D for RH negative
• Post abortion care
• Hysterectomy for pelvic abscess and severe perforation

44. Post abortion care
PAC is an approach for:-
Reducing morbidity and mortality
from complications of unsafe and
spontaneous abortion, and
improving women’s sexual and
reproductive health and lives.

45. Why is PAC an important intervention?
• Saves women’s lives, increases use of FP, and
prevents repeat abortion
• Is acceptable where induced abortion is legally
restricted
• Links curative service (treatment for
complications) with preventive service (FP)
• Should be included in the existing range of
services and should not be a separate , vertical
service
• Can be offered successfully in low resource
settings

46. Magnitude of the problem of
unsafe abortion
• About 40-50 million women experience
abortions annually and 50% of these are unsafe
• 13% of maternal mortality–67,000 women–8
women die every hour
• 38 to 68% are less than 20 years old
• 10 to 50% need medical care
• More than 95% of deaths and injuries from
unsafe abortion occur in developing countries.
• ratio of 1 unsafe abortion for every 7 live births
.

47. Other factors that complicate the problem of
unsafe abortion:-
• Unmet need for contraception to delay, space
or limit pregnancies
• Unmet need for sexually transmitted infection
(STI)/HIV prevention and care

48. Essential Elements of Post abortion Care
1. Treatment
• Treat incomplete and un safe abortion and
potentially life threatening complications.
2. Contraceptive and family planning services
• Help women prevent unwanted pregnancy or
practice birth spacing.

49. cont..
3. Reproductive and other health services
• Preferably provide on - site, or via referrals to
other accessible facilities in provides’ networks.

50. Cont..
4. Community and service provider partnerships
• Prevent unwanted pregnancies and unsafe
abortion.
• Mobilize resources to help women receive
appropriate and timely care for complications
from abortion.

51. Cont..
5. Counseling
• Identify and respond to women's emotional
and physical healthy needs and other concerns

52. 52
*Normal uterus at laparoscopy
*Normal HSG

53. 1 All of the following may be the cause of
recurrent abortion except:
A cervical incompetence
B infection
C chromosome aberrantions
D retroversion of the uterus

54. 2 A patient of 8th week pregnancy, presents
with vaginal bleeding, low abdominal pain,
vaginal examination revealing partially dilatated
cervix, without expelling any tissue, she should
be diagnosed as :
A threatened abortion
B inevitable abortion
C complete abortion
D incomplete abortion