spontaneous abortion pp

7/29/2019 Spontaneous Abortion Pp

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abortionInduced abortion :is accomplished fortherapeutic or elective termination of

pregnancy

Spontaneous abortion


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Spontaneous

abortion


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Definitions* Spontaneous abortion is defined as a pregnancy

terminating before the 20th completed week (139

days) of gestation or the weight is 500g or less .

* Early abortion occurs before 12 weeks

late abortion between 12 and 20 weeks.


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Essentials of diagnosis Suprapubic pain and uterine cramping

Vaginal bleeding

Cervical dilatation

Extrusion of products of conception

Disappearance of symptoms and signs of pregnancy

Negative pregnancy test or quantitative HCG that is not

properly increasing

Adverse ultrasonic findings(eg,empty gestational sac,fetal

disorganization,lack of fetal growth)


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Incidence In the spectrum of reproductive wastage,

spontaneous abortion is probably the largest single

contributor,with an incidence of 15~20%.

Approximately 75% of spontaneous abortions

occur before 16 weeks and 62 % before 12 weeks.


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Etiology*1. chromosomal abnormalities

Malformation of the foetus is the commonest single

cause of abortions. Nearly 60 percent of early abortions

are due to gross malformations of the embryo and feotus.

Autosomal trisomy-constitutes half of the chromosomal

abnormalities.


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Other common abnormalities are:

Aneuploidy,triploidy,tetraploidy

Monosomy

Turner syndrome

such as gross abnormalities lead to non-

development the foetus ,aembroynic pregnancy orblighted ovum.


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Maternal factor1.Maternal infection

2.Endocrine disorder:hyperthyroidism,diabetes

luteal defect and inadequate progesterone production.

3.Anotomic defects

Uterine defects:gross malformation may interfere with the

accommodation of the products of conception and causeabortion.


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congenital abnormalities that distort or reduce the

size of the uterine cavity:

unicornuate,bicornuate ,or septate uterus, double

uterus.


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acquired anomalies:myomas,previous scarring of

the uterus,anatomic and functional incompetence

of the uterine cervix.

4.Immunologic disorder:Blood group incompatibility

due to ABO,Rh

5.Mulnutrition,Emotional disturbance,toxic

factor,trauma


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PathologyIn spontaneous early abortion,hemorrhage into thedecidua basalis often occurs.

Necrosis and inflammation appear in the region ofimplantation.

The pregnancy become partially or entirely

detached and is, in effect, a foreign body in theuterus.


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Uterine contractions and dilatation of the cervix

result in expulsion of most or all of the products of

conception.


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Clinical classificationCommon types:

Threatened abortion Inevitable abortion

Incomplete abortion

Complete abortion


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Special types:

Missed abortion

Septic abortion

Habitual abortion


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A. Threatened abortionIs bleeding of intrauterine origin occuring

before the 20

th

compeleted week, with orwithout uterine contraction, without

dilatation of the cervix,and without expulsion

of the product of conception.The cervixremains closed, although slight bleeding or

cramping may be noted.


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Ultrasonography is helpful in the

management of threatened abortion bydetecting fetal movement of heart beat.This

prognostic sign is most reliable after 7 weeks

gestation.


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Treatment

Place the patient at bed rest, interdict intercourse,and observe the patients progress.

Drug therapy is generally ineffective in preventing

abortion because so many of these uncertainpregnancies are abnormal.

Progesterone use is controversial


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The prognosis in the case of threatened abortion is

good when all abnormal signs and symptoms

disappear and when resumption of the progress of

pregnancy is apparent.

D&Cmay b e necessary if significant bleeding

persists or if product of conception are retained.


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B.Inevitable abortionThe process of abortion has become irreversible

Is bleeding of intrauterine origin before the 20th

completed week,with dilatation of the cervix,and

without expulsion of the products of conception.

Pain ( uterine cramping ) and bleeding with an

open cervix indicate impending abortion; the

expulsion of the uterine contents is imminent.


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Treatment

Evacuation of the uterus by suction D&Cshould bepromptly performed.

The prognosis for the mother is excellent if retained

tissue is promptly and completely evacuated.


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C.Incomplete abortion IN incomplete abortion the products of conception

have partially passed from the uterine

cavity.Retained tissue is evidenced by continued

bleeding, a patulous cervix, and an enlarged,

boggy uterus.

Bleeding generally is persistent and is often severeenough to constitute frank hemorrhage.


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Treatment

D&C should be performed for possible retained tissue.Evacuate the uterus promptly.Suction D&C is most

effective.

Tissue at the external os should be removed with sponge

forceps and examined by a pathologist. If abortion is complicated or has occurred after the first

trimester, the patient may require hospitalization.


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Type and cross-match for possible blood

transfusion if bleeding is brisk or if the initial

hemoglobin is less than 100g/L.

The oxytocin( contracts the uterus, aids

in the expulsion of tissue or clots, and limits blood

loss.


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The prognosis for the mother is good if the

retained tissue is promptly and completely

evacuated.

anemia


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D.Complete abortion Is identified by passage of the entire conceptus.

Marked by cessation of pain as well as termination

of brisk bleeding.

The conceptus be very carefully examined for

completeness and for trophoblastic disease.

The prognosis for mother is excellent.


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The process of the abortion

continue Complete

Threatened

abortion Inevitable

Incomplete


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E.Missed abortion

Missed abortion implies that the foetus dies inside

the uterine cavity and the uterus fails to expel it.

Manifestion:

1. loss of symptoms of pregnancy

2. repeated vaginal bleeding or brownish vaginal

dischargea


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3.decrease in uterine size.

4.State of cervix:not dilated .The cervix remains firm

and closed,and no adnexal abnormality can be

identified.


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Ultrasonograph is effective for following a

pregnancy suspected of being a missed abortion.

An embryo or fetus without heart motionAbnormal gestational sac

The quantitative B_HCG may decline, and urine

pregnancy Tests may become negative .


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TreatmentThe uterus being evacuated soon after diagnosis

In the first trimester this is usually accomplished

by suction curetage

In the second trimester evacuation is most

frequently accomplished using prostaglandin E

suppositories.


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Complications If evidence of a seriously reduced fibrinogen

level,,infection,or anemia exist ,appropirate

threapy must be also instituted.

Hypofibrinogenemia

This complication occurs because of the release of

thromboplastins from the dead products of

conception (if it retained more than four weeks).


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This tromboplastins utilize the available

fibrinogen ,resulting in a defect in the coagulability

of the blood ,which may cause severe bleedingduring or after expulsion of products of

conception.

Treatment: blood infusion, plasmainfusion ,fibrinogen,heparin.


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G.Septic abortionManifested by a malodorous (

discharge from the vagina and cervix, pelvic and

abdominal pain,marked suprapubictenderness,signs of peritonitis,tenderness with

movement of the uterus or cervix.

Fever :37.8-41


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The extent of the infection is usually confirmed by

an Elevated white blood count and other systemic

signs Of infection.

Blood cultures

Endometrial biopsy


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treatmentHospitilization

Intravenous antibiotic therapy coverage for

anaerobic and aerobic bacteria.

Individualize antibiotic therapy if a specific

organism is suspected or if the patients has a known

antibiotic sensitivity.


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D$C should be performed to make certain all of the

products of conception have been removed.

If the patient is bleeding heavily ,the evacuation

should be carried out soon after initiation of

antibiotic therapy. if the patient is not bleeding ,the

Evacuation may be delayed until the sepsis is

brought under control with antibiotics.


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Hysterectomy may have to be performed if the

infection does not respond to treatment.


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F.Habitual abortionDefined as 3 consecutive spontaneous pregnancy

losses before 20weeks.

Incidence:when there is no previous history is 15%

this increases to 25-50% when there are

have been 3 or more miscarriages.


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Etiology :Genetic error:there is a 50-60% incidence of

abnormal karyotype in first-trimester spontaneous

abortion .

anatomic abnormalities is the first reason of

habitual abortion,congenital abnormalities ,cervical

incompetence, submucous leiomyomas)


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Hormonal causes:

Inadequate hormonal support cause to the abortion.

hypothyroidisim, hyperthyroidisim, progesteroneinsufficiency,uncontrolled diabetesmellitus.progesterone deficiency or luteal phase

defect is an important reason of habitualabortion.


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Diagonosis and treatmentGenetic error:Obtain a 3-generation pedigree and

karyotype of both parents and any previously

aborted material.

anatomic abnormalities:diagnosis of anatomic

abnormalities is usually accomplished byhysterosalpingography or hysteroscopy .


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Treatment

If the causative factor is detected the patient should be

treated accordingly.

Uterine operation:reconstruction of the

uterus,myomectomy

cervical incompetence: cervical cerclage.cervical cerclage is recommended between 12-14 weeks

of gestation.success rate with cerclage are 85-90%.


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Horminal factor:Use progesterone,control

diabetes

Infection:should choose low toxic antibiotics.


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differential diagnosisEctopic pregnancy: amenorrhea,menstrual

abnormality,unilateral pelvic pain,uterine

bleeding ,and a tender adnexal mass.

Hydatidiform mole:the uterus may be unusually

large.if theca lutein cysts present cause bilateral

ovarian enlargement,bloody discharge may containhydropic villi.


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ComplicationsSevere or persistent hemorrhage during or

following abortion may be lifethreatening.

Sepsis develops most frequently after criminal or

self-induced abortion. there are sequelae of infection,

eg, salpingitis, infertility

Hypofibrinogenemia


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Perforation of the uterus occur during D and C

Injury to the bowel ,bladder,

spontaneous abortion pp

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