AbortionAbortion Dr. Fakher ShatnawiDr. Fakher Shatnawi

Al-Bashir HospitalAl-Bashir Hospital

Bleeding from the genital tract before viability due to: -Abortion -Ectopic pregnancy -vesicular mole -Local conditions (cervical erosion , polyps, ca……) -Hartman bleeding : bleeding at the time of expected menses before 12 weeks ( due to shedding of part of the decidua

Definition of abortion:Spontaneous or artificial termination of pregnancy before viability of the fetus.Viability: reasonable chance of the fetus for extra uterine survival

*Was before 28 weeks *Now before 24 weeks *In some countries before 22 weeks

Incidence of abortion: Clinical

(10-15%)12%

Preclinical (25-30%)

The overall incidence of AB. Is 45%

Even more

* 75-80% of abortion occurs before 12 weeks gestation

* pts who have no live born and have hx of one abortion the incidence of abortion in the next pregnancy is 20%

* Same pts but with hx of 2 abortions the incidence of abortion in the next pregnancy is 35%

* Same pts with hx of 3 abortions the incidence increase to 45%

*Habitual abortion ( Recurrent ) : if 3 or more successive spontaneous abortion

*Abortion :

Early abortions which occurs before 12 weeks

Late abortion which occur between 13-24 weeks gestation

…Most of early abortions are unembryonic abortions

Blighted ovum

*Usually early abortions due to fetal causes but Late abortions usually due to maternal causes

#Important points :

-abortions increase after the age of 30s

-abortioins increase more after the age of 35 yearsThis increase is about 9 times than pts aged between 20-29 years -the risk of abortion increases with increased gravidity.(parity)

-the risk of abortion increases with increasesd maternal and paternal age (mostly the maternal one)

Ethiology of abortion:

1.Fetal couses (occur in early abortions) --chr. abnormalities (50-60%)The most common are *trisomies the commonest is trisomy 16(21,22)This frequently seen in blighted ova *triploidy : 69 chr. (15-20%) of chr. abnormalities seen in abortions molar pregnancy *monosomies : (45x) 1:15 of all monosomies will not abort TURNER SYNDROM

toxoplasmosies lysteria monocytogenes--infections : rubella cytomegalovirus herpes simplex syphilis

infictions are not considered as frequent couses of recurrent abortions , because they couse abortions only during there acute attacks

2.Maternal causes:Usually lead to abortion in late pregnancy (13-24) weeks

*local causes in the uterus1.Uterine anomalies -spetate uterus -bicornuate uterus -hypoplastic uterus -unicornuate uterus the cause of abortion is: --decreased uterine blood supply --decreased uterine cavity2.Uterine synechia (Asher man syndrome)3.Submucous fibroids decrease of blood supply week decidualization 4.Cervical incompetence: -congenital -iatrogenic

*chronic maternal diseases: (A).chr. Nephritis (B). Renal failure (C). Uncontrolled D.M.

*Endocrine causes:1. Luteal phase defect…. (progesterone deficiency) due to week corpus luteum2. Hypothyroidism (increase prolactin hormone)3. Immunological causes:

-Anticardiolipins Abds. Antiphopholipids Abds. -Lupus anticoagulant These Abds. Lead to Thrombosis in placental vaseles with prolonged PTT at the same time. The antiphospholipd syndr. Leads to sever and early preclampsia < 20 wks If pregnancy continue I.U.G.R

*Other causes:1.Acute fever ( by activation of P.G.)2.Acute hydramnios ( occurs early before 24 wks. While chr. Hydramnios occurs late > 24 wks. Gestation )3.Direct trauma to the abdomen 4.Radiation -ergots (Methergin , Syntometrine) 5.Drugs -Prostaglandins ( cytotec) -Kenins

Types of Abortion: -Threatened Ab. -Missed Ab. -Complete Ab. -Incomplete Ab. -Inevitable Ab. -Septic Ab. May be with any type of mentioned Abs.

Abortions -Medical Ab. -Criminal Ab. septic Abs. mainly occurs with criminal one

**Threatened AB. mild separation of the products of conception. Symptoms : -That of early pregnancy still present -Mild-moderate vaginal bleeding -Mild lower abdominal pain#.vaginal ex.: -uterine size coresponds with gestational age -Cx. Is closed

#.Ultrasound alive fetus#.Treatment: -bed rest -No sexual intercourse -Sedation ( mental rest ) -Treat the cause ( progesterone if luteal phase insufficiency …..etc).

**Missed AB. The fetus is dead and retained in uterus.#.symptoms : -cessation of fetal movements if already present (>18 wks) -sometimes brownish vaginal discharge#.Vaginal ex. : -uterus is smaller than expected gestational age -Cx. Is closed…U\S: No F.H.B. could be seen if pregnancy is >10 wks and if the fetal death is >4 wks we must R\O D.I.C. by doing the coagulation profile: -PT , PTT -S.Fibrinogen -Plat.count -D.dimer -F.D.Ps

If coagulation profile is normal , D&C is the treatment for missed Ab. If gestation Age is less than 12 wks. (But) if gestational age is > 12 wks and bony elements are Present by ultrasound ex. ( of the fetus ) , then medical evacuation of the uterus is The best treatment by using : -cytotec tab. -R.U.486 -P.G. N.B: Hypofibrinogenemia occurs if the death of the fetus is > 4 wks. , due to release of Thromboplasin material from fetal tissue to maternal ciculation

**Inevitable AB.: marked separation of the products of conception -Sever bleeding (with clots). - -Sever lower abdominal painEx.: the Cx is usually dilated. Pts may have signs of hypovolemic shock if bleeding is sever. after 12 wks. Gestation ruptured of membranes indicates inevitable Ab.

Treatment : 1-treatment of the hypovolemic shock if present2-evacuation of thr uterus if less than 12 wks. Gestation by doing D&C. and by P.G. if Gestation is >12 wks ( the presence of fetal bony elements)

**Complete & incomplete Ab.:

**Complete Ab: all products of conception are expelled from uterine cavity The bleeding and the pain are not present ( stopped) The Cx is closed ultrasound ex. Empty uterus

**Incomplete Ab.:Parts of the products of conception are still inside the uterus pts still have vaginal bleeding pts still have lower abdominal pain Cx-opened ultrasound : uterus bulky with products of conception Treatment by E&C or D&C (evacuation) (dilatation)

**Septic AB.

infection superimposed on any type of mentioned Ab.The causative organisms:

-streptococci hemolytic (the commonest organism isolated) -Staphylococci -clostridium Welchii -other organism = gr. +ve -ve The route of infection : -exogenous -endogenous

Septic Ab. Is mostly seen in criminal Abs.…Symptomes and signs: -That of abortion -fever -Lower Abd pain -tachycardia -lower Abdominal tenderness -offensive vaginal discharge

**Treatment:

*-isolation of the pt.

*-exclude septic shock (hypothermia)

*-start Antibiotics as rules to cover both gr. +ve & gr.-ve and to cover anaerobes as well as aerobes. ( Ampcillins + Gentamycins + metronidazol) until the results of the culture is ready. If clostridium Welchii is isolated Give Anti-gas gangrene + Penicilin (Ampicilin)

*-Evacuation of the uterus ( drainage) within 24 hrs after antibiotics if gestation <12 wks better by digital evacuation or suction curettage, and if >12 wks gestation by prostaglandins.

Hysterectomy : is rarely needed if infection by clostridium producing gangrene to the uterine tissue.

Cx - Incompletence:

1.Congenital type usually is associated with other uterine anomalies

2.Iatrogenic type : -after D&C -cervical injury: A. Conisation (cone biopsy) C.I.N. B.After delivery (cervical tears) C.Deep cautary ( incompetence or

stenosis) This type of Cx ( incompetent one) leads to

Ab. In the second trimestre (>12-24 wks) usually it is painless Ab.(or little pain) By ultrasound Funyl shape of the internal

os

Diagnosis :

*-ultrasound (T.Y.V.U) (vaginal ultrasound)*-Heigger test*-History

Treatment: *cervical circalage -shrudkar stich -Mc.Donalled stich

the stich is inserted > 12 wks but check fetal viability before insertion the stich ( by ultrasound)

Recurrent Ab.:

If 3 or more succesive abortions this usually increase the risk of ectopic pregnancy.

*Remember:

**give Anti-D if pts. Blood group is –ve ( her husbands group is +ve). After all types of abortion.

**after cervical stich ( cervical incompetence) No need to give Anti-D if pts blood group is -ve