Spontaneous Abortion also known as Miscarriage and pregnancy loss is the natural death of an

embryo or fetus before it is able to survive independently. Some use the cutoff of 20 weeks of gestation.

Pathophysiology and Etiology

1. Cause frequently unknown, but 50% are due to chromosomal anomalies.
2. Exposure or contact with teratogenic effects.
3. Large doses of any drug consumption.
4. ABO incompatibility.
5. Poor maternal nutritional status.
6. Maternal illness with virus such as rubella, active herpes, or specific bacterial microorganisms
7. Hx of diabetes, thyroid disease, lupus
8. Smoking or drug abuse or both.
9. Immunologic factor by which the mother and father are genetically similar major antigens that cause
the maternal immune system to reject embryo.
10. Psychological factors such as stress and anxiety cause the alteration in the level of pituitary
hormones which affects the uterine activity and lead to abortion.
11. Structural defect in the maternal reproductive system like incompetent cx, retroverted uterus and
myoma.
12. Imperfect sperm or ova.

Clinical Manifestation
1. Uterine cramping, low back pain
2. Vaginal bleeding usually begins as dark spotting, then progress to Frank bleeding as the embryo
separated from uterus.
3. Hcg may be elevated for as long as 2 weeks after the loss of embryo.

Diagnosis
Ultrasonic evaluation of the gestational sac or embryo
Visualization of the cervix, presence of dilation or tissue evaluation.

Types of Spontaneous Abortion

1. Threatened Abortion- it is a clinically entity where the process of Abortion has started but has
not progress to a state from which recovery is impossible.

Clinical Manifestation
Vaginal bleeding or spotting, mild cramps, tenderness over uterus simulates mild labor or persistent low
back pain with feeling of pelvic pressure.
Cx closed or slightly dilated

Investigation
Blood test- hb, hct, ABO Rh, Serum hcg, serum progesterone level.

Management
Bedrest until the bleeding stops
Vaginal examination
Pad count
Observation of v/s
Pain relief

2. Inevitable Abortion
Is the clinical type of Abortion where the changes have progressed to a state from where the
continuation of pregnancy is impossible.

Clinical Manifestation
Bleeding more profuse
Dilated cx
Ruptured membranes
Painful uterine contractions
Management

Before 12 weeks- embryo delivered, followed by d&c

After 12 weeks- the uterine contractions is accelerated by oxytocin drip. If the fetus is expelled and
placenta is retained, it is removed by by ovum forceps. If the placenta is not separated digital separation
followed by its evacuation is to be done under general anesthesia.
Excessive bleeding should be promptly controlled by administering methergin 0.2 ml. if the cx is dilated
and the uterine size is less than 12 weeks.
The shock is corrected by IV fluid therapy and blood transfusion.
If bleeding is profuse with the cx closed, evaluation of the uterus may have to be done by abdominal
hysterectomy.

3. Habitual Abortion
It is defined as a sequence of 3 or more consecutive Spontaneous abortion before 20 weeks.

Management
D&C
Treatment of possible causes- hormonal imbalance, tumors, thyroid dysfunction, abnormal uterus,
incompetent cx
With treatment 70-80% carries a pregnancy successfully.
Surgical suturing of the cervix if incompetent cx is a causative factor.
Hysterogram to rule out uterine abnormalities or infection.

4. Complete Abortion
A complete Abortion is likely to occur prior to 8th week of pregnancy and constitutes the expulsion of
the embryo, placenta and intact membranes.

Clinical Manifestation
Subsidence of abdominal pain, vaginal bleeding becomes trace or absent.
Internal examination reveals:
Uterus is smaller than the period of amenorrhea and a little firmer.
Cervical os is closed
Bleeding is trace
Examination of the expelled fleshy mass is found intact.

Management
The effect of blood loss, if any, should be assessed and treated.
If there is any doubt about complete expulsion of the product, uterine curettage should be done.

5. Incomplete Abortion
When the entire products of conception are not expelled instead a part of it is left inside uterine cavity,
it is called incomplete Abortion.

Clinical Manifestation
Fetus usually expelled, placenta and membranes retained.

Management
D&C

6. Missed Abortion
When the fetus died and retained inside the uterus for a variable period.

Clinical Manifestation
Fetus died in the utero is retained
Maceration
No symptoms of abortion but symptoms of pregnancy regress.

Management
Utz
If in 2nd trimester, fetal monitoring to determine fetal demise.
If fetus did not pass after diagnosis, oxytocin induction maybe used.
 7. Septic Abortion
Any abortion associated with clinical evidences of infection of the uterus and its contents.

Clinical Manifestation
Rise of temperature at least 38 degrees from 24 hours or more
Offensive or purulent discharge.
Lower abdominal pain and tenderness

Clinical Grading:
Grade 1- the infection is localized in the uterus
Grade 2- the infection spreads beyond the uterus to the tubes, ovaries and pelvic peritoneum
Grade 3- generalizes peritonitis and endotoxic shock or jaundice or acute renal failure.

Complications of Abortion
H-emorrhage
I-nfection
S-epticemea
I- intravascular coagulation

Patient Education
Family planning, explain the need to wait at least 3-6 mos for another pregnancy.
Teach the women to observe for signs of infection and to get medical care immediately.
Provide info regarding the genetic testing of the product of conception if indicated, send specimen
accordingly to policy.

Report By: Doriah O. Frankie BSM

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