PATHOLOGIC OBSTETRICS

Topic: Abortion
Lecturer: Dr. Raymundo (NER)

ABORTION Spontaneous Abortion…..

Abortion/Miscarriage:  Fluid-filled gestational sac
 The termination of pregnancy spontaneously or intentionally or  Pathogenesis:
induced o Anembryonic miscarriage or blighted ovum
 Before fetal viability or before the fetus is sufficiently developed to Contains no identifiable embryonic elements
survive
 Premature birth before a live birth is possible o Embryonic miscarriage
 Before 20 weeks gestation (<20 weeks gestation = abortus) With a developmental abnormality of the embryo, fetus,
Age of fetal viability  if it is >20 weeks gestation (it means higher yolk sac, placenta
chance of a fetus to survive)
Mechanisms:
 Fetal birthweight less than 500 grams  Very early abortion  embryonic death precedes expulsion of ovum
o Mean birthweight of:  Late abortion  fetus does not die in utero before expulsion
 20 weeks fetus is 320 g If you have observed that the abortus is still alive when it is delivered
 22-23 weeks fetus is spontaneously, then you consider that as late type of abortion
500 g because majority of the early onset of abortion  they die usually
intrauterine before it will be expelled out of the uterus
In the absence of the LMP (last
menstrual period) which is important Etiology:
for the computation of AOG, always  Fetal Factors
think of the fetal birthweight as 1. Abnormal development of the
another factor to consider for the zygote/embryo
definition of abortion. 2. Aneuploid abortion (abnormal
<500 g fetal birthweight  abortus number of chromosomes)
 Autosomal trisomy
 Monosomy X (45,X)
 Crown rump length of <160 mm (less than 16 cm)  abortus  Triploidy
 Tetraploid abortuses
Early Pregnancy Loss:  Chromosomal structural abnormalities
 Non-viable, intrauterine pregnancy (IUP) with either: 3. Euploid Abortion (abnormal development with a normal
o An empty gestational sac (blighted ovum) number of chromosomes) (46 XX; 46 XY)
o A gestational sac containing an embryo or fetus without fetal
heart activity
o Within the first 12 6/7 weeks AOG or before 13 weeks AOG

Picture Above:

SPONTANEOUS ABORTION Of all the abnormal number of chromosomes, if you will look at the different
trimesters of pregnancy where termination occurs, during the 1st trimester =
 Abortion occurring without medical or mechanical means to empty the
>50% (55%) are secondary to chromosomal abnormalities
uterus
 Pathogenesis: Hemorrhage into the decidua basalis
 Maternal Factors
o Adjacent tissue necrotic
1. Infections (Blood-born transmission) 11. Contraception
o Uterine contractions
2. Chronic debilitating illness 12. Environmental toxins
o Expulsion
3. Hypothyroidism 13. Autoimmune factors
4. Diabetes mellitus 14. Alloimmune factor
Always, there is the progress of uterine contractions associated with 5. Progesterone deficiency 15. Inherited thrombophilias
vaginal bleeding and then later on you will be surprised that the 6. Nutrition 16. Laparotomy
placenta or abortus will be coming out without any warning 7. Alcohol 17. Physical trauma
8. Tobacco 18. Uterine defect
9. Caffeine 19. Incompetent cervix
10. Radiation

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 PATHOLOGIC OBSTETRICS
Topic: Abortion
Lecturer: Dr. Raymundo (NER)

Fetal Factors Maternal Factors

1. Abnormal zygote/embryo development Hypothyroidism
 Display a developmental abnormality of the zygote, embryo, early  Symptoms: poor ability to tolerate cold, feeling of tiredness, dry skin,
fetus, or placenta constipation, depression, weight gain
 Demonstrated degenerated or absent embryos  blighted ovum  Severe iodine deficiency may be associated with miscarriages
 Morphological disorganization of growth in 40% abortuses  Any effects of hypothyroidism (Autoimmune – Hashimoto’s thyroiditis)
on early pregnancy loss — not adequately studied
2. Aneuploid abortion (abnormal number of chromosomes) Hashimoto’s disease – there is ↑ level of TSH but T3 and T4 are ↓
 50-60% of embryos and early fetuses that are spontaneously aborted
contain chromosomal abnormalities  Presence of thyroid auto-antibodies  increased incidence of abortion
 95% of chromosomal abnormalities were due to maternal  Data less convincing that women with recurrent miscarriage have
gametogenesis errors increased anti-thyroid antibodies than normal
It is the oocytes that is considered to be the main reason why there
is an abnormal number of chromosomes Diabetes Mellitus (Pre-gestational or Overt diabetes)
 Type 1 DM or Insulin-dependent diabetes  increase rate of
 5% to paternal errors spontaneous abortion and major congenital malformations
 Most common abnormalities:  Related to the degree of metabolic control in the first trimester
o Trisomy 50-60%
o Monosomy X 9-13% Progesterone Deficiency
o Triploidy 11-12%  Luteal phase defect  Insufficient progesterone secretion by the
corpus luteum or placenta
 Trisomy  If in <10 weeks AOG – corpus luteum is removed, supplemental
o Most frequent chromosomal anomaly in 1st trimester abortion progesterone replacement is indicated
 Increase with maternal age
When couples prevent having a baby during the first few Lecture Discussion: Progesterone deficiency
years of their marriage life we have to tell them that once
Any deficiency of progesterone especially in the first 12 weeks of
the female reaches the age of 35, abnormalities of
gestation might end up with sloughing off or separation of the functional
chromosomes increases. So we recommend that they at
layer of the endometrial lining (decidua compacta & decidua
least get 1 pregnancy before the age of 35
spongiosa). These decidual lining is where your placental are trying to
hold on, if there would be a ↓ in the level of progesterone secretion
o Most common cause of trisomy  result from isolated non- from the corpus luteum = abortion. Also ↓ in progesterone = ↑
disjunction contractions (due to stimulation of estrogen which is unopposed)
o Balanced structural chromosomal rearrangements are present
in one partner in 2-4% of couples with a history of recurrent Tobacco
abortions  ↑ risk of euploidic abortion
9 Mosaic syndrome  More than 14 cigarettes stick a day  the risk increases to twofold
13 Patau syndrome  Risk is 1.2 increase for each 10 cigarettes smoked per day (2014)
16 Mosaic trisomy 16
18 Edward’s syndrome
Lecture Discussion: Tobacco
21 Down syndrome
22 Mosaicism syndrome This is also detrimental to the growing embryo because every time the
**Highlighted in yellow is the most common trisomy** patient smoke, nicotinic particles are being inhaled. These small minute
nicotinic particles will go to the circulation and might cause thrombosis
 Monosomy X (45, X or 45, X0) at the area of placenta precipitating abortion
o Single most common specific chromosomal abnormality
o Results in abortion Alcohol
o Less frequently in liveborn females (Turner syndrome)  First 8 weeks – frequent alcohol use causes both spontaneous abortion
o Autosomal monosomy is rare and incompatible with life and fetal anomalies (teratogenic effects)
 Drinking 2x a week  abortion rates double
 Triploidy (XXX, XXY, XYY)  Drinking daily  abortion rates tripled
o Associated with hydropic or molar placental degeneration
(hydatidiform mole) Caffeine
o Incomplete (partial) hydatidiform moles may contain triploidy  Appears to ↑ risk if consumption is more than 4 cups/day –
or trisomy on chromosome 16 consumption must not exceed 500 mg of caffeine a day
o Fetus within a partial H-mole frequently aborts early and the
 Paraxanthine (a caffeine metabolite - psychoactive CNS stimulant) 
few carried longer are all grossly deformed
levels were extremely elevated had an almost twofold risk of abortion
o Advanced maternal and paternal age does not increase the
incidence
Environmental Toxins
 Tetraploid abortuses  Possible Abortifacient:  NO effects:
o Rarely live-born and most often aborted early in gestation o Lead o Video display terminals
o Formaldehyde o Ultrasound
3. Euploid Abortion (abnormal development with a normal chromosomal complement) o Benzene
o Ethylene oxide
o Nitrous oxide

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 PATHOLOGIC OBSTETRICS
Topic: Abortion
Lecturer: Dr. Raymundo (NER)

Physical Trauma Threatened Abortion

 Major abdominal trauma can precipitate abortion Clinical Diagnosis:
 Minor trauma – risk of abortion is not known  Bloody vaginal discharge or bleeding appears through a closed cervical
 In general, trauma contributes minimally to the incidence of abortion os during the first half of pregnancy
If the physical trauma is directed into the pelvic area = might cause  Vaginal spotting or bleeding may persist for days or week
uterine contractions  abortion  Fetuses are at increased risk for:
o Preterm delivery
Uterine Defects o Low birthweight
 Large and multiple leiomyomas usually doesnot cause abortion – o Perinatal death
location more important
o Submucous myoma Lecture Discussion:
 Ashermann syndrome - uterine synnechiae (adhesions) It will start as hypogastric pain and it will progress to cervical dilatation 
 Developmental Uterine defect we expect that there will be some sort of bleeding (spotting then progressing
o Abnormal mullerian duct formation and fusion defects to gross red blood discharge)
o Occur simultaneously or induced by in utero DES exposure
o Corrective surgery is done as a last resort If you have a threatened abortion which will start with pain, we always try to
address the pain so that it will not progress because if it progresses you might
Incompetent Cervix end up with an inevitable type of abortion or an incomplete abortion. This
 Painless dilatation of the cervix in the 2nd or early 3rd trimester  can be managed medically or by tocolytic agent
prolapse and ballooning of membranes into the vagina  expulsion of
immature fetus Clinical Features:
 Transvaginal ultrasound – funneling, but with a closed external os  Bleeding  cramping abdominal pain follows a few hours to several
 Etiology: days later
o Previous trauma to the cervix:  Pain of abortion may manifest:
 - Dilatation & Curettage o Anterior and clearly rhythmic cramps
 - Cervical conization o Persistent low back ache
 - Cauterization o Associated feeling of pelvic pressure or as a dull, midline,
 - Amputation suprapubic discomfort
o Abnormal cervical development following exposure to DES  Poor prognosis:
 Treatment: Cerclage o Combination of bleeding and pain
o Done after 14 to 24 weeks but not beyond 24-26 weeks  Blood loss sufficient to cause significant anemia or hypovolemia 
o 2 types: uterine evacuation done
1) McDonald’s
2) Shirodkar cerclage Diagnosis:
o Contraindications:  Vaginal ultrasound
 Bleeding, uterine contractions, rupture membranes  Serum β-hCG
o Complications:  Serum progesterone
 Membrane rupture, chorioamnionitis, intrauterine
infection Treatment:
 No effective therapies;
 Bed rest does not alter its course
If your patient is active and is not able to rest during the day, the
best advice is for her to at least go on a 24 hr. bed rest so that there
will be relaxation of the pelvic organs, at the same time, by lying
down there will be ↑ blood supply going to the uterus

 Analgesic for discomfort

Analgesic will de-elevate the pain  will help us address the uterine
contractions. After which, we give tocolytic agents

Inevitable Abortion
Clinical Features:
 Gross rupture of membranes in the presence of cervical dilatation
CATEGORIES OF SPONTANEOUS ABORTION  Uterine contractions begin or infection develops
 Threatened Abortion  Diagnose: Speculum examination, UTZ
 Inevitable Abortion  Treatment:
 Incomplete Abortion o Without pain or bleeding: complete bed rest and observed
 Complete Abortion o With gush of fluid, pain, bleeding and fever: abortion
 Missed Abortion inevitable, uterus emptied (D&C – dilation & curettage)
 Septic Abortion
Lecture Discussion:
This is the opposite of threatened abortion. The progress is the same but this
time, there is cervical dilatation and at the same time rupture of the
amniotic membrane leading to the passage of amniotic fluid

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 PATHOLOGIC OBSTETRICS
Topic: Abortion
Lecturer: Dr. Raymundo (NER)

Complete Abortion Recurrent Miscarriage

Clinical Features:  Also referred to as recurrent spontaneous abortion & recurrent
 Complete detachment and expulsion of the fetus  internal cervical os pregnancy loss
closes  Refers to three or more consecutive pregnancy losses
Diagnosis:
 Ultrasound Causes:
 Genetic (2-4%)
Treatment/Management:  Anatomical (7-15%)
 Expectant  Immunological (15%)
Observe the amount of bleeding and check for the uterine  Inherited thrombophilias
contractions. If there is no more bleeding and lesser uterine
 Endocrine (8-21%)
contractions  everything have passed out of the uterine cavity
 Infections (<10%)

Work-up:
Lecture Discussion:
 Parental karyotyping, HSG, HSSG, aPTT, dRVVT, TSH, serum
There are cases that patient will tell us that there was pain, bleeding and progesterone
spontaneous passage of a meaty material (is made up of placenta, embryo).
The expulsion of the entire product of pregnancy ends up with complete
Lecture Discussion:
abortion
Immunologic  what we called the APAS (antiphospholipid syndrome)
Incomplete Abortion Endocrine  thyroid problems & DM may induce abortion
Clinical Features:
 Placenta in whole or in part, detaches from the uterus, bleeding ensues Induced Abortion
 Internal cervical os remains open and allows passage of blood Clinical Features:
 Medical or surgical termination of pregnancy before the time of fetal
Diagnosis: viability
 Internal exam, ultrasound  Illegal; abortion ratio – 238/1000 live births; abortion rate – 16/1000
Treatment women
 Expectant  60% - performed during the 1st 8 weeks
 Complete curettage  88% - during the 1st 12 weeks
Scrape out the parts that are left inside the uterine cavity
Therapeutic Abortion
Clinical Features:
Lecture Discussion:  Termination of pregnancy before the period of fetal viability for the
Threatened abortion and Inevitable abortion can end up with incomplete purpose of saving the life of the mother
abortion. That means that there are some parts of the product of conception  To prevent serious or permanent bodily injury to the mother
that was retained in the uterine cavity (e.g. placental tissue, part of embryo)  To preserve the life or health of the woman

Missed Abortion Indications:

Clinical Features:
 Uterus retains dead product of conception behind a closed cervical os
for days or even weeks
 Early pregnancy appears normal, with amenorrhea, nausea and
vomiting, breast tenderness, and growth of the uterus
Diagnosis:
 Ultrasound
Treatment/Management:
 Expectant
 Medical
 Surgical
Lecture Discussion:
Females sometimes will tell us that it seems that the uterus is not becoming
bigger (size of her uterus is not the same of her AOG)  when a UTZ is done,
you will be able to find out that there is an embryo/fetus inside the
gestational sac but when you try to look at the heart activity, it’s already
inactive (dead fetus). What should we do? Induce uterine contractions, if
not, you can just wait and expect for the abortus to be expelled out of the
uterine cavity anytime. You can also do curettage (surgical)
 Persistent heart disease after cardiac decompensation
 Advanced hypertensive vascular disease or diabetes
 Invasive CA of the cervix
 Pregnancy resulting from rape or incest
 Possible birth of a child with severe physical deformities or mental
retardation
Elective (Voluntary) Abortion
 Interruption of pregnancy before viability at the request of the woman
but not for reasons of impaired maternal health or fetal disease
Counselling:
 Continued pregnancy with its risks and parental responsibilities
 Continued pregnancy with its risks and responsibilities of arranged
adoption
 Choice of abortion with its risks ACOG supports legal right of women to
obtain an abortion

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 PATHOLOGIC OBSTETRICS
Topic: Abortion
Lecturer: Dr. Raymundo (NER)

SURGICAL TECHNIQUES FOR ABORTION CONSEQUENCES OF ABORTION

 Dilatation and Curettage Maternal Mortality
 Menstrual Aspiration  Legally induced abortion – done during first 2 months
 Laparotomy o 0.7/100,000 procedures
 Rate double for each 2 weeks after 8 weeks’ gestation
Dilatation and Curettage
 Dilating the cervix  Impact on Future Pregnancy
evacuating the pregnancy  Fertility does not appear to diminished by an elective abortion, except
by mechanically scraping as a consequence of infection
out the contents (sharp
curettage), suctioning out Septic Abortion
the contents (suction  Abortion with infection of the products of conception, uterus or with
curettage), or both presence of microorganisms or their products in the systemic
circulation
 Associated with criminal
 Complication:
o Severe hemorrhage, sepsis, bacterial shock and acute renal
failure

 Etiologic agent:
o Anaerobic bacteria, coliforms, H. influenza, Clostridium jejuni,
group A streptococcus
 Diagnostic criteria:
o Temperature of 38oC (100.4oF) of at least 24 hrs. duration not
due to other causes
o History mechanical termination
o Presence of septic cervical discharge
o Presence of uterine, parametrial or adnexal tenderness
Picture Above: Dilatation and Curettage
When you do your dilatation and curettage, there must be visualization first RESUMPTION OF OVULATION AFTER ABORTION
of the cervix. Once the cervix is being visualized you have to clamp the upper  Ovulation may resume as early as 2 weeks after an abortion
lip of the cervix so you will be able to inset the cannula or curette inside the  Therefore, if pregnancy is to be prevented, effective contraception
uterine cavity. Sad to say when you do your curettage, surprisingly you will should be initiated soon after abortion
be getting out piece by piece all the parts of the fetus

Complications:
 Uterine perforation
 Cervical laceration
 Hemorrhage
 Incomplete removal of fetus and placenta
 Infections

Menstrual Aspiration
 AKA: Menstrual extraction, Menstrual induction, Instant period, Mini
abortion, Traumatic Abortion
1. Antiprogestin (Mifepristone)
2. Antimetabolite (Methotrexate)
3. Prostaglandin (Misoprostol)
4. Oxytocin
Increasing uterine contractility,
by reversing the progesterone-
induction of contraction
Increasing uterine contractility,
by stimulating the myometrium
directly
Mixing with isotonic solution,
normal saline

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 PATHOLOGIC OBSTETRICS
Topic: Abortion
Lecturer: Dr. Raymundo (NER)

Threated Abortion Incomplete Abortion Complete Abortion Inevitable Abortion Missed Abortion Septic Abortion
 Uterine bleeding from a  Passage of some but not  Passage of all fetal & placental  Uterine bleeding from  Fetal death before 20  Termination of pregnancy
gestation of <20 wks. all of fetal or placental tissue accompanied with a gestation of < 20 wks. wks. AOG without within the 1st 20 wks. of
without any cervical tissue from the uterine minimal cramping and expulsion of any fetal gestation with infection
dilatation or effacement cavity through the bleeding.  Accompanied with or maternal tissue for of the products of
cervical canal before 20 cervical dilatation BUT at least 8 wks. or more. conception, uterus &
wks. gestation without expulsion of adnexae OR with
any fetal or placental presence of
 Retention of placental tissue through the microorganisms or their
membrane in part or in cervix products in the systemic
whole circulation.
 With or without
rupture of membrane
DIAGNOSTIC CRITERIA
 Minimal bleeding  Ability to pass a ring  History of bleeding, cramping  Progressive cervical  (+) sonographic  Temperature of 38oC or
 With or without cramping forceps through the & passage of tissue dilatation without evidence of a higher at least 24 hrs. &
 Closed internal cervical os internal cervical os  Dilated internal cervical os passage of tissue nonviable pregnancy unattributable to any
 Normal sonographic  Passing of tissue  Minimal current bleeding o Heavy, profuse without bleeding or cause
findings  TVUS: empty uterus with bleeding cramping  History of mechanical
normal “ endometrial stripe” o Severe cramping interference with
o Dilated cervical os Abnormal UTZ findings: pregnancy
 Gestational sac is ( instrumentation)
irregularly shaped or  (+) septic cervical
collapsing discharge
 (-) yolk sac  Tender uterus,
 (-) fetus & FHT parametrium, adnexae
SIGNS
 Amenorrhea with signs of  S/SX of pregnancy  (-) uterine contraction  Similar with  S/SX of pregnancy  S/SX of pregnancy
pregnancy  Presence of lumbosacral threatened abortion  Absent uterine  Lower abdominal &
 Presence of lumbosacral pain  Assoc. uterine contractions cervical motion
& hypogastric pain  Profuse vaginal bleeding cramping pains  Spotting or no tenderness
 Vaginal bleeding from  Profuse vaginal bleeding at all  (+/-) uterine contractions
scanty to moderate, bleeding  Continuous brown (severe, constant, diffuse
continuous, or vaginal discharge after abdominal pain)
intermittent. the cessation of  Foul cervical discharge
bleeding  (+/-) bleeding
UTERINE SIZE vs. AOG
 Incompatible (uterus
fails to continue to
 Compatible  Incompatible  Incompatible  Compatible  (+/-)
enlarge w/ or w/o
uterine spotting)
BOW
 Intact  Ruptured BOW  Not appreciated  Ruptured BOW  Intact/Ruptured BOW  (+/-)
FETAL HEART TONE
 Present  Absent FHT  Absent signs of pregnancy  Present  Absent FHT  (+/-) FHT
INTERNAL EXAM
 Cervix closed &  Cervix is dilated &
 Cervix is dilated  Cervix is closed  Cervix is closed  Cervix is dilated & tender
uneffaced effaced
MANAGEMENT
 Bed rest  Cerclage  Observation  Curettage  D&C  IV antimicrobial usually
 Uterine relaxant  Curettage  Oxytocin  Prostaglandins combined
 Evacuation
 Sometimes hysterectomy

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