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ABORTION

流 产

RenHe Hospital
Wang Junjie
Definition
Abortion is the termination of
pregnancy by any means before
the fetus becomes viable.
Viability is usually reached at 28 weeks
when the fetus weighs slightly more than
1000 g.
However, with the current improvements
in neonatal care, the fetus can survive
even before 28 weeks and in certain
developed countries this definition is
confined to the termination of pregnancy
before 20 weeks. The incidence varies
from 10 to 15%.
Etiology
The etiology of abortion is often
complex and obscure. Various maternal
and fetal factors are said to be
responsible for abortion.
FETAL FACTORS
Intrinsic defects of varying degrees in
the fertilized ovum result in clinical
abortion.
Chromosomal aberrations have been
demonstrated in 25-40% of cases of
spontaneous abortion.
MATERNAL FACTORS
1.Maternal Infections:
Acute infections can cause abortion.
Hyperpyrexia in the mother can result in
fetal anoxia or death. Viral infections,
especially rubella, herpes simplex and
cytomegalovirus infection, and
toxoplasmosis are implicated in abortion.
2. Maternal systemic diseases:
Spontaneous abortion and major
congenital malformations are both
increased in women with insulin
dependent diabetes in the first
trimester of pregnancy.
3. Uterine causes:
Congenital malformations of the uterus
play an important role in causing
abortion, especially repeated abortion.
While milder degrees of malformations
may not interfere with pregnancy,
severe degrees may result in abortion.
Cervical incompetence, either
congenital or acquired as a result of
obstetric or surgical trauma, is an
important factor in repeated
abortions.
4.Immunological factors:
Autoimmune factors have been
detected in women with a history of
repeated abortion. Anti-phospholipid
antibody syndrome is detected by
testing for Lupus anti-coagulant and
anti-cardiolipin antibody.
Investigations
 A detailed history should be taken
regarding the pregnancy which
resulted in abortion.
 Investigations on the woman should
include Screening for diabetes,
serological test for syphilis and other
infections.
 A hysterogram is indicated whenever
uterine malformation or cervical
incompetence is suspected.
 Karyotyping of the parents may be
indicated in repeated early abortions.
 Autoimmune disorder in the woman
may need to be ruled out in repeated
abortions.
Signs and Symptoms
The sign and Symptoms of abortion are :
1) pain due to uterine contractions
2) hemorrhage as a result of separation of
ovum
3)dilatation of the cervix due to the
uterine contraction
4) expulsion of a part or the entire embryo
The patient generally has a history of
amenorrhea followed by more or less
severe pain in the lower abdomen and
back, accompanied by vaginal bleeding.
The extent of hemorrhage varies and may
sometimes be so profuse as to cause
severe collapse.
Usually the hemorrhage continues for
some days, the quantity varying from day
to day.
Types of Abortion
The different types of abortion
depending on the signs and
symptoms are classified as:
 Threatened abortion
 Inevitable or incomplete abortion
 Complete abortion
 Missed abortion
Threatened abortion
In this condition,after a period of
amenorrhea,the patient complains of
slight colicky pain in the lower
abdomen associated perhaps with
backache ,frequency of micturition
and slight bleeding per vagina. The
general condition is usually stable.
A careful bimanual examination
shows a softened cervix, enlarged uterus
which is more or less globular. The size
of the uterus depends on the period of
gestation.
The cervical os is generally closed or
may in some cases be patulous.
An ultrasound examination will
reveal a viable pregnancy indicating
that the amount of bleeding has not
affected the fetus.
Inevitable or incomplete abortion
This term denotes that the ovum has
separated from the uterine wall and is,
therefore, bound to be expelled.
In such case, the pain is more severe,
the bleeding is more and the cervix is
dilated. It is called inevitable abortin.
when the products of conception have
not been expelled but are felt through
the dilated cervix and is in the process
of expulsion. When the products of
conception are partially expelled and
partially retained, it is called incomplete
abortion .
In this case the patient may have
history of expulsion but continues to
bleed; ultrasound examination will
reveal the products in the uterine cavity
or cervical canal.
Complete abortion
Complete abortion is when the entire
ovum or products of conception have
been expelled.
Once this has occurred, the pain
subsides and bleeding decreases and
may have stopped by the time the patient
approaches the doctor. The uterus is
empty and the cervical canal is closed, as
it contracts rapidly after complete
expulsion of uterine contents.
An ultrasound examination would
confirm the diagnosis in doubtful cases.
Missed abortion

In this condition symptoms 0f


abortion occur but subside later
without any products of conception
being expelled. The ovum dies but is
retained in the uterus.
After fetal death, there may or may not
be vaginal bleeding or other symptoms
suggestive of threatened abortion.
Mammary changes usually regress
and the uterus does not enlarge any
more and may become smaller.
If the missed abortion terminates
spontaneously, and most do, the process
of expulsion is the same as in any
abortion. The reason some missed
abortions do not terminate after fetal death
is not clear. If missed abortion occurs
early in pregnancy, the whole of the
uterine contents are changed into a dark
red or brownish shaggy mass known as
carneous mole.
If missed abortion occurs late in
pregnancy, it becomes a shrivelled sac
containing a macerated fetus, depending
on the duration of fetal death. The
pregnancy test is usually negative at this
stage and an ultrasound examination will
confirm the non-viability of the fetus.
Differential diagnosis
An abortion is differentiated from
functional menstrual disturbance and
from ectopic gestation in the following
ways:
1) Functional Menstrual Disturbance
 In this the patient has amenorrhea varying
from 6 to 12 weeks.
 There may be no associated symptoms of
vomiting.
 A profuse bleeding occurring at the end of
that period may suggest the possibilities of an
abortion.
 The pregnancy test is usually negative .
 A careful bimanual examination will
reveal the absence of signs of
pregnancy.
 An ultrasound examination will
confirm the diagnosis.
2) Ectopic Gestation:
 In this condition, there may be a history of
amenorrhea with occasional attacks of colicky
pain in the lower abdomen and vaginal
bleeding which is seldom profuse.
 In an unruptured ectopic gestation,
vaginal examination reveals a normal size
uterus and tenderness or a tender mass in the
adnexa.
 Again, an ultrasound examination will
confirm the diagnosis.
Treatment

Threatened abortion
When a patient reports with an episode of
bleeding and the fetus as seen in
ultrasonography is viable, then rest is advised.
A repeat sonography is done after a week to
confirm continuation of pregnancy.
In about 75% of cases, the pregnancy
continues normally. However, there seems to
be a slightly higher incidence of premature
labour, intrauterine growth retardation and
antepartum hemorrhage. It is, therefore,
advisable to place these patients in the high-
risk category.
Inevitable abortion
Threatened abortion becomes an inevitable
abortion when dilatation of cervix occurs. In
these cases, abortion is bound to occur, but
the question is whether any active
interference is indicated or not.
No definite rule can be laid down. In the
majority of cases, an inevitable abortion
will end spontaneously. On the other
hand, in the presence of severe
hemorrhage or repeated small
hemorrhages or if some products of
conception have been expelled and the
cervix is open, it is necessary to
evacuate the uterus.
1) Evacuation of uterus:
Evacuation, either manual or instrumentum
should be carried out under aseptic conditions
with adequate analgesia.
Manual evacuation can be done if the cervix is
dilated sufficiently to admit a finger freely, and
if the period of amenorrhea is within 12 to 14
weeks.
The products of conception are separated
gently from the uterine wall using a finger. The
procedure is made easier when the other hand
(applied suprapubically ) presses the fundus
downwards so that it is brought within the
reach of the vaginal finger. If the products of
conception has been entirely separated, it may
be removed by expressing it manually or, if this
is not possible, it can be removed by ovum
forceps or sponge forceps.
2) When the cervix is not sufficiently
dilated,preliminary dilatation is essential. After
the cervix has been dilated with the use of
Hegar's dilators, a finger is passed and the
products of conception separated. Care must
be taken in dilating the cervix and in separating
the products to prevent perforation of the
uterus. The products of conception is then
removed by the ovum forceps or sponge
forceps. Methergine is administered
intravenously and a gentle curettage is done.
3) Suction evacuation is safer if facilities
are available

4) Supportive measures such as blood


transfusion may be required occasionally,
if the patient is in shock due to severe
hemorrhage.
5) Antibiotics should be prescribed in all
cases.
Missed Abortion
All missed abortions will be eventually
expelled, but there may be a delay. There is
a risk of developing coagulation disorders if
the dead fetus is retained for more than 5-6
weeks.
If the size of the uterus is less than 10 weeks,
evacuation can be done. Instead of surgical
evacuation, medical methods can be used
and prostaglandins are very useful in these
cases. Administration of prostaglandins
results in expulsion of the products of
conception and a curettage is only done if the
abortion is considered incomplete.
Summary
◆ Definition
◆ Etiology
◆ Investigations
◆ Signs and Symptoms
◆ Types of Abortion
◆ Differential diagnosis
◆ Treatment
Early pregnancy
Vaginal bleeding

Threatened spontaneous abortion


Threatened abortion
Complete abortion
Missed abortion
Ultrasound examination