Abnormal Early Pregnancies

1. AbortionAbortion

2. The term abortion usually designates The term abortion usually designates
termination of gestation before the termination of gestation before the
end of the 28th week of pregnancy. end of the 28th week of pregnancy.
It implies the expulsion of all or any It implies the expulsion of all or any
part of the placenta or membranes, part of the placenta or membranes,
with or without an identifiable fetus with or without an identifiable fetus
or with a live-born or stillborn infant or with a live-born or stillborn infant
weighing less than 1000 g. If weighing less than 1000 g. If
abortion occurs before 12 weeks it is abortion occurs before 12 weeks it is
referred to as early abortion, and referred to as early abortion, and
thereafter the term is late abortion.thereafter the term is late abortion.

3. Types of abortionTypes of abortion
Threatened abortionThreatened abortion
Inevitable abortionInevitable abortion
Incomplete AbortionIncomplete Abortion
Complete AbortionComplete Abortion
Missed AbortionMissed Abortion
Recurrent AbortionRecurrent Abortion

4. Threatened abortionThreatened abortion
The term threatened abortion is used The term threatened abortion is used
when a pregnancy is complicated by when a pregnancy is complicated by
vaginal bleedingvaginal bleeding before the 20th week. before the 20th week.
Pain may not be a prominent feature of Pain may not be a prominent feature of
threatened abortion, although a lower threatened abortion, although a lower
abdominal dull ache sometimes abdominal dull ache sometimes
accompanies the bleeding. Vaginal accompanies the bleeding. Vaginal
examination at this stage usually reveals a examination at this stage usually reveals a
closed cervix. 25% to 50% of threatened closed cervix. 25% to 50% of threatened
abortion eventually result in loss of the abortion eventually result in loss of the
pregnancy.pregnancy.

5. Inevitable abortionInevitable abortion
In case of inevitable abortion, a In case of inevitable abortion, a
clinical pregnancy is complicated clinical pregnancy is complicated
by both by both vaginal bleedingvaginal bleeding and and
cramp-like cramp-like lower abdominal painlower abdominal pain. .
The cervix is frequently partially The cervix is frequently partially
dilated, attesting to the dilated, attesting to the
inevitability of the process. inevitability of the process.

6. Incomplete AbortionIncomplete Abortion
In addition to In addition to vaginal bleeding, vaginal bleeding,
cramp-like pain, and cervical cramp-like pain, and cervical
dilatationdilatation, an incomplete abortion , an incomplete abortion
involves the involves the passage of products passage of products
of conceptionof conception, often described by , often described by
the women as looking like pieces the women as looking like pieces
of skin or liver. of skin or liver.

7. Complete AbortionComplete Abortion
In complete abortion, after passage In complete abortion, after passage
of of allall the products of conception, the the products of conception, the
uterine contractions and bleeding uterine contractions and bleeding
abate, the cervix closes, and the abate, the cervix closes, and the
uterus is smaller than the period of uterus is smaller than the period of
amenorrhea would suggest. In amenorrhea would suggest. In
addition, the symptoms of pregnancy addition, the symptoms of pregnancy
are no longer present, and the are no longer present, and the
pregnancy test becomes negative. pregnancy test becomes negative.

8. Missed AbortionMissed Abortion
The term missed abortion is used The term missed abortion is used
when the fetus has died but is when the fetus has died but is
retained in the uterus, usually for retained in the uterus, usually for
some weeks. After 16 weeks’ some weeks. After 16 weeks’
gestation, dilatation and curettage gestation, dilatation and curettage
may become a problem. Fibrinogen may become a problem. Fibrinogen
levels should be checked weekly until levels should be checked weekly until
the fetus and placenta are expelled. the fetus and placenta are expelled.

9. Recurrent AbortionRecurrent Abortion
Recurrent abortionRecurrent abortion refers to any refers to any
case in which there have been case in which there have been
three consecutivethree consecutive spontaneous spontaneous
abortions. Possible causes are abortions. Possible causes are
known to be genetic error, known to be genetic error,
anatomic abnormalities of the anatomic abnormalities of the
genital tract, hormonal genital tract, hormonal
abnormalities, infection, abnormalities, infection,
immunologic factors, or systemic immunologic factors, or systemic
diseasedisease. .

10. The development of abortion is as follows:The development of abortion is as follows:

continuing continuing
pregnancy pregnancy
 completecomplete
inevitable abortion inevitable abortion
abortion abortion
incompleteincomplete
abortionabortion
threatened threatened
abortionabortion

11. EtiologyEtiology
Much confusion exists about the Much confusion exists about the
etiology of spontaneous abortion. etiology of spontaneous abortion.
Although many factors may result in Although many factors may result in
the loss of a single pregnancy, the loss of a single pregnancy,
relatively few factors are present in relatively few factors are present in
couples who abort recurrently. couples who abort recurrently.
Cause-effect relationships in Cause-effect relationships in
individual patients are frequently individual patients are frequently
difficult to ascertain.difficult to ascertain.

12. General Maternal FactorsGeneral Maternal Factors
InfectionsInfections
Environmental ExposureEnvironmental Exposure
Psychological FactorsPsychological Factors
Systemic DisordersSystemic Disorders

13. InfectionsInfections

14. Despite the present recognition that Despite the present recognition that
microorganisms may cause microorganisms may cause
spontaneous abortions, it is spontaneous abortions, it is
frequently difficult to identify frequently difficult to identify
unequivocally the infectious agent unequivocally the infectious agent
responsible for the loss of a specific responsible for the loss of a specific
pregnancy. Some microorganisms pregnancy. Some microorganisms
have a specific local effect on the have a specific local effect on the
conceptus, whereas infections with conceptus, whereas infections with
others may cause general systemic others may cause general systemic
effects and a fever that result in effects and a fever that result in
abortion. abortion.

15. Very few microorganisms have Very few microorganisms have
been implicated in recurrent been implicated in recurrent
abortions. Infection with abortions. Infection with
Mycoplasma, Listeria, or Mycoplasma, Listeria, or
Toxoplasma should be specifically Toxoplasma should be specifically
sought in women with recurrent sought in women with recurrent
abortions, since despite being abortions, since despite being
infrequently found, they are all infrequently found, they are all
treatable with modern antibioticstreatable with modern antibiotics..

16. Environmental ExposureEnvironmental Exposure

17. Epidemiologic evidence of a causal Epidemiologic evidence of a causal
link between exposure to potentially link between exposure to potentially
mutagenic or teratogenic agents and mutagenic or teratogenic agents and
subsequent abortion is sparse. Such subsequent abortion is sparse. Such
exposures are likely to be uncommon exposures are likely to be uncommon
and not an important cause of and not an important cause of
reproductive loss in the general reproductive loss in the general
population. Exceptions to this are population. Exceptions to this are
maternal smoking and alcohol maternal smoking and alcohol
consumption, for which there is consumption, for which there is
evidence of an increased incidence of evidence of an increased incidence of
chromosomally normal abortions. chromosomally normal abortions.

18. Women who smoke 20 cigarettes Women who smoke 20 cigarettes
daily and consume more than seven daily and consume more than seven
standard alcoholic drinks per week standard alcoholic drinks per week
have a fourfold increase in their risk have a fourfold increase in their risk
of spontaneous abortion. It has also of spontaneous abortion. It has also
been reported that there is a been reported that there is a
doubling of the risk of spontaneous doubling of the risk of spontaneous
abortion with as little as two drinks a abortion with as little as two drinks a
week.week.

19. Psychological FactorsPsychological Factors

20. Systemic DisordersSystemic Disorders
The three general medical The three general medical
disorders commonly related disorders commonly related
to spontaneous abortion are to spontaneous abortion are
diabetes mellitus, diabetes mellitus,
hypothyroidism, and systemic hypothyroidism, and systemic
lupus erythematosus(SLE). lupus erythematosus(SLE).

21. The risk of abortion increases with The risk of abortion increases with
maternal age, and studies linked to maternal age, and studies linked to
prenatal diagnostic procedures have prenatal diagnostic procedures have
revealed that if a live fetus is revealed that if a live fetus is
demonstrated by ultrasonography at 8 demonstrated by ultrasonography at 8
weeks gestational age, fewer than 2% will weeks gestational age, fewer than 2% will
abort spontaneously if the mother is abort spontaneously if the mother is
younger than 30 years. If, however, she is younger than 30 years. If, however, she is
older than 40 years, the risk exceeds older than 40 years, the risk exceeds
10%, and it may be as high as 50% at age 10%, and it may be as high as 50% at age
45 years. The probable explanation is the 45 years. The probable explanation is the
increased incidence of chromosomally increased incidence of chromosomally
abnormal conceptuses in older women. abnormal conceptuses in older women.

22. Local Maternal FactorsLocal Maternal Factors
Endocrine Factors Endocrine Factors
Uterine AbnormalitiesUterine Abnormalities
TraumaTrauma

23. Endocrine FactorsEndocrine Factors
It has been claimed that It has been claimed that
insufficient production of insufficient production of
progesterone by the corpus progesterone by the corpus
luteum before the placenta is luteum before the placenta is
fully formed will lead to fully formed will lead to
inadequate development of inadequate development of
the decidua and abortion.the decidua and abortion.

24. Uterine AbnormalitiesUterine Abnormalities
The incidence of abortion The incidence of abortion
is increased if the uterus is increased if the uterus
is double or septateis double or septate..

25. Retroversion of the uterus is Retroversion of the uterus is
not a cause of miscarriage.not a cause of miscarriage.
A fibromyoma of the uterus A fibromyoma of the uterus
which is closely related to the which is closely related to the
uterine cavity may cause uterine cavity may cause
abortion, but other abortion, but other
fibromyoma will not do so.fibromyoma will not do so.

26. Lacerations of the cervix which Lacerations of the cervix which
extend as far as internal os may extend as far as internal os may
result in abortion in the middle result in abortion in the middle
trimester or in premature labor. trimester or in premature labor.
Very rarely the cervical weakness Very rarely the cervical weakness
is congenital, but it is usually the is congenital, but it is usually the
result of obstetric damage or of result of obstetric damage or of
injurious surgical dilatation of the injurious surgical dilatation of the
cervixcervix. .

27. TraumaTrauma

Abortion may follow surgical Abortion may follow surgical
operations, for example operations, for example
myomectomy, or removal of myomectomy, or removal of
an ovary containing the an ovary containing the
corpus luteum of pregnancy or corpus luteum of pregnancy or
appendectomy.appendectomy.

28. Fetal FactorsFetal Factors
The most common cause of The most common cause of
spontaneous abortion is a spontaneous abortion is a
significant genetic abnormality of significant genetic abnormality of
the conceptus. In spontaneous the conceptus. In spontaneous
first-trimester abortion, first-trimester abortion,
approximately two thirds of approximately two thirds of
aborted fetuses have significant aborted fetuses have significant
chromosomal anomalies.chromosomal anomalies.

29. PathologyPathology
In spontaneous abortion, usually the In spontaneous abortion, usually the
embryo or fetus is compromised first and embryo or fetus is compromised first and
this is followed by hemorrhage into the this is followed by hemorrhage into the
decidua basalis. Necrosis and inflammation decidua basalis. Necrosis and inflammation
appear in the region of implantation. The appear in the region of implantation. The
detached conceptus is, in effect, a foreign detached conceptus is, in effect, a foreign
body in the uterus which causes strong body in the uterus which causes strong
uterine contractions. Uterine contractions uterine contractions. Uterine contractions
and dilatation of the cervix result in and dilatation of the cervix result in
expulsion of partial or all the products of expulsion of partial or all the products of
conception.conception.

30. An abortion is a miniature labour, the An abortion is a miniature labour, the
rhythmical uterine contractions cause the rhythmical uterine contractions cause the
cervix to dilate and embryo or fetus to be cervix to dilate and embryo or fetus to be
expelled with or without its accompanying expelled with or without its accompanying
membranes. If all the products of membranes. If all the products of
conception are expelled, the contractions conception are expelled, the contractions
cease and the bleeding stops. In some cease and the bleeding stops. In some
cases of incomplete abortion a piece of cases of incomplete abortion a piece of
placental tissue may remain in the uterus placental tissue may remain in the uterus
because it is fixed at its base. Bacterial because it is fixed at its base. Bacterial
invasion of the retained products may invasion of the retained products may
occur.occur.

31. ManagementManagement

32. Threatened AbortionThreatened Abortion
The patient is kept at rest in bed until 2 The patient is kept at rest in bed until 2
days after blood loss has ceased. days after blood loss has ceased.
Intercourse is forbidden. As soon as the Intercourse is forbidden. As soon as the
initial bleeding has stopped an ultrasound initial bleeding has stopped an ultrasound
scan is performed. This will reveal whether scan is performed. This will reveal whether
or not the pregnancy is intact. The or not the pregnancy is intact. The
prognosis is good when all abnormal signs prognosis is good when all abnormal signs
and symptoms disappear and when the and symptoms disappear and when the
resumption of the progress of pregnancy is resumption of the progress of pregnancy is
apparent.apparent.

33. Inevitable AbortionInevitable Abortion
The uterus usually expels its The uterus usually expels its
contents unaidedcontents unaided, , and examination and examination
must be made with strict aseptic must be made with strict aseptic
technique. If the abortion is not technique. If the abortion is not
quickly completed, or if hemorrhage quickly completed, or if hemorrhage
becomes severe, the contents of the becomes severe, the contents of the
uterus are removed with a suction uterus are removed with a suction
curettege.curettege.

34. Incomplete AbortionIncomplete Abortion
Patients require admission to the Patients require admission to the
hospital. Treatment is aimed at hospital. Treatment is aimed at
preventing infection, controlling preventing infection, controlling
bleeding and obtaining an empty bleeding and obtaining an empty
and involuting uterus. The chief and involuting uterus. The chief
risks associated with retained risks associated with retained
products are hemorrhage and products are hemorrhage and
sepsissepsis. .

35. Missed AbortionMissed Abortion
Once the diagnosis has been Once the diagnosis has been
made the uterus should be made the uterus should be
emptied. Early in gestation emptied. Early in gestation
evacuation of the uterus is evacuation of the uterus is
usually accomplished by suction usually accomplished by suction
curettage. The prognosis for the curettage. The prognosis for the
mother is good. Serious mother is good. Serious
complications are uncommoncomplications are uncommon..

36. Recurrent abortion Recurrent abortion
Paternal and maternal chromosomes Paternal and maternal chromosomes
shoud be evaluated.shoud be evaluated.
The mother should be ruled out the The mother should be ruled out the
presence of systemic disorders such presence of systemic disorders such
as DM,SLE, and thyroid disease.as DM,SLE, and thyroid disease.
It should rule out the presence of It should rule out the presence of
Mycoplasma, Listeria, Toxoplasma Mycoplasma, Listeria, Toxoplasma
etc. infectious disease.etc. infectious disease.
Pelvic examination Pelvic examination

37. 1 All of the following may be the cause 1 All of the following may be the cause
of recurrent abortion except:of recurrent abortion except:
A cervical incompetenceA cervical incompetence
B infectionB infection
C chromosome aberrantionsC chromosome aberrantions
D retroversion of the uterusD retroversion of the uterus

38. 2 A patient of 8th week pregnancy, presents 2 A patient of 8th week pregnancy, presents
with vaginal bleeding, low abdominal pain, with vaginal bleeding, low abdominal pain,
vaginal examination revealing partially vaginal examination revealing partially
dilatated cervix, without expelling any tissue, dilatated cervix, without expelling any tissue,
she should be diagnosed as :she should be diagnosed as :
A threatened abortionA threatened abortion
B inevitable abortionB inevitable abortion
C complete abortionC complete abortion
D incomplete abortionD incomplete abortion