Lecture 9 . Abortions-1.ppt

How to manage

1. ABORTION
MR CHIBUYE
MPH,BsCM ,Dip CM & Post Graduate
Dip-in Teaching Methodology
Chreso University

2. Introduction
Objectives
Definition
Classification
Causes
Types
Symptoms/features
Investigations
Management

3. Definition
Definition:
Abortion is any fetal loss from conception
until the time of fetal viability at 24 weeks
gestation(WHO).
OR:
The Expulsion of a fetus or an embryo
weighing 500 g or less.

4. Classification of Abortion
1.Spontaneous:
-Occurs without medical or mechanical means.
2. Induced abortion
-Occurs due to either medical or mechanical
interventions.

5. Causes of Abortion
Thecausesofabortionareclassifiedas;
1.Fetalcausesand
2.Maternalcauses

6. Causes of Abortion
1.Fetalcauses
ChromosomeAbnormality:-50%ofspontaneouslossesare
associatedwithfetalchromosomeabnormalities;
-Autosomaltrisomy(nondisjunction/balancedtranslocation):
isthesinglelargestcategoryofabnormalityand→
recurrence.
-Monosomy(45,X;turner):occursin7%ofspontaneous
abortionsanditiscausedbylossofthepaternalsex
chromosome.
-Triploids:foundin8to9%ofspontaneousabortions.itisthe
consequenceofeitherdispermyorfailureofextrusionofthe
secondpolarbody.

7. Causes of Abortion
2.Maternalcauses
Endocrine:PoorlycontrolledDiabetes(type1/type2).-
hypothyroidismandhyperthyroidism.
LutealPhaseDefect(LPD):Asituationinwhichthe
endometriumispoorlyorimproperlyhormonallyprepared
forimplantationandisthereforeinhospitablefor
implantation.asinPCO(questionable).
Infections(maternal/fetal):AsTORCHinfections,Ureaplasma
urealyticum,listeria,BV
Environmentaltoxins:Alcohol,smoking,drugabuse,ionizing
radiation

8. Other potential causes
Nodemonstrablecause–thisisthecommonest
isolatednonrecurringin60%
Anembryonicpregnancies(blightedovum),anabnormalityof
placentaldevelopment
Multiplepregnancy
Uterineanomalye.g.cervicalincompetence(classicallyoccur
inmid-trimester)
CorpusluteumfailureasseeninPCO
Inducedusuallycriminally

9. Other potential causes
Secondtrimesterabortion
causes
Cervicalincompetence
Conebiopsy
Congenitalweakness
Presentation
Feelingofsomethinggivingway
Painless
Management
Treatedwithcervicalcerclageat14weekandremoveitat
37-38weeks

10. Types abortion
1.Threatenedabortion.
2.Inevitableabortion.
3.Incompleteabortion.
4.Completeabortion.
5.Missedabortion
6.Septicabortion:Anytypeofabortion,whichis
complicatedbyinfection
7.Recurrentabortion:3ormoresuccessive
spontaneousabortions
8.Blightedovum(anembronicpregnancy)

11. THREATEN ABORTION
•Threatenedabortionconsistsofanyvaginalbleedingduring
earlypregnancywithoutcervicaldilatationorchangein
cervicalconsistency.
•Hxofamenorrhea
•Usually,nosignificantpainexists,althoughmildcrampsmay
occur.
O/E
•CervixOSisclosed
•Nofetaltissueormembraneshavepassed.
•Uterinesizecorrectfordates
•Theultrasoundshowsacontinuingintrauterinepregnancy
•Bedresthasnoroleinmanagement

12. Investigations
•Ultrasound-willshowiffetusisinuterusandisviable-ifdoubt
repeataweeklater
•HCGbetaunit-doublesby50%in48hoursinnormal
pregnancy
•FBCforHb
•Rhesusgroupshouldbechecked

13. Inevitable abortion
•Inevitableabortionisanearlypregnancywithvaginalbleedingand
dilatationofthecervix.
•Hxofamenorrhea
•Vaginalbleedingisworsethanwithathreatenedabortion,andmore
crampingispresent.
•Notissuehaspassedyet.
•CervicalOsisopen
•Onultrasound,theproductsofconceptionarelocatedintheloweruterine
segmentorthecervicalcanal.
•Uterusmaybesmall,largeorcorrectsizefordates

14. Incomplete abortion
•Incompleteabortionisapregnancythatisassociatedwithvaginal
bleeding,dilatationofthecervicalcanal,andpassageofproductsof
conception.
•Hxofamenorrhea
•Usually,thecrampsareintense,andthevaginalbleedingisheavy.
•Patientsmaydescribepassageoftissue,ortheexaminermayobserve
evidenceoftissuepassagewithinthevagina.
•CervicalOsisopenandsomeproductofconceptionmaybefeltduringEV
•Ultrasoundmayshowthatsomeoftheproductsofconceptionarestill
presentintheuterus.

15. Complete abortion
•Completeabortionisacompletedmiscarriage.
•Typically,ahistoryofvaginalbleeding,abdominalpain,
andpassageoftissueexists.
•Afterthetissuepasses,thepatientnotesthatthepain
subsidesandthevaginalbleedingsignificantly
diminishes.
•Theexaminationrevealssomebloodinthevaginalvault;
aclosedcervicalos;andnotendernessofthecervix,
uterus,adnexa,orabdomen.
•Theultrasounddemonstratesanemptyuterus.

16. Missed abortion
•Amissedabortionisanonviableintrauterinepregnancythat
hasbeenretainedwithintheuteruswithoutspontaneous
abortion.
•Typically,nosymptomsexistbesidesamenorrhea.
•Anultrasoundusuallyconfirmsthediagnosis.
•Novaginalbleeding,abdominalpain,passageoftissue,or
cervicalchangesarepresent
•Uterussmallfordates,cervixosclosed

17. Septic Abortion
•SepticabortionoccurswhenRPOCgetsinfected
•Patientmaypresentwithfeaturesofsepsislikefeverand
tachycardia,generalmalaise,abdominalpain,markedpelvic
tendernessandpurulentvaginaldischarge
•Examinationrevealsanopencervicaloswithinfectedfoul
smellingretainedproductsofconception.
•Commonorganismsare;E.coliandothergramnegatives,
strep(hemolyticandanaerobic),otheranaerobes(e.g.
bacteroides)andstaphylococcus
•Cl.perfringesandcl.tetanirarebutlethal

18. Anembryonic pregnancy(blighted
ovum)
•Agestationsacdevelopsintheabsenceofanembryo
•Diagnosismadeonultrasound
•Manageasformissedabortion

19. Recurrent miscarriage
•Defn:Arecurrentmiscarriageis3ormoreconsecutive,
spontaneouspregnancylosses,under20weekgestationfrom
thelastmenstrualperiod,bythesamepartner.
•Maybeprimaryrecurrentorsecondary
•Incidenceis1%ofwomenofreproductiveage
•Primaryrecurrentpregnancyloss"referstocouplesthathave
neverhadalivebirth,
•secondaryRecurrentPregnancyLoss,referstothosewho
havehadrepetitivelossesfollowingasuccessfulpregnancy
•awomanwhohadamiscarriage,insteadofgettingsympathy
andsupport,ismadetofeelthatitissomehowherfault•Itis
alltoocommontofindrecurrentmiscarrigesleadingto
divorce

20. Causes of Recurrent miscarriage
•PolycysticovariansyndromewithLHhypersecretion
•Autoimmunee.g.SLEandantiphospolipidsyndrome
•Anatomicalfactorssuchasfibroids,congenitaldefects,
cervicalincompetence
•Chromosomaldefects-4%
Investigationofrecurrentmiscarriage
•PelvicultrasoundandurinaryLH
•Lupusanticoagulantandanticardiolipinantibodies
•Hysteroscopy
•Randomglucoseandthyroidfunction•Karyotypingofboth
parents

21. Differential diagnosis
•Ectopic pregnancy
•Acute appendicitis
•Cervical polyps, ectropion, or malignancy
•Ovarian torsion
•Pregnancy,
•Molar pregnancy
•Pregnancy, subchorionic hemorrhage
•Cervical cancer

22. investigations
•Complete blood count-look for anemia and
infections
•Ultrasound to confirm pregnancy, location of
pregnancy. More useful in threatened
abortions and ectopic pregnancies
•Blood type-Rh-women may need anti D,
•Possible DIC profile

23. Treatment
•A complete abortion usually needs no further treatment, medically
or surgically
•Threatened abortions are treated conservatively without any
interventions
•Missed abortions can managed by surgical evacuation or
conservatively and await spontaneous expulsion. Disadvantages of
risk of DIC and psychological morbidity.
•Septic abortions ; Antibiotics; Metronidazole,X –pen and
gentamycin IV thereafter are surgically evacuation of the product
of conception
•Incomplete are treated surgically
•Surgical methods include suction Dilation and Curettage ( D&C),
Manual Vacuum Aspiration (MVA)
•Medical methods with misoprostol have also been used as an
alternative.

24. Induced abortion
•Criminal
•Medical
Methods
•Suctioncurretageupto12completedweeks
•Prostaglandinsinductionafter12weeks+/-oxytocin
•Antiprogesterone-upto9weeksgestationmifepristonecanbe
usedandmaybecombinedwithprostaglandins

25. Induced abortion
AbortionislegalinZambia
2doctorsmustagreetopatient’srequest
Whencomparedwithabortion,continuationofpregnancymust:
1.Endangerthelifeofwoman
2.Endangerthephysicalormentalhealthofwoman
3.Endangermentalorphysicalhealthofsiblings
4.Involveariskthatthefetuswouldbehandicapped
Refertostandardsandguidelinesonmxofabortion2009