Abortion

Dr. F Mardanian MD

Ⅰ. Definition

 Abortion is termination of pregnancy before 20 weeks of gestation and the fetal weight is less tan 500g.

 Abortion : spontaneous: 10%~  The early abortion: occurs before 12w  The late abortion: occurs after 12w

 Miscarriage 8-20% → under 20w  ↓  80% infirst 12 w  Subclinical → 13-26% of all pregnancies

Risk factors:

 Age overall rate = 11% 20-30y→17% clinically SAb 35y →20% 40 y →40% 45 →80%  Previous SAb 5% → in first pregnancy 20% → after one miscarriage 28% → after 2 consecutive miscarriage 43% → after 3 consecutive miscarriage

 Heavy smoking (>10/d)  Vasoconstrictive, antimetabolic effect  paternal smoking  Alcohol  Gravidity  Cocain

 NSAIDs (but not acetaminophen)  Fever > 37/78 ° c → (euploid not aneupleid abortion)  Caffeine 100-300mg/d  Proloned ovulation to implantation interval (>10d)  Prolonged time to pregnancy  Low plasma folate levels  Maternal weight  BMI<18/5kg/m2

Etiology:

 1/3 → before 8w →blighted (anembryonic),  2/3 with embnyo →  Chromosomal abnormalities → 50% all miscarrage (most are aneuploidies)  Autosomal → 52%  Monosomy X → 19%  Polyploidies → 22%  Other → 7%

 Congenital anomalies  Tratogens (D.M-Drug – fever – chemicals)  Genetic  Trauma  (CVS – Amniocentesis)

 Host factors  Uterine anomaly  Acute maternal infections (TORCH Listeria)  Maternal endocrinopathies (thyroid – cushing’s yn -pco - thrombophilia)  Unexplained

3.Pathologic change

 Most commonly, necrotic changes occur in the decidual tissue about the placentation site and result in hemorrhage into this area. As bleeding continues, the sac and the placenta become detached from the uterine wall and are expelled by uterine contractions.

4.Clinical classification and feature

 (1) Threatened abortion  (2)Inevitable abortion  (3)Incomplete abortion  (4)complete abortion  (5)Missed abortion  (6)Habitual abortion  (7)Septic abortion(infect abortion)

Differential diagnosis of varied abortions

History Bleeding Threatened Slight Abdominal pain No/slight Tissues expelled are No Gynecologic examination Cervical os Close Uterine size Pregnancy test Treatment principle Consistent with + Protect fetus Inevitable Middle

→

severa Aggravate No Open =/slight small +/- Curettage Imcomplete Slight

→

severa Decrese Yes(partial) Complete Slight

→

no No Complete Open/tissue blochk < +/- Curettage Close =/slight larger +/- no

Missed abortion

 It is that pregnancy has been retained for 2 months or more following death of the fetus.

 The abnormally protracted retention of a dead fetus in uterus in over 2 months that don’t expelled.

 Missed abortion is manifested by loss of symptoms of pregnancy and decrease in uterine size.

Habitual abortion(recurrent)

 Recurrent, or habitual, is the sequential 3 or more spontaneous abortion.

 Every abortion times is or not same month of pregnancy.

Early cause

 ① hypofunction of corpus luteum  ② emotion factor  ③ hypopituitarism  ④ chromosomal abonormalities

Late abortion

 (1)incompetence of the cervix  (2)congenital anomalies of the uterus  (3)myomas of the uterus  (4)blood type incompatibility between mother and fetus

5. Diagnosis

(1)History

 ① amenorrhea, recurrent abortion symptoms of pregnancy  ② the degree of abdominal pain, vaginal bleeding  ③ the products of gestation were expelled or not

(2)Examination

 ① general examination: temperature , pulse, respiration, blood pressure.

 ② vaginal examination: uterine size: compared to the expected date of pregnancy cervical os: open or close uterine tendeness

(3)anxillary examination

 ① pregnancy test: HCG<625IU/L→abortion  ② measurement of HPL 5~10w: hpl≤0.01mg/L  ③ measurement of E2(estroid) E2<740pmol/L  ④ measurement of pregnanediol 24h urinary<15.6μ/24h, 95%→abortion

 ⑤ B-ultrasound differential of varieties of abortion gestation sac, embryo status, fetal heart tones, fetus movement Incompetence of the cervix, cervical os>19mm and have history of abortion

Normal pregnancy incomplete septic threatened inevitable infection proceed complete delaied treatment missed habitual

6. Treatment

(1)Threatened abortion

 Principle: protect fetus treatment  ① bed rest forbid sexual intercourse  ② drug folic acid 5mg tid. Po.

If corpus luteum or low of uterine pregnanediol progesterone 20mg Qd. Im.

VE 30~50mg Qd po.

Seditive: valium 2.5mg po.

(2)Inevitable and incomplete abortion

 At once D&C(curettage) dilatation  if bleeding is brisk blood transfusion oxytosin 5~10u iv/im  incomplete abortion antibiotic used for preventive infection tissue examination by a pathologist

(3)Complete abortion

 When the uterus is empty, there are no need for further interference.

(4)Missed abortion

 After diagnosis of it ,as soon as expelled product of conception is necessary.

 Because the fetus dead, placenta release thrombocinatse into blood circulation ease occure in coagulability.lead to disseminated intravascular coagulation(DIC)

 ② leveral uterine sentition DES(diethylstibestrol)5~10mg tid po 5d  ③ before curettage, preparey blood during opreation: oxytocin 10u im/iv over than 3 month of pregnancy artificial inducte.

(5)Habitual abortion

 The first should be examinatin cause of habitual abortion and treatment.

 1)rest, increase nutrition, …  2)medical treatment: hypofunction of corpus luteum--progesterone  3)surgical treatment: ① correction of congenital anomalies of uterus,removed of myomas ② repair of the incompetent cervix.12~20w

(7)Septic abortion

 The principle of treatment: bleeding is a few: first treat infection with broad-spectrum antibiotiss second D&C bleeding is sever:

 ※The producte of conception from the cervix are removed with a sponge holder.

 Don’t used curette to curettage uterine wall prevent infection  avoid hematogeous dissemination of the infection.