ABORTION

Definition: Abortion is the termination of pregnancy by any means before the fetus is sufficiently developed to survive. Incidence : 15 % - 20 %

 Abortion may be subdivided into its two main forms: 1.Spontaneous abortion 2.Induced abortion

Spontaneous abortion The termination of a previable conception through natural causes and without the aid of mechanical or medicinal agents

Induced Abortion Induced abortion has two forms: a.Therapeutic abortion b.Criminal abortion

a.Therapeutic abortion The instrumental termination of pregnancy because of some grave maternal disease which would make continuation of gestation extremly hazardous to the mother. b.Criminal abortion The termination of pregnancy without medical and legal justification

Spontaneous abortion
Etiologies of Spontaneous Abortion : 1.Fetal Factors 2.Maternal Factors 3.Paternal Factors

1.Fetal Factors
Abnormal Zygote Development The most common morphological finding in early spontaneous abortion is an abnormality of development of the zygote, embryo,early fetus,or at times the placenta Approximately 50-60 % of early spontaneous abortions are associated with a chromosomal anomaly of the conceptus.

2.Maternal Factors:
a. Infections b. Chronic Debilitating Diseases c. Endocrine Abnormalities - Hypothyroidism - Diabetes Mellitus - Progesterone Deficiency d. Nutrition

e. Drug Use and Environmental Factors - Tobacco - Alcohol - Caffeine - Radiation - Contraceptives - Environmental Toxins

f. Immunological Factors - Autoimmune Factors - Alloimmune Factors

e. Drug Use and Environmental Factors f. Immunological Factors g. Aging Gametes h. Laparotomy i. Physical Trauma j. Uterine Defects k. Incompetent Cervix

Categories Spontaneous Abortion : 1.Threatened Abortion (Abortus Imminens) 2.Inevitable Abortion (Abortus Incipiens) 3.Incomplete Abortion (Abortus Incompletus) 4.Complete Abortion (Abortus Completus) 5.Missed Abortion 6.Recurrent Spontaneous Abortion. (Abortus Habitualis)

1.Threatened Abortion
common in the first trimester occurring in an estimated 30 40 % of pregnancies

A.Symptomps
1.Vaginal bleeding
any bloody vaginal discharge or vaginal bleeding appears during the first half of pregnancy the bleeding frequently is slight the bleeding may persist for days or weeks

2. Pain
Crampy lower quadrant pain may or may not be present

B.Diagnosis 1.Symptoms : Crampy,lower quadrant pain Symptoms of pregnancy Amenorrhea Vaginal bleeding

2.Physical examination : The abdomen is usually not tender Cervix is closed Blood will be identified coming from the os Cervical motion tenderness or adnexal tenderness is usually not present Uterus feels soft on bimanual examination (after 7 weeks gestation)

3.Laboratory examination : a.Pregnancy test Urinary pregnancy test : + b.Ultrasonography Gestational sac if 6 weeks or more

C.Treatment :
Bed rest or significant restriction in activity Counseling and reassurance Treatment of infection Progesterone Sedation

II.Inevitable Abortion
Uterine bleeding from a gestational of less than 20 weeks accompanied by cervical Dilatation but without expulsion of placental or fetal tissue through the cervix

Diagnosis
1.Symptoms : The clinical signs are the same as those for threatened abortion The bleeding is so excessive

2.Physical examination The abdomen is sometimes tender The cervix may be effaced and dilated with blood but not tissue,coming from the cervical os. Cervical tenderness on bimanual examination will usually be present

3.Laboratory examination The same as for threatened abortion 4.Treatment Evacuation of the uterine contents is indicated by :
dilation (if needed) curettage suction curettage

III.Incomplete Abortion

Expulsion of some but not all of the products of conception before 20th completed week of gestation.

Diagnosis
1.Symptoms Vaginal bleeding with passage of blood and tissue Central or slightly bilateral lower quadrant pain

2.Physical examination The cervix is dilated and effaced Blood is coming from the os , often with clot as well as products of conception The uterus may be more firm and smaller than expected for the stated gestational age

3.Treatment Surgical evacuation of the remaining products of conception Antibiotic therapy Oxytocics drugs (Uterotonica)

IV.Complete Abortion

Spontaneous expulsion of all fetal placental tissue from the uterine cavity before 20 weeks gestation.

Diagnosis
1.Symptoms All the products of conception have been spontaneously expelled from the uterus Minimal bleeding The patient may or may not be aware that the products of conception were passed

2.Physical examination The uterus relatively small Firm uterus with a closed cervix 3.Treatment Observation Antibiotic therapy Oxcytocics drugs.

V.Missed Abortion
Death products of conception in utero before the 20th completed week of gestation but is retained in utero for 8 or more weeks (Traditional definition)

A new classification system has been proposed a.An embryonic gestation (empty sac)
no fetus is present at gestational age > 7.5 weeks

b.First trimester fetal death

death of the fetus in the fist 12 weeks of gestation

c.Second trimester fetal death

death of the fetus between 13 and 24 weeks gestational age

Diagnosis
1.Symptoms Initially the patient may demonstrated the subjective symptoms of pregnancy followed by an episode diagnosed as threatened abortion Amenorrhea may persist, but subjective signs of pregnancy may wane
Some patients spotting have minimal vaginal

2.Physical examination Failure of the fetus to grow in accordance with length of amenorrhea Regression in uterine size Rarely vaginal bleeding is noted

3.Laboratory examination Urinary pregnancy test : negative A serial decline in the F hCG titer USG examination
showing intra uterine fetal demise progressive disorganization of the intra uterine content

4.Treatment

Surgical evacuation of the uterus

VI.Recurrent spontaneous abortion

The loss of three or more consecutive pregnancies before 20 weeks gestation.

Etiology

a. Genetic Error b. Anatomic Abnormalities of the Reproductive Tract c. Hormonal Abnormalities d. Infection e. Immunologic Factors f. Systemic Disease

COMPLICATIONS OF ABORTION

1. 2. 3.

Hemorrhage Infection Shock