Abortion

Dr. F Mardanian MDDr. F Mardanian MD

Ⅰ. Definition

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

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

Miscarriage 8-20% → under 20wMiscarriage 8-20% → under 20w

↓ ↓

80% infirst 12 w80% infirst 12 w

Subclinical → 13-26% of all pregnanciesSubclinical → 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 miscarriage20% → after one miscarriage

- 28% → after 2 consecutive miscarriage28% → after 2 consecutive miscarriage

- 43% → after 3 consecutive miscarriage43% → after 3 consecutive miscarriage

Heavy smoking (>10/d)Heavy smoking (>10/d)

Vasoconstrictive, antimetabolic effect Vasoconstrictive, antimetabolic effect

paternal smokingpaternal smoking

AlcoholAlcohol

GravidityGravidity

CocainCocain

NSAIDs (but not acetaminophen)NSAIDs (but not acetaminophen)

Fever > 37/78°c → (euploid not aneupleid abortion)Fever > 37/78°c → (euploid not aneupleid abortion)

Caffeine 100-300mg/dCaffeine 100-300mg/d

Proloned ovulation to implantation interval (>10d)Proloned ovulation to implantation interval (>10d)

Prolonged time to pregnancyProlonged time to pregnancy

Low plasma folate levelsLow plasma folate levels

Maternal weight Maternal weight

BMI<18/5kg/m2BMI<18/5kg/m2

BMI>25 kg/m2BMI>25 kg/m2

Celiac DisCeliac Dis

Etiology:

1/3 → before 8w →blighted (anembryonic),1/3 → before 8w →blighted (anembryonic), 2/3 with embnyo → 2/3 with embnyo → Chromosomal abnormalities → 50% all Chromosomal abnormalities → 50% all

miscarrage (most are aneuploidies)miscarrage (most are aneuploidies) Autosomal → 52%Autosomal → 52% Monosomy X → 19%Monosomy X → 19% Polyploidies → 22% Polyploidies → 22% Other → 7% Other → 7%

Congenital anomaliesCongenital anomalies

Tratogens (D.M-Drug – fever – chemicals)Tratogens (D.M-Drug – fever – chemicals)

GeneticGenetic

TraumaTrauma

(CVS – Amniocentesis)(CVS – Amniocentesis)

Host factorsHost factors

Uterine anomalyUterine anomaly

Acute maternal infections (TORCH-Acute maternal infections (TORCH-

Listeria)Listeria)

Maternal endocrinopathies (thyroid – Maternal endocrinopathies (thyroid –

cushing’s yn -pco - thrombophilia)cushing’s yn -pco - thrombophilia)

UnexplainedUnexplained

3.Pathologic change Most commonly, necrotic changes occur in Most commonly, necrotic changes occur in

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

4.Clinical classification and feature

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

Differential diagnosis of varied abortions

Threatened Inevitable Imcomplete Complete History Bleeding Slight Middle→ severa Slight→ severa Slight→ no Abdominal pain No/slight Aggravate Decrese No Tissues are expelled

No No Yes(partial) Complete

Gynecologic examination Cervical os Close Open Open/tissue blochk Close Uterine size Consistent with =/slight small < =/slight larger Pregnancy test + +/- +/- +/- Treatment principle

Protect fetus Curettage Curettage no

Missed abortion

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

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

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

Habitual abortion(recurrent)

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

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

Early cause

①①hypofunction of corpus luteumhypofunction of corpus luteum ②②emotion factor emotion factor ③③hypopituitarismhypopituitarism ④④chromosomal abonormalitieschromosomal abonormalities

Late abortion

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

mother and fetusmother and fetus

5. Diagnosis

(1)History

①①amenorrhea, recurrent abortion amenorrhea, recurrent abortion symptoms of pregnancysymptoms of pregnancy

②②the degree of abdominal pain, vaginal the degree of abdominal pain, vaginal bleedingbleeding

③③the products of gestation were expelled the products of gestation were expelled or not or not

(2)Examination

①①general examination: temperature , pulse, general examination: temperature , pulse, respiration, blood pressure.respiration, blood pressure.

②②vaginal examination: vaginal examination:

uterine size: compared to the expected uterine size: compared to the expected

date of pregnancydate of pregnancy

cervical os: open or closecervical os: open or close

uterine tendenessuterine tendeness

(3)anxillary examination

①①pregnancy test: HCG<625IU/L→abortionpregnancy test: HCG<625IU/L→abortion ②②measurement of HPLmeasurement of HPL

5~10w: hpl≤0.01mg/L5~10w: hpl≤0.01mg/L ③ ③ measurement of E2(estroid)measurement of E2(estroid)

E2<740pmol/LE2<740pmol/L ④④measurement of pregnanediolmeasurement of pregnanediol

24h urinary<15.6μ/24h, 95%→abortion24h urinary<15.6μ/24h, 95%→abortion 　　　　

⑤⑤B-ultrasoundB-ultrasound

differential of varieties of abortiondifferential of varieties of abortion

gestation sac, embryo status, fetal heart tones, gestation sac, embryo status, fetal heart tones, fetus movementfetus movement

Incompetence of the cervix, cervical Incompetence of the cervix, cervical os>19mm and have history of abortionos>19mm and have history of abortion

Normal pregnancyNormal pregnancy

incomplete incomplete septicseptic

threatened inevitable infectionthreatened inevitable infection

proceed completeproceed complete

delaieddelaied

treatmenttreatment

missed habitual missed habitual

6. Treatment

(1)Threatened abortion Principle: protect fetus treatmentPrinciple: protect fetus treatment ①①bed restbed rest

forbid sexual intercourseforbid sexual intercourse ②②drugdrug

folic acid 5mg tid. Po.folic acid 5mg tid. Po.

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

VE 30~50mg Qd po.VE 30~50mg Qd po.

Seditive: valium 2.5mg po. Seditive: valium 2.5mg po.

(2)Inevitable and incomplete abortion At once D&C(curettage) dilatationAt once D&C(curettage) dilatation if bleeding is brisk blood transfusionif bleeding is brisk blood transfusion

oxytosin 5~10u iv/imoxytosin 5~10u iv/im incomplete abortion antibiotic used for incomplete abortion antibiotic used for

preventive infection preventive infection

tissue examination by a pathologisttissue examination by a pathologist

(3)Complete abortion

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

(4)Missed abortion

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

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

②②leveral uterine sentitionleveral uterine sentition

DES(diethylstibestrol)5~10mg tid po 5dDES(diethylstibestrol)5~10mg tid po 5d ③③before curettage, preparey bloodbefore curettage, preparey blood

during opreation: oxytocin 10u im/ivduring opreation: oxytocin 10u im/iv

over than 3 month of pregnancy artificial over than 3 month of pregnancy artificial inducte. inducte.

(5)Habitual abortion The first should be examinatin cause of habitual The first should be examinatin cause of habitual

abortion and treatment.abortion and treatment. 1)rest, increase nutrition, …1)rest, increase nutrition, … 2)medical treatment: hypofunction of corpus luteum--2)medical treatment: hypofunction of corpus luteum--

progesteroneprogesterone 3)surgical treatment:3)surgical treatment:

① ①correction of congenital anomalies of correction of congenital anomalies of

uterus,removed of myomasuterus,removed of myomas

② ②repair of the incompetent cervix.12~20wrepair of the incompetent cervix.12~20w

(7)Septic abortion

The principle of treatment:The principle of treatment:

bleeding is a few: first treat infection with bleeding is a few: first treat infection with

broad-spectrum broad-spectrum antibiotissantibiotiss

second D&Csecond D&C

bleeding is sever:bleeding is sever:

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

Don’t used curette to curettage uterine wall Don’t used curette to curettage uterine wall prevent infectionprevent infection

avoid hematogeous dissemination of the avoid hematogeous dissemination of the infection. infection.