Abortion

ABORTION

DEFINITION • Abortion Spontaneous abortion Induced abortion Early abortion Late abortion

Abortion Abortion refers to the termination of pregnancy before 28 weeks gestation, and the fetal weight is less than 1000 gram. The gestation based on the first day of the last menses. spontaneous abortion induced abortion

Spontaneous abortion Spontaneous abortion means expulsion of products of conception without using artificial interference before the time of fetal viability. The incidence is 10~18 percent of all pregnancies. Two types: early abortion late abortion

Induced abortion Induced abortion means that abortion happens for certain reason by artificial methods.

Early abortion & Late abortion • Early abortion occurs in the first 12 weeks of pregnancy. • Late abortion occurs between 12 weeks and 28 weeks.

ETIOLOGY Genetic factors: It is the most common reason. Abort 50~60 percent of early spontaneous abortion. It is a natural biological selectivity. Environmental factors:arsenic,lead, Benzene,formaldehyde,radiation

 Maternal

factors systemic disease endocrine effects uterine defects: septate uterus,leiomyomas cervical incompetence or laceration  Immunology factors antiphospholipid antibodies blood incompetibility due to ABC,Rh

Abnormal development of the ovum

Cervical incompetence

fibroids

Congenital abnormality of the uterus

PATHOLOGY the death of the embryo or fetus hemorrhage of the decidua basalis the ovum separated from the decidu acting as a foreign body in the uterus stimulates uterine contraction expulsion of most or all of the produces of conception

CLINICAL CLASSIFICATION AND FEATURE There are four kinds of common type abortion and three kinds of special type abortion in clinical classification. • threatened abortion • missed abortion • inevitable abortion

• • incomplete abortion recurrent spontaneous •complete abortion

• septic abortion

Threatened abortion •any bloody, •vaginal discharge or vaginal bleeding •lower abdominal pain •cervix is close, •without expulsion of products of conception, •there is possibility of continuation of pregnancy.

Inevitable abortion •vaginal bleeding •abdominal pains •with or without rupture of membranes •cervical dilatation •uterus corresponds to or less than weeks of pregnancy

•sometimes amniotic sac can be seen from external os.

Incomplete abortion •expulsion of part products of conception •the rest is retained in the uterus which interferes with myometrial contraction

•bleeding ensues sooner or later,often profuse, occasionally producing shock.

be

massive,

Complete abortion •the products of conception have been expelled completely

•slight vaginal bleeding •cessation of pain •close of cervix •normal uterine size or slight larger

Missed abortion •embryo or fetus has died but retained in uterus

•the uterine size has not only ceased to enlarge but also become smaller

•feels no enlargement of abdomen or fetal movement in the second trimester

•close of cervix •size of uterus less than weeks of pregnancy •fetal heart sounds cannot be heard.

Recurrent spontaneous abortion It means three or more consecutive spontaneous abortions. The time of each abortion occurrence may or may not be the same. Reasons in early stage : psychogenesis factor, pituitary dysfunction, chromosomal abnormalities, and sperm defect etc. in late stage : cervical incompetence, uterine deformity, leiomyomas, and mother-fetus blood incompatibility, etc.

Septic abortion Septic abortion means abortion associated with signs of infection.

DIAGNOSIS History Physical examination Supplementary examination

History •amenorrhea history •reappeared abortion history •early symptoms of pregnancy •vaginal

bleeding inquired carefully

should

be

Physical examination •general condition •existence of anemia or no •measure BP, P, T •pay attention to dilation of cervix, uterine size and uterine adnexa mass

•examination is performed in sterile condition

Supplementary examination HCG determination B-mode ultrasonographic picture : To differentiate the abortion type. In condition of the width of internal os of uterus more than 19mm, and abortion history, the diagnosis of incompetence can be proved.

DIFFERENTIAL DIAGNOSIS Differentiate with functional uterine bleeding, tubal pregnancy, hydatidiform mole, and leiomyomas. Moreover, type of abortion should be differentiated in order to diagnosis and treat.

Differential diagnosis of the type of abortion Type

history

examination

bleeding Abdominal Products pain delivery Threatened

Slight

Os

size

Close

Normal

No or slight

No

Inevitable Middle to large

Severe

No

Dilation Normal or slight small

Incomplete

Less to large

Slight

Part

Dilation Less than age

Complete

Less or no

No

all

close

Normal or slight large

MANAGEMENT

Management of threatened abortion The patient should be kept in bed. Progesterone 20mg intramuscularly daily. Vitamin E 50-100 mg daily. If bleeding slight, pregnancy may continue to term without any harm to fetus, if bleeding prolonged abortion will become inevitable.

Management of inevitable abortion Evacuation of uterus should be done early as possible after diagnosis. In early abortion, do curettage. In late abortion, given oxytocin. If spontaneous evacuation is not successful, uterus should be evacuated by suction curettage.

Management of incomplete abortion Immediately do curettage after diagnosis. After

curettage

give

appropriate

antibiotics and transfusion of fluid and blood if necessary.

Management of complete abortion Not need specific treatment. Do curettage earlier if existence of gestational products was suspected.

Management of missed abortion Detect coagulation function. If evidence of a seriously coagulation defect exists, give fibrinogen intravenously, and heparin intravenously, fresh blood transfusion as well. Estrogen 5-10 mg 3 times daily for 5 days to improve the sensitivity of uterine muscle to oxytocine.

Management of habitual abortion • Find the reason first, do etiologic therapy. • General therapy: Adequate rest and care. • Sedative, vitamin and progesterone given. • Uterine deformity should be operated. • Prophylactic cervical cercalage should be taked in cervical incompetence

Management of septic abortion •Curettage usually delayed until infection is under control by antibiotics unless severe bleeding occurs.

•Give antibiotics after operation. •If severe infection of uterus cannot be controlled by drug, perform hysterectomy necessarily.