Abortion(miscarriage)

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Abortion(miscarriage)

• Dr. Isaac Makanda

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INTRODUCTION

• DEFINITION
• Abortion is the expulsion or extraction of an
  embryo weighing 500g from its mother when its
  not capable of independent survival.(WHO)
• 500g of fetal development is attained at
  approximately 22 weeks GA
• Developed countries-20 weeks GA
• Developing countries 28 weeks GA

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EPIDEMIOLOGY

• 10 -20 of all clinical pregnancies end in
  miscarriage and another optimistic figure of 26
  are induced abortions.
• Spontaneous abortion 75 occur before 16th week
  and of these 80 occur below 12th week.
• About 56 million abortions are performed each
  year in the world with about 45 done unsafely.
• Approximately 20 million unsafe abortions are
  performed annually with 97 taking place in
  developing countries

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EPIDEMIOLOGY

• In Tanzania, an estimated 405,000 abortions were
  performed in 2013 the abortion rate being 36
  abortions per 1000 women aged 15-49 years old and
  a ratio of 21 abortions per 100 live births.
• This rate is the same as the estimated rate for
  the whole East African region and slightly higher
  than that of the Sub Saharan Africa (31).
• In 2013 in Tanzania, 15 of pregnancies ended in
  abortion,52 in intended births ,18 in
  unintended births and 15 in miscarriages.

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CLASSIFICATION OF ABORTION
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Spontaneous abortion.Causes (isolated)

• 1. Genetic factors
• Chromosomal abnormalities, the common cause
• of first trimester abortions eg autosomal
  trisomy, polypoidy, monosomy
• 2. Infections
• Bacteria
• Listeria monocytogenes, Chlamydia trachomatis,
  Ureaplasma urealyticum , Mycoplasma hominis
  ,Bacteria causing vaginosis
• Viruses
• Cytomegalovirus (CMV) ,Rubella ,Herpes simplex
  virus (HSV) ,Human immunodeficiency Virus (HIV)
  ,Parvovirus

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Causes, Cont

• Parasites
• Toxoplasma gondii, Plasmodium falciparum
• Spirochetes - Treponema pallidum
• 3.Endocrine abnormalities
• Poorly Diabetes mellitus, Hyperthyroidism and
  Hypothyroidism, progesterone deficiency, luteal
  phase defect.
• 4.Environmental factors Tobacco, caffeine,
  alcohol, radiation and IUCDs.
• 5.Drugs e.g. Anaesthetics gases, formaldehyde,
  lead, arsenic, quinine, and ergots.

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Causes, Cont

• 6.Immunological factors
• Autoimmune- Antiphospholipid antibodies( LAC,
  aCL).
• Antifetal antibodies e.g anti-D antibodies.
• 7.Inherited thrombophilias Factor V Leiden,
  Protein C and S Deficiency, Anti thrombin III
  deficiency.
• 8.Physical trauma

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Spontaneous abortion Causes (recurrent)

• Defined as having 3 or more consecutive
  spontaneous abortion before 20 weeks
• Affects 1 of the women, risk increases with each
  successive abortion, reaching over 30 after 3
  consecutive losses.
• Causes may include
• Genetic factors (parental chromosomal
  abnormalities)

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Causes, Cont

• 2.Maternal medical illness eg cyanotic heart
  disease
• 3. Anatomical (cervico-uterine factors)eg
  cervical incompetence, congenital malformation of
  the uterus, uterine fibroid, intrauterine
  adhesions
• 4. Paternal factors Chromosomal abnormalities in
  the sperm

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CLINICAL TYPES OF ABORTION(varieties)

1. Threatened abortion
2. Inevitable abortion
3. Incomplete abortion
4. Complete abortion
5. Septic abortion
6. Missed abortion
7. Recurrent(Habitual)

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Threatened abortion

• Signs and symptoms
• When a woman known to be pregnant or showing
  signs and symptoms of early pregnancy
  ,experiences uterine bleeding
• The bleeding is an indication of some degree of
  separation of the chorion from decidua.The
  uterine bleeding varies in amount,duration and
  type.
• It is bright red at first .When changes to dark
  brown it means that active bleeding has ceased
  and that old blood is undergoing dissolution.

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Threatened abortion .

• Even when the blood loss is sharp and prolonged
  ,the pregnancy may still survive undamaged
• The passage of clots generally denotes that the
  pregnancy is inevitable
• Persistent pyrexia is an evidence of infection or
  degeneration of clots in the uterus
• Sometimes the patient complains of lower backache
  and slight lower abdominal pain due to uterine
  contractions.
• Significant pain indicates expulsion of products
  of conception is usually taking place

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Threatened abortion .

• Vaginal examination
• Reveals that the cervix is NOT DILATED
• The uterus otherwise manifests the usual signs of
  pregnancy and is usually of the same size
  corresponding to gestational age

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Diagnosis of threatened abortion

• Uterine bleeding
• or low backache and cramp-like pains
• NO Cervical dilatation
• Note 70-80 of diagnosed threatened abortion in
  the first trimester continue to term.
• Confirm signs and symptoms of pregnancy
• Vaginal examination
• (a) speculum examination- to exclude other
  causes of bleeding
• (b) Bimanual-to assess the size of the uterus
• Do obstetric ultrasound
• Pregnancy test not very helpful.

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Differential diagnosis of threatened abortion

• Other types of abortion especially inevitable and
  incomplete abortion
• Ectopic pregnancy
• Molar pregnancy
• Other causes of p.v bleeding
• Urinary tract infection

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Management

• Bed rest until 2 days after the blood loss has
  ceased
• Save all pads and anything passed for examination
• Avoid sexual intercourse to prevent infection and
  contractions until 2 weeks after the blood loss
  has ceased
• MILD Sedative if the patient is restless or
  anxious eg diazepam or phenobarbitone
• Hormonal therapy endocrine therapy is of
  unproved value
• Treat the cause if known eg hypertension,malaria
• Psychotherapy reassurance

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Inevitable abortion

• If in addition to the clinical features of
  threatened abortion there are
• Painful uterine contractions
• Dilatation of the cervix
• Extrusion of some parts of conception through the
  os uteri
• Other suggestive signs ballooning of the upper
  vagina, tenderness of the uterus and pyrexia

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Diagnosis of inevitable abortion

• It is diagnosed when 2 of the following are
  noted
• Moderate effacement of the cervix cervical
  dilatation 3 cm
• Rupture of the membranes
• Pv bleeding for 7 days
• Persistence of cramps despite narcotic analgesia
• Signs of termination of pregnancy

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Management of inevitable abortion

• Conservative treatment
• confine to bed until the abortion is complete
• relieve pain and anxiety
• Save everything passed from the uterus
• 2. Active management
• curretage
• if the abortion does not proceed quickly and
  smoothly
• When the placenta or other products of conception
  are retained
• Bleeding is getting too profuse
• NOTE Danger of perforation of the uterus by
  curretor

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Management of inevitable abortion..

• (b) oxytocin preferably i.v in dextrose
  5N/saline ,ringers lactate solution 20 i.u at
  30-40 drops /minute
• (c) treat hypovolaemic shock if any i.v fluid or
  blood transfusion
• (d ) adequate analgesiaeither pethidine 100mg
  i/m or morphine 15mg i/m

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Incomplete abortion

• Is when the products of conception have partially
  passed from the uterine cavity.
• Clinical features
• Persistent uterine bleeding
• The cervix is open
• Lower abdominal pains/backache persist
• The size of the uterus becomes smaller than the
  gestational age
• Note the bleeding may persist leading toshock
  or infection
• Products of conception may be see by ultrasound
  scanning

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Management of incomplete abortion

• Curettage (evacuation)-To empty the uterus
  preferably under GA.OXYTOCIN 10IU I/M OR I/V
  after evacuation
• Manual vacuum aspiration(MVA)
• Analgesics
• Antibiotics to protect against infection
• Treat hypovolaemic shock?I/V fluids,Blood
  transfusion

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Complete abortion

• Defined as cessation of pain and brisk bleeding
  after the ENTIRE conceptus has been passed out
• Slight bleeding may continue for a short while
• The conceptus,the placenta and membranes are
  completely expelled from the uterus
• The uterus is firmly contracted on palpation and
  an empty uterine cavity is seen on ultrasound
• NO medical intervention is usually required
• NOTEComplete abortion is rare in early pregnancy

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Missed abortion

• This implies that the pregnancy has been retained
  for (2months) following the death of the fetus
• Missed abortion usually does not occur until the
  pregnancy has advanced into the second trimester
• The normal reaction of the uterus to the death of
  the foetus is to EXPEL it ,but for some
  unexplained reasons ,this may not occur.
• Women report reduction,then cessation of symptoms
  of pregnancy

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Missed abortion .

• The uterus stops to grow and there is absence of
  foetal heart pulsation(detectable by ultrasound.
• NOTE Missed abortion occurs when the embryo dies
  ,but the gestational sac is retained in the
  uterus for several weeks.

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Diagnosis of missed abortion

• Clinical features of missed abortion(signs and
  symptoms)
• Loss of symptoms of pregnancy
• Decrease in uterine size
• There may be a Brownish vaginal discharge but no
  fresh bleeding
• Pain or tenderness is unlikely
• A bizare configuration of foetal bones may be
  seen on the x-ray
• Foetal movements if previously present, cease
• Foetal heart pulsations can not be picked by
  U.S.S or doptone machine.

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Laboratory findings

• The pregnancy test becomes negative often only
  after the foetus has been dead for several weeks
• Levels of other chorionic hormones and their
  derivatives may also be slow to fall
• Note confirmation is best done by USS.
• The aftermath of missed abortionIf retained long
  enough may end up into
• Carneous mole ,or
• Macerated foetus

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• A carneous mole -is a lobulated mass of laminated
  blood clots
• The projections into the shrunken cavity are
  caused by repeated haemorrhages in the
  chorio-decidual space
• In very early pregnancies (up to
  12weeks),complete absorption of the dead ovum may
  occur.

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A macerated foetus

• The skull bones collapse and override and the
  spine is flexed
• There is little or no amniotic fluid on the USS
• The internal organs degenerate and the abdomen is
  filled with blood-stained fluid
• The skin peels off easily
• The pathological changes in the foetus such as
  mummification(foetus papyraceous) and
  calcification (lithopaedion) are exceedingly rare
  

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Differential Diagnosis missed abortion

• Normal pregnancy inaccurately dated
• Pelvic tumour without pregnancy
• Pseudocyesis (false or phantom pregnancy)
• Other types of abortion especially incomplete
  abortion

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Complications of missed abortion

• In a few cases of missed abortion products of
  placental degeneration(probably thromboplastin)
  enter the maternal circulation and
  cause?intravascular clotting failure

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Intravascular clotting

• This results in hypofibrinogenaemia and increase
  of FIBRINOLYSINS and FIBRIN DEGRADATION
  PRODUCTS(F.D.P) in circulation
• The blood changes are complicated and varied but
  results is Coagulation failure
• This manifests itself by capilary haemorrhages
  such as
• Epistaxis
• Haematemesis
• Ecchymosis
• Sometimes prolonged and difficulty to control
  uterine bleeding at the same time the pregnancy
  is evacuated

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Intravascular clotting.

• Note check for
• Blood fibrinogen content
• Clot stability
• Normal fibrinogen level is 350-450mg/dl.
• The danger level is more than 100mg /dl clotting
  time 6-10 minutes

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Treatment of missed abortion

• If left alone, most missed abortions will be
  expelled spontaneously .But during the waiting
  period ,there is a slight risk of coagulation
  defect.
• This should be investigated before embarking on
  evacuation of the uterus in cases of foetal death
  of more than 4 weeks
• Surgical
• a) For uterus not greater 8-10nweeks in size
• Curettage
• MVA
• b)For bigger pregnancies
• Hysterectomy

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Treatment of missed abortion

• Medical
• a) Induction with Oxytocin eg 5IU in Dextrose 5
  500mls
• b) Prostaglandins
• i) Mifepristone (RU486)
• An antiprogesterone
• Given orally
• Dose 600mg

• ii) Misoprostol
• A protaglandin E analogue
• Given vaginally or orally
• Dose vaginally 800mcg
• Orally 600mcg
• c) Gemeprost (protaglandin E1)
• As vaginal pessary
• Dose 1mg

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Recurrent(Habitual abortion)

• Defined as sequential loss of 3 previable
  pregnancies
• The occurrence of 3 consecutive spontaneous
  abortions
• This problem affects about 15 of all women
• There is usually no satisfactory explanation for
  many of these cases
• Although the pattern of pregnancy loss may be
  similar from one pregnancy to another the cause
  may be different.
• It is usually due to a recurrent factor rather
  than accidental one

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Risk factors for habitual abortion

• 1. Genetic factors
• Eg. Trisomy No treatment
• 2. Anatomic factors
• Uterine congenital anomalies
• Hypoplasia of the uterus
• Uterine myomas
• Cervical incompetency
• 3.Hormaonal abnormalities
• Hypothyroidism
• 4. Maternal Diseases
• Viral infections
• Syphylis
• 5.Immunological factors

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Risk factors for Habitual abortion

• 6. Environmental factors
• 7. Blood group incompatibility
• Nutritional deficiencies
• Protein starvation
• Avitaminosis

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Investigations for habitual abortion

• I) Proper history
• Previous septic abortion
• -previous history of surgery
• C/S
• Myomectomy
• multiple D/C
• Difficulty instrumental delivery (by V/E or
  Forceps )
• II) Pelvic examination
• Evidence of previous trauma eg deep lateral
  cervical lacerations
• Partial or complete amputation of the cervix
• Congenital abnormalities of the cervix or uterus

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Treatment of habitual abortion

• Treat the cause
• Cervical incompetency ? cerclage

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Septic abortion

• An abortion which become INFECTED .
• The infection may occur during the spontaneous
  abortionbut it is often after induced abortion.
• Blood clots and necrotic debris in the uterus
  form excellent culture media
• infection may spread rapidly to surrounding
  structures , causing Pelvic or generalised
  peritonitis
• ,PELVIC Cellulitis and salpingitis sometimes
  with SEPTICAEMIA

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Causes of septic abortion

• 1. Delay in evacuation of the uterus
• Either the the patient delays seeking medical
  advice or
• Surgical evacuation has been incomplete
• Infection occurs from vaginal organisms after
  48hrs
• 2. Trauma
• Either by perforation or
• Cervical tear
• Healing is delayed and infection is more likely
  to be peritonitis or cellulitis
• Criminal abortions are particularly liable to
  sepsis

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Infecting organisms in septic abortion

• They are usually vaginal or bowel commensals
  .They include
• Group B haemolytic Streptococcus
• Anaerobic Streptococcus
• Coliform Bacillus
• Clostridium welchii
• Bacteroides necrophorus
• NOTE any of the above but the last two may be
  the cause of septic shock syndrome
• The most common infecting organisms are
• Sterptococcus aureus
• Coliform bacteria
• Bacteroides
• Clostridium welchii

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• The most dangerous are the GRAM NEGATIVE and the
  anaerobic organisms which produce ENDOTOXIC SHOCK

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Clinical features of septic abortion

• Pyrexia
• Tachycardia
• Offensive vaginal discharge
• Tenderness of the uterus
• Leucocytosis
• Ileus ?vomiting and abdominal distension
• General systemic upset
• -anorexia
• -vomiting
• -joint pains
• -headache
• -sweating dehydration
• -mental disorientation
• -coma

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Complications of septic abortion

• 1. BACTERAEMIA (ENDOTOXIC) SHOCK
• The shock represents and antigen-antibody
  reaction of the anaphylactic type motivated by
  ENDOTOXINS released from bacteria entering the
  circulation in large numbers
• The organisms are usually GRAM-NEGATIVEThe
  commenest being E.coli and Proteus vulgaris which
  can operate even when they are dead.
• Endotoxic shock is manifested by sudden collapse
  of the patient with severe HYPOTENSION and
  sometimes heralded by a rigor

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Complications of septic abortion

• 2. OLIGURIA
• The most serious which leads to RENAL FAILURE
  .It is partly caused by ISCHEMIA associated with
  HYPOTENSION,but the effect is on the tubules
  rather than the Glomeruli of the kidney

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Investigations for septic abortion

• Full blood picture Total/Differential
  Leucocytosis
• High vaginal swab for culture and sensitivity
• Cervical swab for c/s
• Blood for c/s
• Msu for c/s
• Serum Electrolytes
• Renal function tests
• Liver function tests pelvic ultrasound

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Treatment of septic abortion

• I. Medical
• Treatment of shock
• Intravenous fluids
• Blood transfusion
• Treatment and management of oliguria ?i.v fluids
  ,renal dialysis
• Broad spectrum antibiotics cover both gram
  negatives and gram positive organisms while
  waiting for culture and sensitivity results
• II. SURGICAL
• CURETTAGE Should be done as soon as possible
• In cases of peritonitis
• Uterus a) repair ,b) hysterectomy
• Bowels anastomosis

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Criminal(illigal ) abortion

• Unlawful administration of any poison ,noxious
  thing ,any instrument or any other means
  whatsoever with intent to produce a miscarriage .
• It can be done by the Doctor, the patient herself
  or any other person.
• Methods used
• I. a) Strong purgatives
• b) Intrauterine instrumentation
• Hair pins
• Knitting needles
• Pieces of wood etc
• c) Dilatation of the cervix
• Slippery Elm bark
• Midrib of cassava leaf

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Criminal(illigal ) abortion.

• d) Single administration of Oxytocics Loca herbs
  (orally or vaginally
• e) Administration of
• Quinine tabs
• Chloroquine tabs
• Blue cubes
• f. Potassium permanganate crystals vaginally
• g. Prostaglandins
• h. Insertion of catheter through the cervical
  canal

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Therapeutic abortion

• Termination of pregnancy to save the life or the
  health of the mother (and not for social or
  economic reasons/indications )
• That the continuation of pregnancy would involve
  risk of the life of the pregnant woman or
  existing children in her family, greater than if
  the pregnancy was terminated
• That there is a substantial risk if the child
  were born would suffer such physica or mental
  handicapped

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Indications for therapeutic abortion

• 1. Pre-existing maternal Disease
• Severe cardiac disease
• Severe degree of chronic hypertension
• Chronic renal disease
• Pulmonary disease eg ca lungs
• Severe alimentary tract disease eg liver
  disease,pancreatitis
• Metabolic Disorders eg. osteomalacia
• blood disorders eg. Leukaemia
• Diseases of the central nervous system eg
  Disseminated sclerosis ,Mental disorders
• Malignant diseases
• Diseases of pregnancy eg Hyperemesis gravidarum

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Indications for therapeutic abortion.

• 2. Fetal diseases and malformations
• Rubella within 3 months of pregnancy
• Two previous malformed or mentally defective
  children
• 3. ? Rape ?

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Methods of termination of pregnancy

• I. Medical
• 1. Oxytocin with i/v fluids drip
• 2. A. Mifepristone (RU486)
• An antiprogesterone
• Used in early pregnancy(up to 63 days
  from the LNMP
• DOSE 600MG orally
• B.GEMEPROST 1mg vaginal pessary 36-48hrs latter
• C .Misoprostol
• A prostaglandin E analogue
• May be used instead of Gemeprostol
• Dose 600mcg orally or 800mcg vaginally
• Note pregnancies thus aborted may require
  curettage
• Analgesia may be required for pain

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Methods of termination of pregnancy

• II. SURGICAL
• MVA(manual vacuum aspiration)
• DC (Dilatationcurettage)
• Extramniotic abortion
• PGE 2-Very low instillation into the
  cervix through a Foleys catheter at the
  rate of not exceeding 2.5ml/hr
• Oxytocin infusion
• Increase to 150ml/hour
• Iv Intra amniotic injection
• Hypertonic solutions
• Prostaglandins
• v. Hysterotomy
• Vi.Hysterectomy

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Complications of therapeutic abortion

• Immediate
• MAJOR
• Haemorrhage
• Perforation
• Thromboembolism
• Infection
• MINOR
• Lower abdominal pains
• Late
• Pelvic inflammatory disease (PID)
• Infertility
• Psychology
• Rh isoimmunization in Rh incompatibility

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Post abortal care

• a)Counsel the patient before discharge on
• Signs of normal recovery may have mild
  uterine cramping relieved by mild analgesia eg
  paracetamol
• Normal menstrual flow should begin within 4-6
  weeks
• Return immediately if there are signs of
  complications such as
• - Increased bleeding
• -severe increased pain
• - fever or chills
• iv. Advice to avoid coitus and douches post
  abortion for at least 2 weeks
• v. Counsel and provide contraception or referral
  to contraceptive services

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Post abortal care

• b). Follow up visit
• Assess the patients recovery
• Feedback on contraception
• Discuss the need for contraception if not yet
  initiated
• Histology results

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Thank you for listening