ABORTION OR MISCARRIAGE
- Miscarriage is the loss of pregnancy before 20 completed week’s gestation or the expulsion of fetus or embryo weighing less than 500 grams.
- Genetic: 50 % of first trimester miscarriages is associated with abnormal chromosomal and the most common is trisomy, monosomy X and triploidy.
- Infection: with Listeria monocytogenes, brucella, mycoplasma hominis, campylobacter, cytomegalovirus, rubella and coxsackie.
- Second trimester miscarriage may be associated with uterine abnormalities, cervical incompetence, bacterial vaginosis and multiple pregnancy.
- 25 % of miscarriages are unexplained
Types of spontaneous abortion
- Threatened miscarriage: any vaginal bleeding, with or without pain before 20 week’s gestation is considered threatened miscarriage
- Complete abortion - The complete expulsion of all products of conception (POC) before 20 weeks’ gestation.
- Incomplete abortion - it is partial expulsion of some but not all POC before 20 weeks’ gestation.
- Inevitable abortion: vaginal bleeding and dilation of cervix without expulsion of POC
- Missed abortion: death of the embryo or fetus before 20 week’s gestation with retention of POC.
- Recurrent pregnancy loss: when woman has there or more consecutive spontaneous abortions
First Trimester Abortion
- 60% of spontaneous abortion is chromosomally abnormal
- Patient present with vaginal bleeding, cramps, abdominal pain and decreased symptoms of pregnancy.
- Pelvic examination is performed to find the sources of bleeding and cervical changes
- Laboratory tests include quantitative B-HCG, CBC, blood type and antibody screen.
- Ultrasound can assess fetal viability and placentation and must consider ectopic pregnancy in the differential diagnosis.
- Treatment: -Stabilize the patients if hypotensive
- An incomplete abortion can be allowed to finish on its own if no excessive bleeding
- Also it can be treated medically (Misoprostol) or surgically (D&C)
- In threatened abortion place the patient on pelvic rest with nothing pre vagina.
- All Rh-negative pregnant women should receive RhoGAM to prevent isoimmunization.
- Any tissue has passed at home or at hospital maybe sent us to pathology.
Second Trimester Abortion
Recurrent pregnancy loss
- Abortions at 12-20 week’s gestation have many causes:
- Infection, uterine anatomical abnormalities, cervical incompetence, maternal systematic disease, trauma, bacterial vaginosis and multiple pregnancies.
- Late second trimester abortion are also seen as PTL and incompetent cervix and can be differentiated clinically as PTL begins with contractions leading to cervical change, whereas an incompetent cervix is characterized by painless dilation of the cervix.
- In the case of incompetent cervix, an emergent cerclage can be offered and PTL can potentially managed with Tocolysis and betamethasone with strict bedrest.
- Abortion can be allowed to finish on their own. But often is taken to completion with D&E (Dilation and evacuation).
- Induction of labor allows completion of the abortion without the inherent risks of instrumentation and also allows for genetic examination or autopsy of the POC.
- Defined as three or more consecutive spontaneous abortions
- Chromosomal abnormalities, maternal systemic disease, maternal anatomic defects and infections.
- 50% of patients have antiphospholipid antibody (APA) syndrome. Also some patients thought to have luteal phase defect.
- Karyotype for both parents and Karyotype of the POC – complete genome hybridization (CGH)
- Examine for maternal anatomy: HSG – hysteroscopy, laparoscopy
- Screen tests for hypothyroidism, diabetes mellitus, APA syndrome, hypercoagulability, and systemic lupus erythematosus (SLE).
- Cultures of the cervix, vagina, endometrium to rule out infection
- Depends on the etiology of abortion
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