SPONTANEOUS ABORTION (MISCARRIAGE)

DEFINITION:
Abortion is the expulsion or extraction from its mother of an embryo or fetus
weighing 500 g or less when it is not capable of independent survival (WHO).
 500 g of fetal development is attained approximately at 22 weeks (154 days) of
gestation
INCIDENCE:
 Globally, 56 million abortions take place every year.
 It is estimated that 15.6 million abortions take place in India every year.
ETIOLOGY
 Genetic
 Endocrine and metabolic
 Anatomic
 Infection
 Immunological
 Thrombophilias
 Environmental
 Others and Unexplained
Genetic factors
 Autosomal trisomy(trisomies of the non-sex chromosomes) eg; trisomy 21-down
syndrome
 Polyploidy (presence of three or more multiples of a haploid number of chromosome,
e.g. 3n = 69)
 Structural chromosomal rearrangements (these include translocation, deletion,
inversion and ring formation)
 Monosomy x (45, x)
Endocrine and metabolic factors
 Luteal phase defect (LPD) [implantation and placentation are not supported
adequately]
 Deficient progesterone
 Thyroid abnormalities: overt hypothyroidism or hyperthyroidism is associated with
increased fetal loss.
Anatomical abnormalities
 Cervical incompetence
 Congenital malformation of the uterus
 uterine (fibroid)
 Intrauterine adhesions
Infections
1. Viral: rubella, cytomegalovirus, variola, vaccinia or hiv.
2. Parasitic: toxoplasma, malaria
3. Bacterial: ureaplasma, chlamydia.
Immunological disorders
 Antiphospholipid antibody syndrome (APAS)—is due to the presence of
antiphospholipid antibodies.
 Autoimmunity: Natural killer (NK) cell
Maternal medical illness
Cyanotic heart disease, hemoglobinopathies are associated with early miscarriage.
Premature rupture of the membranes
Environmental factors:
Cigarette smoking [due to formation of carboxyhemoglobin and decreased oxygen transfer to
the fetus.]
Contraceptive agents—IUD in situ increases the risk whereas oral pills do not.
Drugs, chemicals, noxious agents
Unexplained

MECHANISM OF MISCARRIAGE:
BEFORE 8 WEEKS
 The ovum, surro unded by the villi with the decidual coverings, is expelled out intact.
 Sometimes, the external os fails to dilate so that the entire mass is accommodated in
the dilated cervical canal and is called CERVICAL MISCARRIAGE
BETWEEN 8 WEEKS AND 14 WEEKS:
 Expulsion of the fetus commonly occurs leaving behind the placenta and the
membranes.
 A part of it may be partially separated with brisk hemorrhage or remains totally
attached to the uterine wall
BEYOND 14TH WEEK:
 The process of expulsion is similar to that of a “mini labor”.
 The fetus is expelled first followed by expulsion of the placenta after a varying
interval.
 CLASSIFICATION OF ABORTION

Abortion

spontaneous Induced

Threatened Inevitable Complete Incomplete Missed Septic Legal Illegal

THREATENED MISCARRIAGE
Definition:
It is a clinical entity where the process of miscarriage has started but has not
progressed to a state from which recovery is impossible.
Clinical Features:
 Bleeding per vaginam
 Pain [mild backache or dull pain in lower abdomen.]
Pain appears usually following hemorrhage.
 Pelvic examination should be done.
(a) Speculum examination reveals—bleeding
(b) Digital examination reveals the closed external OS.
(c) The uterine size corresponds to the period of amenorrhea.
(d) Pelvic examination is avoided when ultrasonography is available.
THREATENED MISCARRIAGE
Definition:
It is a clinical entity where the process of miscarriage has started but has not
progressed to a state from which recovery is impossible.
Clinical features:
Bleeding per vaginam
Pain
Pelvic examination
(a) Speculum examination reveals—bleeding if any, escapes through the external os.
(b) Differential diagnosis includes cervical ectopy , polyps or carcinoma, ectopic
pregnancy and molar pregnancy.
(c) Digital examination reveals the closed external os.
(d) The uterine size corresponds to the period of amenorrhea.
(e) The uterus and cervix feel soft.
(f) Pelvic examination is avoided when ultrasonography is available.
INVESTIGATIONS
Routine investigations include:
 Blood
 Urine
 Ultrasonography (TVS)
(1) A well-formed gestation ring with central echoes from the embryo indicating
healthy fetus
(2) Observation of fetal cardiac motion. With this there is 98% chance of
continuation of pregnancy.
(3) A blighted ovum is evidenced by loss of definition of the gestation sac, smaller
mean gestational sac diameter, absent fetal echoes and absent fetal cardiac
movements
 Serum progesterone value of 25 ng/mL or more generally indicates a viable
pregnancy in about 95% of cases.
 Serial serum hCG level is helpful to assess the fetal well-being.
Treatment:
 Rest; The patient should be in bed for few days until bleeding stops.
 Drugs; diazepam 5 mg tablet twice daily.
 Treatment with progesterone.
Advice on discharge:
 The patient should limit her activities for at least 2 weeks and avoid heavy work
 Coitus is avoided during this period
 She should be followed up with repeat sonography at 3–4 weeks’ time
Prognosis
(1) In about two-thirds, the pregnancy continues beyond 28 weeks.
(2) In the rest, it terminates either as inevitable or missed miscarriage
If the pregnancy continues, there is increased frequency of
 preterm labor,
 placenta previa,
 intrauterine growth restriction of the fetus and fetal anomalies.
Blighted ovum (silent miscarriage)
 It is a sonographic diagnosis.
 There is absence of fetal pole in a gestational sac with diameter of 3 cm or more.
 Uterus is to be evacuated once the diagnosis made.
INEVITABLE MISCARRIAGE
Definition:
It is the clinical type of abortion where the changes have progressed to a state from
where continuation of pregnancy is impossible.
Clinical features:
(1) Increased vaginal bleeding.
(2) Aggravation of pain in the lower abdomen which may be colicky in nature.
(3) Internal examination reveals dilated internal os of the cervix through which the
products of conception are felt.
Management
is aimed: (a) to accelerate the process of expulsion. (b) to maintain strict asepsis
General measures:
 Administration of Methergine 0.2 mg(to control excessive bleeding) if the cervix
is dilated and the size of the uterus is less than 12 weeks.
 The blood loss is corrected by intravenous (IV) fluid therapy and blood
transfusion.
Active Treatment:
 Before 12 weeks:
(1) Dilatation and evacuation followed by curettage of the uterine cavity by blunt
curette using analgesia or under general anesthesia.
(2) Suction evacuation followed by curettage is done.
 After 12 weeks:
(1) The uterine contraction is accelerated by oxytocin drip (10 units in 500 mL of
normal saline) 40–60 drops per minute.
(2) If the fetus is expelled and the placenta is retained, it is removed by ovum
forceps
(3) If the placenta is not separated, digital separation followed by its evacuation is
to be done under general anesthesia.
COMPLETE MISCARRIAGE
Definition:
When the products of conception are expelled en masse,it is called complete miscarriage
Clinical features:
 expulsion of a fleshy mass per vaginam
 Subsidence of abdominal pain
 Vaginal bleeding becomes trace or absent
 Internal examination reveals:
(a) Uterus is smaller than the period of amenorrhea and a little firmer.
(b) Cervical os is closed
(c) Bleeding is trace.
 Examination of the expelled fleshy mass is found complete.
 Ultrasonography (TVS): reveals empty uterine cavity.
Management:
 Transvaginal sonography is useful to see that uterine cavity is empty,
 Evacuation of uterine curettage should be done.
Rh-NEGATIVE WOMEN:
An Rh-negative patient without antibody in her system should be protected by anti-D
gamma globulin 50 μg or 100 μg intramuscularly in cases of early miscarriage or late
miscarriage respectively within 72 hours.

INCOMPLETE MISCARRIAGE
 DEFINITION: When the entire products of conception are not expelled, instead a part
of it is left inside the uterine cavity, it is called incomplete miscarriage.
CLINICAL FEATURES:
(1) Continuation of pain in lower abdomen. (2) Persistence of vaginal bleeding.
(3) Internal examination reveals— (a) uterus smaller than the period of
amenorrhea (b) patulous cervical os often admitting tip of the finger and (c)
varying amount of bleeding. (4) on examination, the expelled mass is found
incomplete
(2) Ultrasonography—reveals echogenic material (products of conception) within
the cavity
COMPLICATIONS:
The retained products may cause:
(a) profuse bleeding
(b) sepsis or
(c) placental polyp.
MANAGEMENT
evacuation of the retained products of conception (ERCP) is done.
She should be resuscitated
Early abortion:
Dilatation and evacuation under analgesia or general anesthesia is to be done.
Evacuation of the uterus may be done using MVA also.
Late abortion:
The uterus is evacuated under general anesthesia and the products are removed by
ovum forceps or by blunt curette.
Medical management
Tablet misoprostol 200 µg is used vaginally every 4 hours
MISSED MISCARRIAGE
Definition:
When the fetus is dead and retained inside the uterus for a variable period, it is called
missed miscarriage or early fetal demise
PATHOLOGY:
 The causes of prolonged retention of the dead fetus in the uterus are not clear.
 Beyond 12 weeks, the retained fetus becomes macerated or mummified.
 The liquor amnii gets absorbed and the placenta becomes pale, thin
 Before 12 weeks, the pathological process differs when the ovum is more or less
completely surrounded by the chorionic villi.

CARNEOUS MOLE (Syn: blood mole, fleshy mole):

By this time, the ovum becomes dead and is either completely absorbed or
remains as a rudimentary structure.
, The fluid portion of the blood surrounding the ovum gets absorbed and the
wall becomes fleshy, hence the term fleshy or carneous mole .
CLINICAL FEATURES:
(1) Persistence of brownish vaginal discharge
(2) Subsidence of pregnancy symptoms
(3) Retrogression of breast changes
(4) Cessation of uterine growth
(5) Non-audibility of the fetal heart sound
(6) Cervix feels firm.
(7) Immunological test for pregnancy becomes negative
(8) Ultrasonography reveals an empty sac.
COMPLICATIONS:
 Hemorrhage
 Sepsis
 Septic shock
 DIC [Disseminated Intravascular Coagulopathy]
MANAGEMENT:
 Expectant
 Medical
 Surgical
Uterus is less than 12 weeks:
(i) Expectant management——Many women expel the conceptus spontaneously
(ii) Medical management: Prostaglandin E1 (misoprostol) 800 mg vaginally in the
posterior fornix is given and repeated after 24 hours if needed.
Expulsion usually occurs within 48 hours