AbortionAbortion (miscarriage)(miscarriage)AbortionAbortion (miscarriage)(miscarriage)

Dongzi Yang 杨冬梓

The Second Affiliated Hospital

Sun Yat-Sen University

DefinitionDefinitionDefinitionDefinition

The termination of pregnancy before the 28th week, when the fetus weight is less than 1000 grams.

Early abortion: <12th week of pregnancyLate abortion: 12th-28th week of pregnancy

Spontaneous abortionArtificial abortion

EtiologyEtiologyEtiologyEtiology

Genetic factors: chromosomal abnormal accounts 50 ～ 60% of the early abortions• Numeral abnormalities: polyploidy, triploidy, monosomy• Structural abnormalities: break, translocation, deletion

EtiologyEtiologyEtiologyEtiology

Extrinsic factors• Chemical: mercury, lead, cadmium,

smoking, • Physical: video display terminals,

radioactive materials, noise,

hyperthermia

EtiologyEtiologyEtiologyEtiology

Maternal factors• General diseases:

infection, heart diseases, hypertension, anemia• Reproductive organic diseases:

congenital uterine malformation, pelvic tumor, cervical incompetence

• Endocrine disorders:

LPD, hypothyroidism• Injuries

EtiologyEtiologyEtiologyEtiology

Defects in the developing placenta

Immunologic factors: paternal histo-compatibility antigen , maternal cellular immunity regular disorder, deficiency of maternal blocking antibody

PathologyPathologyPathologyPathology

The death of the embryo or rudimentary analog

Hemorrhage into the decidua basalis

Uterine contraction, dilation of the cervix

Expulsion of the products conception

PathologyPathologyPathologyPathology

Before the 8th week of the pregnancy, the abortus can be expelled completely

During the 8th-12th week of the pregnancy, retention of the tissue is common

After the 12th week of the pregnancy, the abortus may be expelled totally

Clinical subgroups Clinical subgroups of abortionof abortionClinical subgroups Clinical subgroups of abortionof abortion

Theatened miscarriage

Inevitable miscarriage

Incomplete miscarriage

Complete miscarriage

The developing processesThe developing processesof the abortionof the abortionThe developing processesThe developing processesof the abortionof the abortion

Threatened miscarriage

Normal pregnancy Inevitable miscarriage

Complete miscarriage Incomplete miscarriage

Classifications and Classifications and characteristicscharacteristicsClassifications and Classifications and characteristicscharacteristics

conceptus Vaginal abdominal Cervix os Uterine Subgroups expulsion bleeding pain dilation enlargement

Threatened no ＋ －＋ － compatible

miscarriage

Inevitable no ＋ ＋ ＋ ＋ ＋ － compatible or miscarriage smaller

Incomplete part ＋ ＋ ＋ ＋ ＋ － smaller

miscarriage

Complete all ＋ － － － normal

miscarriage

Alternative Alternative classificationclassificationAlternative Alternative classificationclassification

Blighted ovum

Missed miscarriage

Live miscarriage

Classification of miscarriage

Normal pregnancyBlighted

ovum

Missedmiscarriage

Threatenedmiscarriage

Inevitablemiscarriage

Continuingpregnancy

Incompletemiscarriage

Completemiscarriage

Special subgroups:Special subgroups:

Missed MiscarriageMissed MiscarriageSpecial subgroups:Special subgroups:

Missed MiscarriageMissed Miscarriage

Expulsion of the conceptus does not occur

despite a prolonged period after embryonic

death.

Symptoms of pregnancy regress

Pregnancy test becomes negative

No fetal heart motion is detected

Uterine enlargement ceases

Special subgroups:

Recurrent miscarriageRecurrent miscarriageSpecial subgroups:

Recurrent miscarriageRecurrent miscarriage(Habitual abortion)

Three or more consecutive spontaneous losses

of pregnancy

First-trimester: LPD, hypothyroidism, chromosomal abnormalities, immunologic factors

Second-trimester: uterine malformations, cervical incompetence, myomas

Special subgroups:

Septic miscarriageSeptic miscarriageSpecial subgroups:

Septic miscarriageSeptic miscarriage

Any type of spontaneous miscarriage is

complicated by infection

Endometritis, parametritis, peritonitis

Fever, abdominal tenderness, uterine pain

Septicemia, septic shock

DiagnosisDiagnosisDiagnosisDiagnosis

History: amenorrhea, symptoms of pregnancy, vaginal bleeding……

Examination: general and pelvic

Ultrasounograph

Pregnancy test, ß-HCG

Others:

Differential diagnosisDifferential diagnosisDifferential diagnosisDifferential diagnosis

Ectopic pregnancy

Molar pregnancy

Dysfunctional uterine bleeding (DUB)

Pelvic infective diseases (PID)

Acute appendicitis

ManagementManagementManagementManagement

Threatened miscarriage:

rest, follow-up

Inevitable & incomplete miscarriage: Evacuation of the uterus,vacuum or suction curettage, oxytocin iv, antibiotics

Complete miscarriage:

no further therapy is necessary.

Management

Missed miscarriageMissed miscarriageManagement

Missed miscarriageMissed miscarriage

First- trimester:

suction curettage

The second-trimester:

D&E(dilation and evacuation)

D&C(dilation and curettage)

Induction of labor with intravaginal prostaglandin E2 or misoprostol

Management

Recurrent miscarriageRecurrent miscarriageManagement

Recurrent miscarriageRecurrent miscarriage

A workup for possible causes of recurrent pregnancy loss (RPL): anatomic, hormonal,genetic,and autoimmune factors (underlying maternal factors)

Incompetent cervix: cerclage designed to reinforce the cervix at the level of the internal os at the end of the first trimester, the suture is removed after 37 weeks’ gestation

Management

Septic miscarriageSeptic miscarriageManagement

Septic miscarriageSeptic miscarriage

Evacuation of the uterus within a few hours after antibiotics iv

High-dose, broad-spectrum coverage antibiotics, aggressive use before, during, and after removal of necrotic tissue by curettage

hysterectomy

Summary pointsSummary pointsSummary pointsSummary points

The most frequent etiology of miscarriage is a chromosomal abnormality of the conceptus and most of the abortions occur in the first-trimester.

The processes of the pathology decide the characteristics of the subgroups.

Ultrasound is helpful in diagnosis.

Problem-based learning (1)Problem-based learning (1)Problem-based learning (1)Problem-based learning (1)

A 22 year old women attends you with a 12 h history of vaginal bleeding accompanied by cramping lower abdominal pain. She has had 6 weeks amenorrhoea and tells you that she recently used a urinary pregnancy test from her local pharmacy; the test proved to be positive. She has had no previous pregnancies and was using no contraception.

Problem-based learning (2)Problem-based learning (2)Problem-based learning (2)Problem-based learning (2)

What is the differential diagnosis?

What features would you look for on examination?

What investigations, if any, are required?

Problem-based learning (3)Problem-based learning (3)Problem-based learning (3)Problem-based learning (3)

On examination you find no abnormality on abdominal palpation and in particular, no tenderness. On vaginal examination, however, you find blood clot in the vagina and products of conception are present in the cervix, which is dilated. What is the diagnosis and how would you manage the situation?

Figure them outFigure them outFigure them outFigure them out

May the miscarriage be converted in

inevitable miscarriage?

What is the common important procedure of the management in inevitable,

incomplete and missed miscarriage?

The End The End