Mujib Ur RahmanMujib Ur Rahman

Termination of pregnancy, either

spontaneously or intentionally

prior to 20 weeks’ gestation or less than 500-g birth weight

The early abortion: occurs before 12w The late abortion: occurs after 12w

Abortion occurring without medical or mechanical means to empty the uterus is referred to as spontaneous

Another widely used term is miscarriage

>80 percent occur in the first 12 weeks AOG

At least half result from chromosomal anomalies

After the first trimester, both the abortion rate & the incidence of chromosomal anomalies decrease

Etiology

The risk of spontaneous abortion increases with

parity as well as with maternal and paternal age

The frequency of abortion increases from 12 percent in women younger than 20 years to 26 percent in those older than 40 years

If a woman conceives within 3 months following a term birth

→ incidence of abortion ↑

Hemorrhage into the decidua basinalis, followed by

necrosis of tissues adjacent to the bleeding If early, the ovum detaches, stimulating uterine

contractions that result in its ovulation Gestational sac is opened , fluid surrounding a small

macerated fetus or alternatively no fetus is visible → blighted ovum

Spontaneous abortion Pathology

In later abortion, the retained fetus may undergo

maceration The skull bones collapse, the abdomen distends with

blood-

stained fluid, and the internal organs degenerate The skin softens and peels off in utero or at the

slightest tough

When amnionic fluid is absorbed, the fetus may

become compressed and desiccated → fetal compressus

The fetus become so dry and compressed that it resembles parchment - a fetus papyraceous

Abnormal zygotic development

Early spontaneous abortion commonly display a developmental abnormality of the zygote, embryo, early fetus, or placenta

Spontaneous abortion –factors Fetal factors

Aneuploid abortion - Autosomal trisomy The most frequently identified chromosomal anomaly

associated with first-trimester abortionsAutosomes 13, 16, 18, 21, and 22 – most common

Spontaneous abortion - Fetal factors

Monosomy X

The second frequent chromosomal abnormality Usually results in abortion

Triploidy

Associated with hydropic placental (molar) degeneration

Incomplete (partial) hydatidiform moles may contain triploidy or trisomy for only chromosome 16

Spontaneous abortion - Fetal factors

Infections

Uncommon causes of abortion in human

Listeria monocytogenes Clamydia trachomatis Mycoplasma hominis Ureaplasma urealyticum Toxoplasma gondii

Spontaneous abortion – Maternal factors

Chronic debilitating diseases Celiac sprue

Spontaneous abortion – Maternal factors

Endocrine abnormalities

Hypothyroidism

Diabetes mellitus

Progesterone deficiency

Spontaneous abortion – Maternal factors

Drug use and environmental factor

Tobacco ↑ Risk for euploid abortion More than 14 cigarettes a day → the risk twofold

greater ↑AlcoholCaffeine

Immunological factors – alloimmune factors

Allogeneity Human fetus is allogenic transplant tolerated by mother

Spontaneous abortion – Maternal factors

Uterine defects – acquired uterine defects

Uterine leiomyoma : Uterine synechiae (Asherman syndrome)

Incompetent cervix Painless dilatation of cervix in the 2nd or early in the

3rd trimester → prolapse & ballooning of membranes into vagina → rupture of membrane & expulsion of immature fetus

Spontaneous abortion – Maternal factors

Little is known in the genesis of spontaneous

abortion

Chromosomal translocations in sperm can lead to abortion

Spontaneous abortion – Paternal factors

(1) Threatened abortion (2)Inevitable abortion (3)Incomplete abortion (4)complete abortion (5)Missed abortion (6)Habitual abortion (7)Septic abortion(infect abortion)

Clinical classification /differential's

  Threatened Inevitable Imcomplete Complete

History        

Bleeding Slight Middle→ severa Slight→ severa Slight→ no

Abdominal pain No/slight Aggravate Decrese No

Tissues are expelled No No Yes(partial) Complete

Gynecologic examination

       

Cervical os Close Open Open/tissue blochk Close

Uterine size Consistent with =/slight small <  =/slight larger

Pregnancy test + +/- +/- +/-

Treatment principle Protect fetus Curettage Curettage no

INDUCED ABORTION

The medical or surgical termination of pregnancy

before the time of fetal viability

Therapeutic abortion

Termination of pregnancy before of fetal viability for the purpose

of saving the life of the mother

Induced abortion

Elective (voluntary) abortion

Interruption of pregnancy before viability at the request of the women, but not for reasons of impaired maternal health or

fetal disease

Induced abortion

Septic abortion manifested by fever, malodorous vaginal discharge,

pelvic and abdominal pain, and cervical motion tenderness.

Most often associated with criminal abortion Metritis is usual outcome, but parametritis, peritonitis,

endocarditis, and septicemia may all occur

Consequences of elective abortion

Dilatation and curettage

Performed first by dilating the cervix & evacuating the product of conception Mechanically scraping out of the contents (sharp curettage) Vacuum aspiration (suction curettage) Both

Before 14 weeks, D&C or vacuum aspiration should be performed

After 16 weeks, dilatation & evacuation (D&E) is performed Wide cervical dilatation Mechanical destruction & evacuation of fetal parts

Surgical techniques for abortion

Ovulation may resume as early 2 weeks after an

abortion

Therefore, if pregnancy is to be prevented, effective contraception should be initiated soon

after abortion

Resumption of ovulation after abortion