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Spontaneous Abortion
etiology
fetus
environment mother
Etiology
1 Chromosomal abnormality
at least 10% of human conceptions are thought to
have chromosomal abnormalities. There are
number(abnormal karyotype: aneuploid, euploid)
and structure abnormal(rupture replacement),
other factors(drugs, infections) leading genetic
abnormal
Abortion in these circumstances is a beneficial
process and represents a form of natural selection.
6
2 Maternal factors
(1) Endocrine defects It is
probably related to failure of the
corpus luteum
(2) Multiple pregnancy
The larger the number of fetuses,
the greater the tendency to abortion.
This may be due to overdistension of
the uterus
7
(4) Infections
a Any severe pyrexial illness may cause
abortion.
b Specific infections such as syphilis,
brucellosis and listeriosis have been
suggested as causes of abortion.
Conclusive evidence on these subjects is
lacking.
12
(5) Poisons
A number of systemic poisons may cause
abortion, particularly cytotoxic drugs.
(6) Radiation
As with cytotoxic drugs, abortion following
radiotherapy is sometimes encountered
during treatment for cancer.
13
4 Environmental factors:
lead, arsenic, benzene
Pathology
hemorrhage
into the decidua basalis .
pathology
In cases of missed abortion, there may be
partial organization of the blood clot
surrounding the conceptus. This results in
the formation of a fleshy, nodular, dark red
mass called a carneous mole, or blood
mole.
18
clinical features
amenorrhea
vaginal bleeding
suprapubic pain
19
Pragnancy
go on
Threatened
abortion Incomplete
Inevitable abortion
abortion
Complete
abortion
Types
Threatened abortion : bleeding ; P45
with or without uterine contractions,
without dilatation of the cervix,
without expulsion of the products of conception.
Inevitable abortion : bleeding
with dilatation of the cervix
without expulsion of the products of conception.
with or without rupture of the membranes
Complete abortion : the expulsion of all of the products of conception
bleeding
with the cervix from dilatation to close
Incomplete abortion : the expulsion of some, but not all, of the products of
conception.
bleeding generally is persistent and is often severe.
Cramps are usually present.
Less than 10 weeks' duration:the fetus and placenta are usually passed together.
After 10 weeks, they may be passed separately with a portion of the products retained in
the uterine cavity.
Types
A complete history
A general physical examination
Laboratory findings
Ultrasonography
29
Threatened abortion
Symptoms:
1. Bleeding after amenorrhea
2. Usually no uterine contractions and no
pain or slight abdominal pain
Signs:
1. Cervix remains closed
2. Uterus is expected sizes for dates
30
Notices:
The key is the embryo is still alive
The criterion of pregnancy is going on or
not: ultrasonography, hCG, progesterone
The following condition prompts the
pregnancy prognosis is not well:
Lower hCG
Continue sonography, 7~10 days after
gestational sac appears, not seeing fetal heart
Progesterone level in blood <5ng/ml,
Treatment
31
Inevitable abortion
The progress of threatened abortion
It refers to the state in which
bleeding of intrauterine origin occurs
before the 20th completed week with
continuous and progressive dilatation
of the cervix, but without expulsion of
the products of conception.
33
Symptoms:
a Increased bleeding----clots often passed.
b Uterine contractions and severe
abdominal pain
c Vaginal discharge
Signs:
a On examination, cervix is found to be
dilating and products projecting.
b The size of uterus is the same as the
gestational days
34
Examination:
a. Negative pregnancy urine tests
b. Ultrasonography shows no evidence of fetal heart action
and perhaps no fetus at all----as in the blighted ovum
c. The level of hCG or progesterone is low
35
diagnosis
36
diagnosis
37
Treatment
a. Termination of the pregnancy--- D & C
Incomplete abortion
Incomplete
abortion is the
expulsion of some,
but not all, of the
products of
conception before
the 20th complete
week of gestation.
39
This is often the result of interference
Symptoms:
a Part of conceptus has been passed or
has been removed.
b Bleeding continues and may be severe.
c Vagina may be full of clot and patient
may become shocked(hypovolemia) before
adequate treatment is started.
d Relieving abdominal pain
f Infection may supervene.
Signs: 40
patulous cervix
often seeing tissues at the external os (picture)
the body of uterus is smaller than the days of
gestation
Treatment:
if diagnosis is made correctly ---- evacuate the uterus
promptly,oxytocin iv
blood transfusion if bleeding is brisk
antiseptic
intravenous injection
41
42
Complete abortion
Complete
abortion is the
expulsion of all of
the products of
conception before
the 20th complete
week of gestation
43
Characteristics:
a Whole conceptus is expelled.
b Slight bleeding and bleeding stops.
c Cessation of pain
d Closed of cervix, uterus contracts down to near
normal size.
e Negative pregnancy test
f Ultrasonic examination shows no
tissue in uterine cavity
44
Treatment
If the abortion is complete no
specific treatment is necessary
If the ultrasonic examination
shows an empty uterus, curettage
may be unnecessary.
45
Differential diagnosis
1.Various types of abortion
2. Early abortion must be different from
ectopic pregnancy, hydatidiform
mole, dysfunctional uterine bleeding
etc.
P48
Differentiation diagnosis 46
missed abortion
habitual abortion or recurrent
spontaneous abortion
septic abortion
48
missed abortion
Definition
49
amenorrhea
slight abdominal pain, companying or not
vaginal bleeding
Symptoms and signs of pregnancy----e.g.
breast enlargement/nauseated ---- will
regress.
Brown vaginal discharge may be present.
Signs:
closed cervix
the size of uterus is smaller than the
days of gestation
51
Diagnosis
Clinical features
signs
HCG
ultrasound
52
Treatments:
1. Determination of coagulation:
1) Routine Blood Test and
2) Blood fibrinogen, time of thrombinogen, 3P
test
2. Giving estrogen
3. <12 weeks: curettage (if adhesion is
tightly, giving multiple operation,
avoiding perforation )
>12 weeks: induced abortion
(oxytocin, prostaglandin )
54
Recurrent spontaneous
abortion
(Habitual abortion)
55
Definition
Recurrent abortion is defined as 3
consecutive spontaneous
pregnancy wastages before 20
weeks gestation with a fetus
weighing less than 500g.
56
Characters:
every time it appears in the same
gestational week
its clinical process is the same as
other abortion
57
Reasons:
Early abortion: genetic,endocrine factors
immunological defect etc.
Late abortion: cervical incompetence
malformation of uterus etc.
58
Incompetent cervix
59
septic abortion
63
Definition
Notice :
1. severe bleeding
2. slight bleeding
66
Thank You for your Interest
Vocabulary
67
Spontaneous abortion
Threatened abortion
Inevitable abortion
Incomplete abortion
Complete abortion
Missed abortion
Septic abortion
Habitual abortion (recurrent abortion)
Induced abortion
Early abortion
Late abortion
Ectopic pregnancy
Ectopic Pregnancy
Definition
A fertilized ovum implants in an area other
than the endometrial lining of the uterus .
2. Other ( < 5% )
Includes : cervical , ovarian , and abdominal ( most abdominal pregnancies are
secondary pregnancies, from tubal abortion or rupture and subsequent
implantation in the bowel, omentum, or mesente
Etiology
1. Tubal Factors
salpingitis ; and in most of these patients, the uninvolved tube is also abnormal.
2. Ovarian Factors
fertilization of an unextruded ovum, transmigration of the ovum into the contralateral
tube with subsequent delayed and faulty implantation, and postmidcycle ovulation and
fertilizatio
3. Other Factors
Intrauterine device ( IUD
Etiology
1. Tubal factores
(1) chronic salpingitis: the most common reason
Endosalpingitis ( : agglutination of the
gonorrhea
tubal
abortion
2.Tubal rupture.
Trophoblast erodes through the tube causing massive and
sometimes fatal haemorrhage.
Rupture may be intracapsular or extracapsular.
Isthmic: often occurs at 6-8 weeks gestation ampullary: at 8-
12 weeks
interstitial : at about 3~4 months ,rarely,very dangerous the
reasons are:
A. Misdiagnosis as uterine pregnancy before rupture
B. The result almost is rupture and severe hemorrhage
e.g.
Tubal rupture
A. Tenderness
over 80% Diffuse or localized abdominal tenderness
over 75% Adnexal and/or cervical motion tenderness
B. Adnexal Mass
30-50% A unilateral adnexal mass is palpated
C. Uterine Changes
The uterus may undergo typical changes of pregnancy, including softening and a slight
increase in size
Diagnostic aids
Gist of diagnosis: Taking history in detail,
combing symptoms, signs and pelvic
examination
1.Pregnancy tests
hCG is positive, it is the most sensitivity index
in diagnosis of pregnancy
Urinary pregnancy test: qualitative
Serum hCG: quantitative
notices:
urine tests are of doubtful value. a positive test
only confirms pregnancy and does not indicate
whether it is intrauterine or extrauterine.
Meanwhile, a negative test does not rule out an
ectopic gestation.
Consecutive testing hCG can be used as a
credibility index in differential diagnosis of
uterine pregnancy, uterine abortion, ectopic
pregnancy.
2.Sonography the very important methods
Characters:
1 enlarge of uterus, no sac in cavity
2 abnormal echo in one side of uterus,
if embryo sac or heart beat can be seen the
diagnosis is confirmed
3 there is no echo character around
uterus if abortion or rupture had happened. If
there is some fluid in the cul-de-sac, diagnosis can
be made.
(4) It needs some time to diagnosis early
pregnancy by sonography. 5~6 weeks
conception appears gestational sac.
What may appear on the sonogram as a
small sac or a collapsed sac may be a blood
clot or decidual cast.
It must combined with consecutive hCG
test.
(5) vaginal sonography had higher accuracy
3. Culdocentesis:
Culdocentesis is the transvaginal passage of a needle
(posterior to the cervix) into the cul-de-sac (pouch of
Douglas) for the purpose of determining whether
free blood is present in the abdomen.
simple, safe, practicality, useful in the diagnosis of
intraperitoneal bleeding
culdocentesis
Methods: Patient is in the dorsal lithotomy
position. A speculum is placed in the vagina and
the posterior lip of the cervix grasped with an
tenaculum. The vagina is cleansed. A needle is
attached to a 10 ml syringe, and with gentle
traction on the cervix, the needle is passed into
the cul-de-sac (pouch of Douglas), whence fluid
can be aspirated.
Aspirating dark red bloody and nonclotting fluid
means positive.
If hemorrhage in peritoneum is more than 50 ml,
the positive results may reach 95%.
Notices
1 negative results cant exclude ectopic
pregnancy: such as unruptured or before abortion
ectopic pregnancy, slight hemorrhage, adhesion of
peritoneum
2 positive results only show
hemoperitoneum, it needs to diagnosis the cause of
bleeding.
4.laparoscopy-Laparoscopy is the most
valuable of all the diagnostic aids.
It is increasingly being used in the diagnosis
of early and unruptured atypical ectopic
pregnancy.
Characters
(1) Swelling and indigo in oviduct
(2) superficial blood vessels is infuriate
(3) hemoperitoneum
(4) rupture of oviduct or hemorrhage in
fimbria
Contraindication:
Severe hemorrhage
Hypovolemic shock