1. AbortionAbortion
Dr. Fakher ShatnawiDr. Fakher Shatnawi
Al-Bashir HospitalAl-Bashir Hospital

2. Bleeding from the genital tract before viability due to:
-Abortion
-Ectopic pregnancy
-vesicular mole
-Local conditions (cervical erosion , polyps, ca……)
-Hartman bleeding : bleeding at the time of expected
menses before 12 weeks
( due to shedding of part of the decidua

3. Definition of abortion:
Spontaneous or artificial termination of pregnancy
before viability of the fetus.
Viability: reasonable chance of the fetus for extra
uterine survival
*Was before 28 weeks
*Now before 24 weeks
*In some countries before 22 weeks

4. Incidence of abortion:
Clinical (10-15%) 12%
Preclinical (25-30%)
The overall incidence of AB. Is 45%
Even more

5. * 75-80% of abortion occurs before 12 weeks gestation
* pts who have no live born and have hx of one abortion the
incidence of abortion in the next pregnancy is 20%
* Same pts but with hx of 2 abortions the incidence of
abortion in the next pregnancy is 35%
* Same pts with hx of 3 abortions the incidence increase to
45%

6. *Habitual abortion ( Recurrent ) : if 3 or more successive
spontaneous abortion
*Abortion:
Early abortions which occurs before 12 weeks
Late abortion which occur between 13-24 weeks gestation
…Most of early abortions are unembryonic
abortions
Blighted ovum
*Usually early abortions due to fetal causes but Late
abortions usually due to maternal causes

7. #Important points :
-abortions increase after the age of 30s
-abortioins increase more after the age of 35 years
This increase is about 9 times than pts aged between 20-29
years
-the risk of abortion increases with increased gravidity.
(parity)
-the risk of abortion increases with increasesd maternal and
paternal age (mostly the maternal one)

8. Ethiology of abortion:
1.Fetal couses (occur in early abortions)
--chr. abnormalities (50-60%)
The most common are *trisomies the commonest is trisomy
16(21,22)
This frequently seen in blighted ova
*triploidy : 69 chr. (15-20%) of chr.
abnormalities seen in abortions molar pregnancy
*monosomies : (45x)
1:15 of all monosomies will not abort TURNER SYNDROM
toxoplasmosies
lysteria monocytogenes
--infections : rubella
cytomegalovirus
herpes simplex
syphilis
infictions are not considered as frequent couses of recurrent
abortions , because they couse abortions only during there acute attacks

9. 2.Maternal causes:
Usually lead to abortion in late pregnancy (13-24) weeks
*local causes in the uterus
1.Uterine anomalies -spetate uterus
-bicornuate uterus
-hypoplastic uterus
-unicornuate uterus
the cause of abortion is:
--decreased uterine blood supply
--decreased uterine cavity
2.Uterine synechia (Asher man syndrome)
3.Submucous fibroids
decrease of blood supply
week decidualization
4.Cervical incompetence:
-congenital
-iatrogenic
*chronic maternal diseases:
(A).chr. Nephritis
(B). Renal failure
(C). Uncontrolled D.M.

10. *Endocrine causes:
1. Luteal phase defect…. (progesterone deficiency) due to week
corpus luteum
2. Hypothyroidism (increase prolactin hormone)
3. Immunological causes:
-Anticardiolipins Abds.
Antiphopholipids Abds.
-Lupus anticoagulant
These Abds. Lead to Thrombosis in placental vaseles with
prolonged PTT at the same time.
The antiphospholipd syndr. Leads to sever and early preclampsia
< 20 wks
If pregnancy continue I.U.G.R
*Other causes:
1.Acute fever ( by activation of P.G.)
2.Acute hydramnios ( occurs early before 24 wks. While chr. Hydramnios
occurs late > 24 wks. Gestation )
3.Direct trauma to the abdomen
4.Radiation
-ergots (Methergin , Syntometrine)
5.Drugs -Prostaglandins ( cytotec)
-Kenins

11. Types of Abortion:
-Threatened Ab.
-Missed Ab.
-Complete Ab.
-Incomplete Ab.
-Inevitable Ab.
-Septic Ab. May be with any type of
mentioned Abs.
Abortions
-Medical Ab.
-Criminal Ab.
septic Abs. mainly occurs with criminal one
**Threatened AB.
mild separation of the products of conception.
Symptoms :
-That of early pregnancy still present
-Mild-moderate vaginal bleeding
-Mild lower abdominal pain
#.vaginal ex.:
-uterine size coresponds with gestational age
-Cx. Is closed

12. #.Ultrasound alive fetus
#.Treatment:
-bed rest
-No sexual intercourse
-Sedation ( mental rest )
-Treat the cause ( progesterone if luteal phase
insufficiency …..etc).
**Missed AB.
The fetus is dead and retained in uterus.
#.symptoms :
-cessation of fetal movements if already present
(>18 wks)
-sometimes brownish vaginal discharge
#.Vaginal ex. :
-uterus is smaller than expected gestational age
-Cx. Is closed
…US: No F.H.B. could be seen
if pregnancy is >10 wks and if the fetal death is >4 wks we must RO
D.I.C. by doing the coagulation profile:
-PT , PTT
-S.Fibrinogen
-Plat.count
-D.dimer

13. If coagulation profile is normal , D&C is the treatment for missed
Ab. If gestation Age is less than 12 wks. (But) if gestational age is >
12 wks and bony elements are Present by ultrasound ex. ( of the
fetus ) , then medical evacuation of the uterus is The best treatment by
using :
-cytotec
tab.
-R.U.486
-P.G.
N.B: Hypofibrinogenemia occurs if the death of the fetus is > 4
wks. , due to release of Thromboplasin material from fetal tissue to
maternal ciculation
**Inevitable AB.:
marked separation of the products of conception
-Sever bleeding (with clots).
- -Sever lower abdominal pain
Ex.: the Cx is usually dilated. Pts may have signs of hypovolemic shock if
bleeding is sever.
after 12 wks. Gestation ruptured of membranes indicates inevitable

14. **Complete & incomplete Ab.:
**Complete Ab:
all products of conception are expelled from uterine
cavity
The bleeding and the pain are not present
( stopped)
The Cx is closed
ultrasound ex. Empty uterus
**Incomplete Ab.:
Parts of the products of conception are still inside the
uterus
pts still have vaginal bleeding
pts still have lower abdominal pain
Cx-opened
ultrasound : uterus bulky with products of
conception

15. **Septic AB.
infection superimposed on any type of mentioned Ab.
The causative organisms:
-streptococci β hemolytic (the commonest organism
isolated)
-Staphylococci
-clostridium Welchii
-other organism = gr.
+ve
-ve
The route of infection :
-exogenous
-endogenous
Septic Ab. Is mostly seen in criminal Abs.
…Symptomes and signs:
-That of abortion
-fever
-Lower Abd pain
-tachycardia
-lower Abdominal tenderness

16. **Treatment:
*-isolation of the pt.
*-exclude septic shock (hypothermia)
*-start Antibiotics as rules to cover both gr. +ve & gr.-ve and to
cover anaerobes as well as aerobes. ( Ampcillins + Gentamycins +
metronidazol)
until the results of the culture is ready.
If clostridium Welchii is isolated Give Anti-gas gangrene +
Penicilin (Ampicilin)
*-Evacuation of the uterus ( drainage) within 24 hrs after
antibiotics
if gestation <12 wks better by digital evacuation or suction
curettage, and if >12 wks gestation by prostaglandins.
Hysterectomy : is rarely needed if infection by clostridium
producing gangrene to the uterine tissue.

17. Cx - Incompletence:
1. Congenital type usually is associated with other
uterine anomalies
2.Iatrogenic type :
-after D&C
-cervical injury:
A. Conisation (cone biopsy) C.I.N.
B.After delivery (cervical tears)
C.Deep cautary ( incompetence or stenosis)
This type of Cx ( incompetent one) leads to Ab. In
the second trimestre (>12-24 wks)
usually it is painless Ab.(or little pain)
By ultrasound Funyl shape of the internal os

18. Diagnosis :
*-ultrasound (T.Y.V.U) (vaginal ultrasound)
*-Heigger test
*-History
Treatment:
*cervical circalage
-shrudkar stich
-Mc.Donalled stich
the stich is inserted > 12 wks but check fetal
viability before insertion the stich ( by ultrasound)

19. Recurrent Ab.:
If 3 or more succesive abortions
this usually increase the risk of ectopic pregnancy.
*Remember:
**give Anti-D if pts. Blood group is –ve ( her husbands group is +ve). After all types of
abortion.
**after cervical stich ( cervical incompetence) No need to give Anti-D if pts blood
group is -ve