Abortion (miscarriage) Dongzi Yang 杨冬梓 The Second Affiliated Hospital Sun Yat-Sen University

Definition The termination of pregnancy before the 28th week, when the fetus weight is less than 1000 grams. Early abortion: <12th week of pregnancy Late abortion: 12th-28th week of pregnancy Spontaneous abortion Artificial abortion

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

Etiology Extrinsic factors Chemical: mercury, lead, cadmium, smoking, Physical: video display terminals, radioactive materials, noise, hyperthermia

Etiology Maternal factors General diseases: infection, heart diseases, hypertension, anemia Reproductive organic diseases: congenital uterine malformation, pelvic tumor, cervical incompetence Endocrine disorders: LPD, hypothyroidism Injuries

Etiology Defects in the developing placenta Immunologic factors: paternal histo-compatibility antigen , maternal cellular immunity regular disorder, deficiency of maternal blocking antibody

Pathology The death of the embryo or rudimentary analog Hemorrhage into the decidua basalis Uterine contraction, dilation of the cervix Expulsion of the products conception

Pathology 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 of abortion Theatened miscarriage Inevitable miscarriage Incomplete miscarriage Complete miscarriage

The developing processes of the abortion Threatened miscarriage Normal pregnancy Inevitable miscarriage Complete miscarriage Incomplete miscarriage

Classifications and characteristics 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 Complete all ＋ － － － normal

Alternative classification Blighted ovum Missed miscarriage Live miscarriage

Classification of miscarriage Blighted ovum Normal pregnancy Missed miscarriage Threatened miscarriage Inevitable miscarriage Continuing pregnancy Incomplete miscarriage Complete miscarriage

Special subgroups: Missed 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 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 miscarriage Any type of spontaneous miscarriage is complicated by infection Endometritis, parametritis, peritonitis Fever, abdominal tenderness, uterine pain Septicemia, septic shock

Diagnosis History: amenorrhea, symptoms of pregnancy, vaginal bleeding…… Examination: general and pelvic Ultrasounograph Pregnancy test, ß-HCG Others:

Differential diagnosis Ectopic pregnancy Molar pregnancy Dysfunctional uterine bleeding (DUB) Pelvic infective diseases (PID) Acute appendicitis

Management 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 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 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 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 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) 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) What is the differential diagnosis? What features would you look for on examination? What investigations, if any, are required?

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 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