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

2. 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

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

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

6. 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

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

9. 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

10. 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

11. Clinical subgroups of abortion
Theatened miscarriage
Inevitable miscarriage
Incomplete miscarriage
Complete miscarriage

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

13. 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

14. Alternative classification
Blighted ovum
Missed miscarriage
Live miscarriage

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

16. 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

17. 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

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

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

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

21. 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.

22. 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

23. 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

24. 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

25. 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.

26. 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.

27. Problem-based learning (2)
What is the differential diagnosis?
What features would you look for on examination?
What investigations, if any, are required?

28. 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?

29. 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?

30. The End