ABORTION

(Miscarriage)
Vaginal bleeding in early pregnancy
Dr. Esam Nureldin O. Elzain
Associate Prof. OBST.&GYN.
Faculty of Medicine.

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 Problem (Final Exam)
• Hind is P2+2 presented with a menorrhea for 4 months , mild abdominal pain
and minimal vaginal bleeding , which is dark brownish in colour . Her
pregnancy symptoms disappeared.
• On abdominal examination , the fundal level is just palpable above the
symphesis pubis . per vaginal examination (P.V) the cervix was closed.
• Mention 2 differential diagnosis?
•
• What is the most likely diagnosis?
•
• How are you going to confirm this diagnosis?
• What other necessary investigations you need. mention(4)?
•
• What is the treatment for this condition?
• Mention 2 possible complications of this condition?
•
• Mention 2 possible complications may arise from the treatment of this
condition?

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 Bleeding in Early Pregnancy

First trimester vaginal bleeding or spotting occurs in up to 25% of

pregnancies. It does not inevitably lead to miscarriage. In many
cases the pregnancy proceeds without further problems and
results in the birth of a normal baby.

However, vaginal bleeding at any stage of pregnancy is not

normal. Sometimes no obvious cause is found for first trimester
bleeding but it is important that the condition is assessed by a
doctor to rule out potentially serious problems such as an ectopic
pregnancy, impending miscarriage and cervical or placenta
problems.

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 Bleeding in early pregnancy may occur in the following
conditions:-

A- abortion (miscarriage)
B- ectopic pregnancy
C- local lesions :-
cervical erosion -polyps -carcinoma
D- Hydatidiform (vesicular) mole or
choriocarcinoma

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 Abortion:-

• Definition :
Termination of pregnancy before viability of the Foetus
ie.22 weeks, or the foetal weight less than 500g.

Miscarriage :
Expulsion of the conceptus before the end of the 22 (??).Week
of pregnancy . (before the fetus is viable)

-late abortion and early premature labour (Viability & modern pedia.
Medicine)

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 Miscarriage

• Frequency:- (incidence)

• Not exactly known due to:-

• In early pregnancy < 3/52 can pass without being noticed by the mother.
• Spontaneous abortions ranging between 10 – 15 % of all pregnancies.

• -Commonest time of occurrence is between 8 -13 / 52 .

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Pathological Anatomy & Mechanism :-

* up to 8 weeks

* from 8 to 12 weeks

* after 12 weeks

(Means of management differs according to

the gestational age.)
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 Pathological Anatomy & Mechanism :-

In the 1st. Trimester the attachment of the chorine to

the decidua is very weak .
• So that Strong uterine contractions might lead to separation .

• ( = Hemorrhage into the choriodecidual space  further

separation Death of the embryo )

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 Cont. Pathological Anatomy & Mechanism

• In most of the cases :-

the Decidua besalis remains & other expelled. in some cases the
Decidua capsularis thorn expelling the embryo .

- After the 12th . Week - placenta is already formed.

(So abortion resembles labor.)

Bleeding + painful contractions 

cx .dilatation +/ – rupture of membranous 
expulsion of fetus & placenta.

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Aetiology:
1-chromosomal abnormalities(70%).
2-blighted ovum.
3-maternal infections.
4-endocrine causes.
5-trauma.
6- some drugs.
7-maternal anoxia and malnutrition.
8-overdistension of the uterus.
9-immunological causes.
10-aging of the sperm or ovum.
11-utrine defects.
12-nervous ,psychological conditions.
13-idiopathic.

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 Aetiology:
Causes :-

1/ malformation of the zygote.

• mostly chromosomal abnormalities & it is mostly not recurrent.

2/immunological rejection of the fetus

3/general disease of the mother :-
malaria (fever) ,Brucellosis ,Toxoplasmosis

- late abortion / I . U . F . D
- D . M ( non controlled D.M )
- Renal failure ( I.U.F.D )
- Sever Malnutrition.

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 Cont.causes
4/ Uterine Abnormalities .
- Double biseptale uterus.  

- Fibroid (sub mucous) 

- R.V ut (incarcerated)

- Lacerations of the internal os  cervical incompetence.)

5/ Hormonal insufficiency :-
- Progesterone ( increased or decreased.) ??
- Thyroxin ( increased or decreased.)

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 Cont. causes

• 6/ Others :-

1- irradiation x-ray.

2- Drugs. - Prostaglandins.
- Ergot.
- Quinine.

3- Foreign body & Trauma.

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 clinical Types of Miscarriage:-

1/ Threatened. 2/ Inevitable.

3/ Complete. 4/ Incomplete.

5/ Septic. 6/ Missed.

7/ Recurrent.

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 1 - Threatened:-

Hemorrhage without CX. Dilatation + / – very little or No pain.

either single attack or repeated short episodes of bleeding

or – spotting of blood may occur.

-Red fresh blood followed after few days by old brown altered
blood May indicate Dead embryo = Missed abortion.

Heavy bleeding = Bad Prognosis

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 - Diag. (Threatened) :-

• Inspection = bleeding p/ vagina

• Gentle P.V = OS. Closed
• Speculum = local lesions + CX , OS.

• U/S :-
G. Sac = 8mm = 6/52
C.R.L 23mm = 8/52
+ve Heart beets. (sonic aid)

- Repeated Scanning reveals :- Continuous growth

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 Cont. threatened abortion

Laboratory :-

• Serial serum Progesterone level if decreasing = doubtful Survival.

• HCG (pregnancy test = P.T) :-

remains +ve for 2-3/52 after death of the embryo.

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 Treatment of Threatened abortion

(No specific ttt. )

1/ Complete Bed rest
till few days after stopping of bleeding.

2/ re-assurance & Sedation of the patient.

Regular u / s F. up to make sure Not Converted into inevitable or

other types of abortion.

3/ Some use to give progesterone

(if serum level proved to be low.)

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 2 - inevitable abortion:- (irreversible)

More Bleeding + regular (rhythmical) uterine

contractions (Pain)  CX. Dilatation Prognosis:-

always bad  expelling of the contents

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 (Cont. inevitable) Management:-

• History:- pain +bleeding

• inspection :- v. bleeding
• P.V :-
CX.OS. Opened +or- protruding product through the CX. Canal .
• Drugs:-
analgesics (pain killers)

• If bleeding is excessive incomplete abortion  suction curette.

• Give Anti–D 100 micro from I.M if –ve. Rh (or not known)

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 3 - Complete abortion :-
All the products of conception been expelled out of the uterine cavity
spontaneously & completely

• No More Pain

• Less or No More Bleeding

• Uterus firmly contracted & os closed.

• Inspection of the products = complete.

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 4 - Incomplete abortion
• Only part of the products been expelled & other remains inside the
uterus
• Bleeding continue amount depends on the gestational age.
(the more the gestational age the more the bleeding is)
• Uterus still bulky & cervical os open.

• Management :-
1- correct shock if any.
2- Surgical evacuation under anesthesia.
3- +/- prophylactic antibiotics.

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 5 - Septic abortion
• Infection following any spontaneous abortion but More common after illegal
induced (criminal) abortion
• Remaining products (bl_clolt or necrotic debris)= good culture medium for
bacteria spread of infection pelvic peritonitis +cellulites salpingitis septicemia.

- Clinical picture:- 1- Fever. 2- raised pulse rate 3- abd. Pain.

- Complications:- blockage of the fallopian tubes  infertility.

- Commonest organisms involve:-

(1)Staphlococcus aureis (2)coliform bacteria
(3)Bacterioids organisms. (4)clostridium wellchi
(5)Gr.-ve organisms  endotoxic shock .

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 Cont. Septic
abortion
Treatment

(1) hospitalization & isolation (sepsis) ttt- of shock and D.I.C if

any.

(2) H.V.S for direct microscopy + c&s

(3)start.Br.spectrum antibiotic e.g.: ampcillin +flagyl for anaerobes.

•If low Hb% = correct anemia

•If G.age <10/52 = suction curettage.

•If >14/52 = induction ( prostaglandin, oxytocin)

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 6 - missed abortion (miscarriage)

Death of the embryo & retained products of conception inside the

uterus.
Hage. into the choriodecidual space long period  (carneous mole)

Clinical picture:-
• Mild symptoms resemble those of threatened abortion followed by
disappearance of symptoms & signs of pregnancy.

• Uterine size: remains stationery or decreased.

• Cx-os: tightly closed.

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 Cont. missed abortion (miscarriage)

• HCG (P.T) :- remains +ve for weeks ( chorionic villi )

• U/S :-
- No F.H. action – ( heart champers filled with gases)
- Repeated u/s : no progressive growth.
- Overlapped bones skull (Spaulding sign)
- Fate:-
usually expelled spontaneously-but-surgical interference +may be needed.
- Complications:-
sepsis  Hypofibrinogenaemia (D.I.C)
-Treatment :
- Spontaneous expulsion usually occurs within few days, if not then:
- Emptying the uterus either by (1) induction. (Prostaglandins & i.v syntocinon.)
or (2) surgical evacuation.
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 7 - Recurrent Miscarriage 1

Three or more repeated consecutive

spontaneous (painless) Miscarriages.
Aetiology:-
1-chromosomal 2- uterine abnormality

3-infection 4-hormonal (↓↓ progesterone)

5- immunological 6- miscellaneous (CX. Incompetence)

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 Aetiology of Habitual Abortion

Immunological:
1.Parental compatibility: excessive homozygosity
for human leucocytic antigen (HLA) between the
husband and wife. The close antigenic similarity
prevents the woman from secreting blocking
antibodies which coat the trophoblastic villi
preventing rejection of the conceptus.
2.Antiphospholipid syndrome: the presence of
lupus anticoagulants and cardiolipin antibodies.
These immunoglobulins lead to placental
thrombosis and fetal loss.
3.Rh-incompatibility: sensitized RH-ve mother
pregnant in an RH +ve fetus.
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 Cont. Recurrent Miscarriage 2

Diagnosis:
A . History
B. General examination and local examination
C. Special investigation

surgical treatment
*cervical cerclage:
*abdominal cerclage:
*metroplasty
*asherman syndrome
*myomectomy

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 Cont. Recurrent Miscarriage 3

a) early repeated Miscarriage

.If↓↓↓ progesterone: give I.M.i of hydroxy
pregesterone hexanoate (primolet –depot-250mg twice weekly) .or
(H.C.G 10,000 i.v or I.M.i twice weekly) to support the
corpus luteum

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 Cont. Recurrent Miscarriage 4

b) Mid-trimester: (cervical incompetence)

after 16/52 cx.int.os.
+resulting from previous surgical obstetric trauma:
. injudicious surgical dilatation , cone biopsy ,cx-amputation.

• None pregnant :- int.os dilated to heger 1.

• Pregnant:- bulging membranes.
- surgical treatment
*cervical cerculage.
*abdominal cerclage.
*metroplasty.
- Purse-string suture (non absorbable suturing material )
before the 16/52 – shirodkhar operation
- MacDonald's operation

Removed before term

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 Other causes of early pregnancy v. Bleeding
(Differential diagnosis)
1- Ectopic pregnancy.

2- V. mole & choriocarcinoma.

3- Cervical lesions :-

(1) Cervical erosion

(2) Cervical adenomatous Polyp
(3) Cervical Carcinoma

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 threatened miscarriage (QUIZ)
in threatened miscarriage:
a) the uterus size is typically less than
expected for the period of gestation.
b)progesterone therapy is useful.
c)cervical os is closed. *
d)vaginal bleeding is present in only few
cases.
e)bed rest may prevent miscarriage.
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 threatened abortion
• threatened abortion is characterized
by :
• pain may be absent
• vaginal bleeding is present in most
cases
• ends as an incomplete abortion
• Cervical os is opened.
• Admission to hospital is mandatory.
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 missed abortion
• 9) Regarding missed abortion , the following
is excluded:
• a) ultrasound help in diagnosis
• b) there is increased risk of coagulopathy
• c) may develop septic abortion
• d) present with slight bright red vaginal
discharge
• e) milk secretion may start from the breast

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 inevitable abortion
• 10) In inevitable abortion of 10 weeks
pregnancy, the following are true except
• a) bleeding is heavy
• b) Colicky abdominal pain
• c) Internal os is closed
• d) Shock may be present
• e) Termination of pregnancy is recommended

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• 13) the most common cause of mid-
trimesteric abortion is
• a) uterine fibroids
• b) rhesus incompatibility
• c) cervical incompetence
• d) congenital anomalies
• e) syphylis

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 Cervical Incompetence.
•     Cervical Incompetence.
• a.occurs in 5% of women who have had suction
termination in the first trimester 
• b.usually manifests itself in late miscarriage 
• c.is treated with 2nd. trimester cervical cerclage 
• d.is usually treated with a Shirodkar suture 
• e.usually causes ante-partum
haemorrhage f.may present with premature
rupture of membranes

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 cervical incompetence
• 27)Regarding cervical incompetence :
a. It causes a high
proportion of all pre-term delivery
b. It is characteristically associated with pain
c. It should not be considered if pre-term
delivery is preceded by spontaneous rupture
of the membranes
d. Treatment is by cervical cerclage *
e. Cervical sutures should
be removed at 32 weeks to prevent cervical
trauma from pre-term labour .

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 cervical incompetence?

• 46)Which one of the following methods

is the primary management for cervical
incompetence?
• Progestational agents
• Bed rest
• Tocolytic agents
• Cervical cerclage *
• Myomectomy
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 Problem (Final Exam)
• Hind is P2+2 presented with a menorrhea for 4 months , mild abdominal pain
and minimal vaginal bleeding , which is dark brownish in colour . Her
pregnancy symptoms disappeared.
• On abdominal examination , the fundal level is just palpable above the
symphesis pubis . per vaginal examination (P.V) the cervix was closed.
• Mention 2 differential diagnosis?
•
• What is the most likely diagnosis?
•
• How are you going to confirm this diagnosis?
• What other necessary investigations you need. mention(4)?
•
• What is the treatment for this condition?
• Mention 2 possible complications of this condition?
•
• Mention 2 possible complications may arise from the treatment of this
condition?

46