Miscarriage or abortion
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An abortion is the expulsion of the products of
conception before the 24th week of pregnancy.
The word abortion is often considered by women
to be a procured termination of pregnancy, legal or
criminal. Hence, the softer term miscarriage is better
used for the spontaneous event. A simple classification
is helpful in understanding the various
terms used (Fig. 8.1).
Causes of spontaneous miscarriage
These are maternal, fetal and possibly paternal or
genetic.
Maternal causes
General
• Age.
• Obesity.
• Acute febrile illness.
• Septicaemia with infection of the fetus.
• Severe hypertension or renal disease.
• Diabetes.
• Hypothyroidism.
• Trauma.
• A surgical operation.
• Emotional shock, perhaps more in folklore than
actuality.
Drugs like ergot, quinine and lead may be taken
to induce abortion. They are not very effective and
the risk of poisoning is great.
Local
• Uterine fibroids.
• Congenital uterine malformations.
• Incompetence of the internal os:
• congenital;
• acquired after difficult dilatation of the
cervix.
• Hormone deficiency:
• progesterone—the corpus luteum usually produces
progesterone which helps embedding of
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... method of man-made abortions. VII. First of all, how many ... accomplished VI. What is abortion A. Abortion is the termination of a pregnancy B. That includes natural abortion miscarriage C. The numerous ... percent tragically ended in a miscarriage c. And sadly enough, forty-seven percent ended in abortions IX. (Graph 3) The United ...
the embryo;
• systemic lupus erythematosus;
• anti-phospholipid syndrome.
Fetal causes
• Genetic abnormalities.
• Congenital malformations.
• Faulty implantation.
Congenital and genetic malformations
Examination of the chromosomes in material from
spontaneous abortion shows gross abnormalities
in over half—often the embryo has failed to develop
or has been absorbed. In these cases, miscarriage
usually takes place at about eight weeks. Ultrasound
shows that the amniotic sac contains no
95
Chapter 8
Bleeding in pregnancy
Chapter 8 Bleeding in pregnancy
96
embryo. In other cases, gross malformation of the
fetus is shown.
Faulty implantation
The embryo may become implanted in an unfavourable
site in the uterus, for example in the
isthmus, cervical canal or in the uterine cornu.
Most of these cases end in spontaneous miscarriage;
rarely the pregnancy continues.
Incidence of spontaneous miscarriage
The frequency depends on the definition:
• in clinically diagnosed pregnancies 15–20% will
miscarry in early pregnancy;
• non-development of the blastocyst within 14
days occurs in up to 50% of conceptions.
Clinical features and management of
spontaneous miscarriage
Threatened miscarriage
Symptoms
• Scanty uterine bleeding preceded by symptoms
of pregnancy.
• Pain is usually absent; there may be backache or
slight uterine contractions.
Examination
• The breasts may be active.
• The uterus is enlarged corresponding with dates
of amenorrhoea.
• The cervix is closed.
• There is no pelvic tenderness.
Differential diagnosis
• Delayed miscarriage when the uterus is smaller
than expected. Check with ultrasound.
• Ectopic pregnancy when pain generally precedes
bleeding.
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• Dysfunctional uterine bleeding—where no signs
of pregnancy.
Ultrasound can show a sac (five weeks), an embryo
and the fetal heart beat (six weeks).
Human
chorionic gonadotrophin (hCG) can be measured
in blood or urine.
Treatment
Treatment is usually rest until fresh bleeding has
ceased.
After bleeding has ceased, the woman should
avoid exertion and intercourse till after the 12th
week of pregnancy. Progesterone therapy is ineffective,
but still used.
Inevitable miscarriage
Symptoms
Bleeding and pain are characteristic, bleeding is
heavier than in threatened miscarriage. There may
be crampy, low abdominal pains and an escape of
amniotic fluid.
Examination
• Uterus enlarged.
• The internal os of the cervix is dilated. Prod-
Threatened
Delayed Complete Incomplete Septic
Inevitable
Spontaneous Induced
Miscarriage Abortion
Recurrent Illegal Legal
Therapeutic
Figure 8.1 A simple classification of
the terms used.
Bleeding in pregnancy Chapter 8
97
ucts of conception may be felt in the cervical
canal. Once this has occurred, miscarriage is
inevitable.
Treatment
Before 12 weeks’ gestation, evacuate the uterus
under general anaesthesia in an operating
theatre.
After 12 weeks, allow miscarriage to take place
spontaneously, but be prepared to evacuate the
uterus if it is incomplete. If bleeding is severe,
Syntometrine should be given, 5 units/0.5mg
intramuscularly.
Incomplete miscarriage
An incomplete miscarriage occurs when some
of the products of conception are retained in
the uterus. These are usually parts of the
placenta or chorionic tissue attached to the uterine
wall.
Symptoms
• Continued bleeding after a period of
amenorrhoea.
Differential diagnosis
• Threatened miscarriage.
• Ectopic pregnancy.
• Dysfunctional uterine bleeding.
Ultrasound may help to clarify the diagnosis.
Treatment
• Conservative management.
• Evacuation of the uterus in the operating
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theatre.
Complete miscarriage
If all the products of conception have been passed
and the uterus is empty, the miscarriage is complete.
There is little bleeding, the uterus is small
with the cervix closed or merely patulous in a multiparous
woman.
No treatment is required provided the differential
diagnosis of ectopic pregnancy has been excluded
(see p. 100).
Delayed or missed miscarriage
The embryo dies in early development and is
retained there and/or the sac continues to develop.
The early embryo is commonly reabsorbed leaving
an empty sac—a blighted ovum (a term with
unpleasant connotations for the parents and is
best avoided when talking to the patient and her
partner).
Symptoms
• At first those of pregnancy, but these disappear.
• The breasts become soft.
• Dark brown vaginal discharge.
The cervix is closed and the uterus smaller than
would be expected; hCG levels drop in 7–10 days.
Differential diagnosis
• Tubal mole.
• An incomplete miscarriage.
• A complete miscarriage.
Ultrasound will confirm the diagnosis.
Treatment
• Surgical evacuation. This should be offered if an
embryo with an equivalent size of >8 weeks is
present.
• Medical treatment. Evacuation of the uterus can
be successful in 50% of cases by giving vaginal or
oral prostaglandins every three hours until miscarriage
takes place.
• Expectant management. This is usually safe and
effective if the sac is empty or the embryo is
