Complete abortion

When the products of conception are expelled completely with masse, it is called abortion.

Clinical features -
- Subsidence of abdominal pain.
- Vaginal bleeding becomes trace or absent.
- Cervical os (opening) is closed.

Management -
a) The effect of blood loss should be assessed and treated. If there is double about complete expulsion of the products, uterine curettage should be done.
b) Transvaginal sonography is useful to prevent unnecessary surgical procedure.

Inevitable abortion

It is the clinical type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible.

Clinical features -
- Increased vaginal bleeding.
- Pain in the lower abdomen.
- Internal examination reveals dilated internal opening of cervix.

Management -

General measures :-
- Excessive bleeding should be controlled by administering methergin 0.2 mg.
- The shock is corrected by I.V. fluid therapy and blood transfusion.

Active management :-
1. Before 12 weeks - Dilation and evacuation followed by curettage of the uterine cavity by blunt curette under general anaesthesia. Alternatively, suction evacuation followed by curettage is done.

2. After 12 weeks - The uterine contraction is acceleration by oxytocin drip. If bleeding is profuse with the cervix closed evacuation of the uterus may have to be done by abdominal hysterotomy.

What is threatened abortion

It is a clinically entity where the process of abortion has started but has not progressed to
a state from which recovery is impossible.

Clinical features -
1. Bleeding :- The bleeding is usually slight and bright red in colour.
2. Pain :- Pain appears usually following haemorrhage.

Investigation - 
Ultrasonography is helpful in observation of fetal status.

Treatment - 
Rest :- 
The patient should be in bed for few days until bleeding stops.

Drugs :- 
Sedation and relief of pain may be ensured by phenobarbitone 30 mg or diazepam 5 mg
tablet twice daily.

General measures :- 
- The patient is advised to preserve the vulval pads and anything expelled out per vaginum,
  foor inspection.
- To report if bleeding or pain.
- Routine note of pulse, temperature and vaginal bleeding.

Advice on discharge -

• The patient should limit her activities for at least two weeks.
• Avoid heavy work.
• Coitus is contraindicated during this period.

Types of abortion

Abortion is the expulsion or extraction from its mother of an embryo weighting 500 gm or less when it is not capable of independent survival. It is mainly divided into two types -
1. Spontaneous abortion
2. Induced abortion

Spontaneous abortion - It is divided in following types:

• Threatened abortion
• Inevitable abortion
• Complete abortion 
• Incomplete abortion 
• Missed abortion
• Septic abortion

Induced abortion - It has two types:

• Legal abortion - Medical termination of pregancy (MTP)
• Illegal (criminal) abortion

Factors responsible for abortion

1. Endocrine and metabolic factors -
Luteal phage defect (LPD) results in early miscarriage as implantation and plancental are not supported adequately. Deficient progesterone secretion from corpus luteum or poor endometrial response to progesterone is the cause. Diabetes mellitus when poorly controlled, causes increased miscarriage.

2. Anatomical abnormalities - 
These are related mostly to the second trimester abortions.
- Cervical incompetance.

- Congenital malformation of the uterus is cause of fetal loss.

- Reduced intrauterine volume.

- Increased uterine irritability and contraction.

- Intrauterine adhesions interfere with implantation, placental and fetal growth.

3. Infections -

Infections are accepted causes of late as well as early abortions. Infections could be :

i) Viral :- Rubella, HIV.

ii) Parasitic :- Toxoplasma, malaria.

iii) Bacterial :- Chlamydia, brucella.

4. Immunological disorders

5. Environmental factors

6. Genetic factors

7. Others -

- Maternal medical illness.

- Cyanotic heart disease (CHD).

- Blood group incompatibility.

- Premature rupture of membranes.

- Inherited thrombophilia.

Immunological disorders are responsible for abortion

Both autoimmune and alloimmune factors can cause miscarriage.

• Autoimmune disease :- It can cause miscarriage usually in the second trimester. These patient form antibodies against their own tissue and the placenta. These antibodies ultimately cause rejection of early pregnancy. placental thrombosis, infarction and fetal hypoxia is the ultimate pathology of cause abortion.

• Alloimmune disease :- Paternal antigens which are foreign to the mother invoke a protective blocking antibody response. These blocking antibodies prevent maternal immune cells from recognising the fetus as a foreign entity. Therefore, the fetal allograft containing foreign paternal antigens are not rejected by the mother. Paternal human leukocyte antigen (HLA) sharing with the mother lead to diminished fetal-maternal immunologic interaction and ultimately fetal rejection (abortion).

How environmental factor is responsible for abortion

Smoking -
Cigarette smoking increases the risk due to formation of carboxy haemoglobin and decreased oxygen transfer to the fetus. Alcohol consumption should be avoided or minimized during pregnancy.

X-Irradiation and antineoplastic drugs are known to abortion. X-ray exposure is a risk of abortion,
so it is avoided or minimized in the pregnancy period.

Contraceptive agents -
IUD (Intrauterine device) increases the risk whereas oral pill do not.

Drugs, chemicals and noxious agents -
Anaesthetic gases, arsenic, lead, formaldehyde increases the risk.

Miscellaneous - 
Exposure to electro-megnetic radiation from video display terminals does not increase the risk. Woman can safely use hair dyes, watch television and fly in airlines during pregnancy.