Defined as proliferation and degeneration of the chorion

A benign neoplasm of the chorionThe embryo fails to develop in most

casesOccurs in 1 of 2000 pregnanciesMore often in low socioeconomic

groups with low protein dietsMore often is the younger or older

mother

Uterus expands faster and reaches landmarks earlier

More morning sicknessEarlier signs of PIHVaginal bleeding in the 4th

monthDischarge with grape-like

vesicles

A d & c is done to evacuate the mole

Follow-up care is very importantTends to be carcinogenic—

choriocarcinomaRecommend no future

pregnancies for at least a yearEvaluate HCG levels closelyChest x-rays at interverals

Cervix dilates prematurely, painlessly, when the fetus is of sufficient weight to put pressure on the cervix.

Signs/symptoms: mucousy, pink discharge ROM Onset of contractions Birth of the fetus

Treatment/Care --Incompetent Cervix

Cervical circlage done between 4-6 months

Earliest time maybe 14 weeksSuccess rate as good as 80 %Must be removed prior to the onset

of labor

Loss of a pregnancy during the first 20 weeks of pregnancy, at a time that the fetus cannot survive.

Such a loss may be involuntary (a "spontaneous" abortion), or it may be voluntary ("induced" or "elective" abortion).

Miscarriage is the term used for spontaneous abortion, an unexpected 1st trimester pregnancy loss.

These include: 1.Threatened 2.Inevitable 3.Incomplete 4.Complete 5.Septic

Such losses are common, occurring in about one out of every 6 pregnancies.

These losses are unpredictable and unpreventable.

About 2/3 are caused by chromosome abnormalities.

About 30% are caused by placental malformations and are similarly not treatable.

The remaining miscarriages are caused by miscellaneous factors but are not usually associated with:

Minor trauma Intercourse Medication Too much activity

Following a miscarriage, the chance of having another miscarriage with the next pregnancy is about 1 in 6.

Habitual abortion, recurrent miscarriage or recurrent pregnancy loss (RPL) is the occurrence of three or more pregnancies that end in miscarriage of the fetus, usually before 20 weeks of gestation.

RPL affects about 0.34% of women who conceive.

Anatomical conditions:1. Uterine conditions2. Cervical conditions Chromosomal disorders Endocrine disorders Immune factors Lifestyle factors Infection

Spontaneous abortion (also known as miscarriage) is the expulsion of an embryo or fetus due to accidental trauma or natural causes before approximately the 22nd week of gestation; the definition by gestational age varies by country.[

Most miscarriages are due to incorrect replication of chromosomes; they can also be caused by environmental factors

A pregnancy can be intentionally aborted in many ways. The manner selected depends chiefly upon the gestational age of the embryo or fetus, which increases in size as the pregnancy progresses.

Specific procedures may also be selected due to legality, regional availability, and doctor-patient preference. Reasons for procuring induced abortions are typically characterized as either therapeutic or elective.

Therapeutic abortion when it is performed to:1. save the life of the pregnant woman2. preserve the woman's physical or mental health3. terminate pregnancy that would result in a child

born with a congenital disorder that would be fatal or associated with significant morbidity or selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy.

An elective abortion:When it is performed at the request of

the woman "for reasons other than maternal health or fetal disease.

A threatened abortion means the woman has experienced symptoms of bleeding or cramping.

At least one-third of all pregnant women will experience these symptoms.

Half will abort spontaneously. The other half , bleeding and crampingwill

disappear and the remainder of the pregnancy will be normal.

These women who go on to deliver their babies at full term can be reassured that the bleeding in the first trimester will have no effect on the baby and that you expect a full-term, normal, healthy baby.

1.  History Mild vaginal bleeding. No abdominal pain or

mild abdominal pain 2. Examination Good general

condition. The cervix is closed

The uterus is usually the correct size for date

3. U/S which is essential for the diagnosis Showed the presence of fetal heart activity

1. Reassurance If fetal heart activity is present, > 90% of cases will be progressed satisfactorily

2. Advice: Decrease physical activity (bed rest is of no therapeutic value) avoid intercourse

3. Hormones i.e. Progesterone & hCG Which are used in the first trimester to support pregnancy, (but they are of no proven value)

4. Anti- D: An adequate dose of anti-D should be given to all Rh –ve,non-immunised patients, whose husbands are Rh +ve

5. ANC as high risk patients Because those patients are liable to late pregnancy complications such as APH and preterm labour .

A condition in which:Vaginal bleeding has been profuse The cervix has become dilatedAbortion will invetably occur.

1. History Heavy vaginal bleeding. with no passage of products

conception (inevitable) with the passage of products of

conception (incomplete abortion)Severe lower abdominal pain which

follows the bleeding

2. Examinations Poor general condition. The cervix is dilating and products of

conception may be passing trough the os

The uterus may be the correct size for date (inevitable abortion) or small for date (incomplete abortion)

3. U/S Fetal heart activity may or may not present in inevitable abortion or retained products of conception ( RPOC ) in incomplete abortion

1. CBC , blood grouping , XM 2 units of blood

2. Resuscitation large IV line, fluids & blood transfusion

3. Oxytoxic drugs Ergometrine 0.5 mg IM + Oxytocin infusion (20-40 units in 500 cc saline)

4. Evacuation & curettage. 5. Post-abortion management.

1. History Heavy vaginal bleeding which has

been stopped. lower abdominal pain which follows the

bleeding which has been stopped.2. Examination

The cervix is closed 3. U/S

showed empty uterine cavity or PROP

1. - Evacuation & curettage in the presence of RPOC.

2. Post-abortion management.

Retention of products for several weeks

No increase in fundal heightAbsence of FHTRegressions of signs of pregnancyLoss of wight

1. Most of missed abortions are diagnosed accidentally during routine U/S in early pregnancy .

In some cases there may be a history of : Episodes of mild vaginal bleeding Regression of early symptoms of pregnancy . Stop of fetal movements after 20 weeks

gestation.

2. Examination The uterus may be small for date

3. U/S (which is essential for diagnosis ) diagnosed if two ultrasound ( T/V or T/A) at least 7days apart showed an embryo of > 7 weeks gestation ( CRL > 6mm in diameter and gestational sac > 20 mm in diameter ) with no evidence of heart activity .

1. CBC , blood grouping 2. Platelets count, to exclude the

risk of DICNB : DIC does not occur before 5

weeks of missed abortion or IUFD and if occurred will be of mild grade

3.Options of treatment Conservative treatment: if left alone spontaneous

expulsion will occur Surgical evacuation of the uterus; by D & C:

Indicated in 1st trimester missed abortion Medical termination of pregnancy: by Misoprostol (PGE1) Cytotec: Indicated in 1st & 2nd trimesters missed

abortions. Cytotec vaginal ( is the best) or oral tab. 200 μg, 2 tab/ 3 hrs/

up to 5 doses daily, which can be repeated next day if there is no response in the first day

Subsequent surgical evacuation is needed in cases of RPOC The main side effects of cytotec are nausea, vomiting and

fever. 

4.Post-abortion management.

It is due to an early death and resorption of the embryo with the persistence of the placental tissue

It is diagnosed if two ultrasound ( T/V or T/A) at least 7 days apart showed after 7 weeks of gestation i.e. gestational sac > 20mm , an empty gestational sac with no fetal echoes seen .

It is treated in a similar way to missed abortion .

Spontaneous or induced termination of a pregnancy in which the mother's life may be threatened because of the invasion of germs into the endometrium, myometrium, and beyond.

The woman requires immediate and intensive care

Massive antibiotic therapy Evacuation of the uterus Emergency hysterectomy to prevent death from

overwhelming infection and septic shock.

1. Haemorrhage .2. Complication related to surgical evacuation ie

E&C and D&C. Uterine perforation- which may lead to rupture uterus

in the subsequent pregnancy. Cervical tear & excessive cervical dilatation – which

may lead to cervical incompetence. Infection – which may lead to infertility & Asherman's

syndrome. Excessive curettage – which may lead to

Adenomyosis3.  Rh- iso immunisation if the anti –D is not given or

if the dose is inadequate .4. Psychological trauma .

In cases of incomplete, inevitable, complete, missed & septic abortions

1.Support: from the husband, family& obstetric staff

2.Anti D – to all Rh –ve, nonimmunised patients, whose husbands are Rh+ve

3. Counseling & explanation:A.Contraception (Hormonal,

IUCD, Barrier) Should start immediately after abortion if the patient choose to wait , because ovulation can occur 14 days after abortion and so pregnancy can occur before the expected next period .

3. Counseling & explanation:B.When can try again : Best to wait for 3 months before trying

again . This time allow to regulate cycles and to know the LMP, to give folic acid, and to allow the patient to be in the best shape (physically and emotionally) for the next pregnancy

C.Why has it happened In the fiIn the majority of cases there is no

obvious causeIn the first trimester abortion , the most

common cause is fetal chromosomal abnormality

3.Counseling & explanation:D. Can it happen again As the commonest cause is the fetal

chromosomal abnormality which is not a recurrent cause , so the chance of successful pregnancy next time in the absence of obvious cause is very high even after 2 or 3 abortions

E. Not to feel guilty as it is extremely unlikely that anything the patient did can cause abortion

No evidence that intercourse in early pregnancy is harmful

No evidence that bed rest will prevent it ..

Definition : Is defined as 3 or more consecutive

spontaneous abortions It may presented clinically as any of other types

of abortions .

 Types : Primary : All pregnancies have ended in loss Secondary : One pregnancy or more has

proceeded to viability(>24 weeks gestation) with all others ending in loss

Incidence : occurs in about 1% of women of reproductive

age .

Causes Idiopathic recurrent abortion, in about 50%,

in which no cause can be found . The known causes include the followings :

1.Chromosomal disorders:

Fetal chromosomal abnormalities & structural abnormalities

Parental balanced translocation

2. Anatomical disorders: Cervical incompetence: →congenital and aquired Uterine causes: → submucous fibroids, uterine

anomalies & Asherman’s syndrome  

Causes3. Medical disorders: Endocrine disorders : diabetes , thyroid disorders ,

PCOS & corpus luteum insufficiency . Immunological disorders : Anticardiolipin syndrome

& SLE. Thrombophilia: congenital deficiency of Protein

C&S and antithrombin III, & presence of factor V leiden. Infections

ToRCH - CMV may be a cause of recurrent abortion, but ToRH are not causes of recurrent abortion.

Genital tract infection e.g Bacterial vaginosis

Rh – isoimmunization

Diagnosis : 1.History :

Previous abortions : gestational age and place of abortions & fetal abnormalities.

Medical history : DM , thyroid disorders, PCOS, autoimmune diseases & thrombophilia.

2.Examination : General : weight , thyroid & hair distribution Pelvic: cervix ( length & dilatation ) and uterine

size.

Diagnosis : 3.investigations :

A. Investigations for medical disorders: Blood grouping & indirect Coomb’s test in Rh –ve

women Endocrinal screening: Blood sugar , TFT & LH /FSH ratio Immunological screening: Anti anticardiolipine

antibodies & lupus inhibitor. Thrombophilia screening: Protein C & S, antithrombin III

levels, factor V leiden, APTT and PT. Infection screening

High vaginal & cervical swabs ToRCH profile ( which scientifically is not

necessary )

Diagnosis : 3.investigations :

B. Investigations for anatomical disorders: TV/US: fibroids, cervical incompetence & PCOS. Hystroscopy or HSG, fibroids, cervical incompetence,

uterine anomalies & Asherman's syndromeC. Investigations for chromosomal disorders: Parental karyotyping: Parental balanced translocation. Fetal karyotyping: Fetal chromosomal anomalies.

Management: 3.in idiopathic recurrent abortion.With support and good antenatal care , the chance of successful spontaneous pregnancy is about 60-70%

Support : from husband, family & obstetric staff. Advice : stop smoking & alcohol intake, decrease

physical activity Tender loving care Drug therapy

• Progesterone & hCG: start from the luteal phase & up to 12 weeks.•Low dose aspirin ( 75 mg/day ) start from the diagnosis of pregnancy & up to 37 weeks •LMWH (20-40 mg/day) start from the diagnosis of fetal heart activity & up to 37 ws

Management: 3.In the presence of a cause treatment is

directed to control the cause Endocrine disorders

• Control DM and thyroid disorders before pregnancy• Ovulation induction drugs , ovarian drilling or IVF in PCOS.• Progesterone or hCG in corpus luteum insufficiency .

:In anti-cardiolipin syndrome: • Low dose aspirin ( 75 mg/day ) & prednisilone ( 20-30 mg /

day), starting when pregnancy is diagnosed till 37 weeks.• These drugs are not teratogenic.

Management: In thrombophilia:

• Low dose aspirin ( 75 mg/day) starting when pregnancy is diagnosed and low molecular weight heparin ie LMWH ( 20-40 mg/day) starting when fetal heart activity diagnosed & to continue both till 37 weeks .

In uterine disorders • Cervical cerclage in cervical incompetence, best time at

the 14 weeks of pregnancy.• Myomectomy in submucus fibroid, excision of uterine

septum in septate & subseptate uterus & adhesolysis in Asherman's syndrome.

Management: In infection:: treatment of the genital tract infection. In Rh isoimmunization: Repeated intrauterine

transfusion In parental balanced translocation

• Explain the risk of fetal chromosomal disorders ( about 30% )

• Encourage to try again or adoption.