Abortion (Obstetric)

Classification

By Cause

By Clinical Presentation (Spontaneous)

Epidemiology

• Spontaneous abortion occurs in approximately 15–20% of all clinically recognized pregnancies (Medication Management for Early Pregnancy Loss, p. 2).
• The majority (>80%) occur in the first trimester.
• Recurrent pregnancy loss affects ~1% of couples trying to conceive.

Etiology & Risk Factors

First-Trimester Loss

• Chromosomal/genetic abnormalities (~50–60% of cases) — most common cause; trisomies, monosomy X, polyploidy
• Advanced maternal age
• Uterine anomalies (fibroids, septum, Asherman's syndrome)
• Endocrine disorders (uncontrolled diabetes, thyroid disease, hyperprolactinaemia)
• Thrombophilias (antiphospholipid syndrome — especially in recurrent loss)
• Infections (Listeria, Toxoplasma, CMV, Rubella)
• Smoking, alcohol, cocaine use
• Obesity

Second-Trimester Loss

• Cervical incompetence/insufficiency
• Uterine anomalies
• Placental abruption
• Infection
• Chromosomal abnormalities (less common than first trimester)

Clinical Features

Diagnosis

Investigations

• Serum β-hCG: Serial measurements every 48 hours — a rise of <53% or a falling trend is suspicious for non-viable pregnancy; should approximately double every 48h in viable early pregnancy.
• Transvaginal ultrasound (TVUSS): Primary diagnostic tool
  • Empty gestational sac (mean sac diameter ≥25 mm) without embryo → anembryonic pregnancy
  • Crown-rump length ≥7 mm without cardiac activity → missed abortion
  • Absent fetal heart activity
• Full blood count: Assess for anaemia
• Blood group and Rh factor: Anti-D prophylaxis required in Rh-negative patients
• Cervical swabs: If septic abortion suspected
• In recurrent pregnancy loss: thrombophilia screen, karyotyping (both partners), uterine cavity assessment (hysteroscopy/sonohysterography), thyroid/endocrine workup

Management

General Principles

1. Expectant Management

• Suitable for: incomplete abortion, missed abortion (haemodynamically stable patient with no infection)
• Allow spontaneous passage of POC
• Success rate: ~50–80% within 2 weeks for missed abortion; higher for incomplete
• Monitor β-hCG to confirm resolution
• Patient must have 24-hour access to emergency care

2. Medical Management

• Misoprostol (prostaglandin E₁ analogue): sublingual, buccal, or vaginal; causes uterine contractions and cervical softening
• Mifepristone + misoprostol (combined regimen): more effective than misoprostol alone for missed/anembryonic pregnancy
  • Mifepristone 200 mg orally, followed 24–48 hours later by misoprostol 800 µg vaginally/buccally
  • Success rate >80% within 2 weeks (Abortion Care, p. 17; Medication Management for Early Pregnancy Loss, p. 2)
• Side effects: cramping, nausea, vomiting, diarrhoea, fever
• Follow-up USS or β-hCG to confirm complete evacuation

3. Surgical/Procedural Management

• Uterine aspiration (manual vacuum aspiration [MVA] or electric vacuum aspiration [EVA]): preferred surgical method; safe and highly effective (>95%)
• Sharp curettage (D&C): less preferred due to risk of intrauterine adhesions (Asherman's syndrome); generally reserved where aspiration not available
• Indications for urgent surgical management:
  • Heavy haemorrhage / haemodynamic instability
  • Suspected or confirmed intrauterine infection (septic abortion)
  • Patient preference when other methods have failed

Septic Abortion

• Medical emergency
• Broad-spectrum IV antibiotics (e.g. metronidazole + cephalosporin ± gentamicin)
• Prompt uterine evacuation (after stabilisation and antibiotics initiated)
• ICU support if septic shock

Rh-Negative Patients

• Anti-D immunoglobulin (Rh prophylaxis) should be given to all Rh(D)-negative women undergoing surgical evacuation or where gestational age is ≥10 weeks (local guidelines vary on threshold).

Complications

Prognosis & Counselling

• After a single spontaneous abortion, >80% of women will have a successful subsequent pregnancy.
• After 3 consecutive losses, the risk of another is ~40–45% without intervention; systematic investigation and treatment of underlying causes improves outcomes significantly.
• Women should be offered psychological support and counselling; grief is a normal response.
• Pregnancy can usually be attempted again after one normal menstrual cycle following a first-trimester loss.

Vaginal Bleeding During Pregnancy

Approach: First vs. Second Half

Critical rule: All patients with painless second-trimester/third-trimester vaginal bleeding should be assumed to have placenta previa until proven otherwise. Digital or instrumental examination of the cervix must be avoided until this diagnosis is excluded by ultrasound — it may precipitate catastrophic haemorrhage. — Rosen's Emergency Medicine [block31]; Tintinalli's Emergency Medicine [block8]

1. First-Trimester Bleeding

Causes

Ectopic Pregnancy

• The classic triad is amenorrhoea, abdominal pain, and abnormal vaginal bleeding ("the three A's") — ectopic pregnancy until proven otherwise. — Swanson's Family Medicine Review [block4]
• Risk factors: prior tubal surgery, PID, previous ectopic, IUD use, assisted reproduction.
• β-hCG present but intrauterine gestational sac absent on TVUSS → highly suspicious.
• Tubal rupture = surgical emergency; vasovagal attacks and orthostatic hypotension are strong indicators. — Swanson's Family Medicine Review [block4]

Molar Pregnancy

• Presents with vaginal bleeding, uterus large-for-dates, hyperemesis, early pre-eclampsia, and markedly elevated β-hCG.
• USS shows characteristic "snowstorm" appearance (see image below).
• Up to two-thirds are diagnosed only on pathological specimens after miscarriage; USS is only 58% sensitive.
• Management: uterine D&C + surveillance for gestational trophoblastic disease (invasive mole, choriocarcinoma). — Rosen's Emergency Medicine [block31]

2. Second-Half Bleeding

A. Abruptio Placentae (Placental Abruption)

Abruptio placentae: placenta has separated from the superior pole of the uterus. — Tintinalli's Emergency Medicine

• Mild: small retroplacental clot; vaginal bleeding may be minimal; no fetal distress
• Moderate: painful uterine contractions + vaginal bleeding; fetal distress present
• Severe: board-like rigid uterus; heavy bleeding (may be concealed); coagulopathy (DIC); fetal death; maternal haemorrhagic shock

Up to 20% of cases have no pain or vaginal bleeding (concealed abruption) — assessment relies on clinical features, coagulation parameters, and fetal monitoring. — Rosen's [block31]

• IV access × 2; FBC, coagulation studies, blood group + crossmatch
• IV fluid resuscitation; blood transfusion as needed
• Continuous fetal monitoring
• Obstetric consultation urgently
• Delivery timing based on gestational age, severity, and fetal/maternal condition

B. Placenta Previa

• Painless, bright red vaginal bleeding — classic hallmark
• Onset typically after 28 weeks (most commonly in the third trimester)
• Uterus non-tender, soft
• Abnormal fetal lie common (placenta occupies lower segment)
• Bleeding may be precipitated by intercourse, examination, or occur spontaneously

• Complete (total): placenta covers internal os entirely
• Partial: placenta partially covers internal os
• Marginal: placental edge at margin of internal os
• Low-lying: placental edge within 2 cm of os but not covering it

• Haemodynamically stable + remote from term: expectant management, pelvic rest, hospitalisation (if severe bleeding)
• Haemodynamically unstable or near term: caesarean section
• Rh-negative patients: anti-D immunoglobulin
• Avoid vaginal delivery with complete previa

C. Vasa Previa

• Sudden onset vaginal bleeding coinciding with rupture of membranes
• Rapid fetal bradycardia or sinusoidal CTG pattern
• Maternal haemodynamics may remain stable while fetus exsanguinates

D. Uterine Rupture

• Rare but catastrophic; risk factors: prior uterine scar (caesarean, myomectomy), obstructed labour, oxytocin misuse, grand multiparity.
• Sudden severe abdominal pain + vaginal bleeding + fetal bradycardia/loss of fetal heart tones.
• Loss of uterine contour on palpation; presenting part may retract.
• Emergency laparotomy + caesarean section.

Comparative Summary: Major Second-Half Causes

Initial Assessment & Emergency Management (All Causes)

1. History: gestational age, onset/character of bleeding, pain, trauma, prior USS, placental location, Rh status
2. Vitals + fetal heart rate (normal 120–160 bpm)
3. Do NOT perform digital/speculum examination until placenta previa/vasa previa excluded by USS
4. IV access × 2; bloods: FBC, coagulation studies, blood group + crossmatch, Kleihauer-Betke test (feto-maternal haemorrhage)
5. Transvaginal USS by experienced operator to localise placenta
6. Continuous CTG (>24 weeks)
7. Obstetric consultation — urgent/emergent based on severity
8. Anti-D immunoglobulin for all Rh(D)-negative patients
9. Resuscitate with crystalloid/blood products as needed; prepare for emergency delivery if haemodynamically unstable

The Control Panel (Left — Program Dial)

What's Happening Right Now

• "58" on the screen — this is the time remaining: 58 minutes
• The three blue icons at the top (wash tub, rinse, spin) — the machine is actively mid-cycle
• Red speaker icon (🔇) — the sound/beep is muted
• Red key icon (🔑) — the child lock is active (door/controls are locked)
• Temperature: the lit indicator appears to be around 40°C
• Rinse: 2 rinses selected (lit indicator)
• Spin speed: 1200 rpm selected

Other Buttons (Right Side)

To Turn Off Child Lock

Samsung Eco Bubble 7.0kg — Complete Simple Guide

🔵 What is Eco Bubble?

🎛️ THE DIAL — Wash Programs & Which Clothes to Use

🟤 COTTON (Хлопок)

• Toughest wash — removes heavy dirt
• Can handle high temperatures (60–90°C)
• Safe for most everyday clothes

🟢 ECO COTTON (Eco Хлопок)

• Uses less water and electricity
• Takes longer but is gentler on the environment
• Good for clothes that aren't very dirty

⚡ 15-MINUTE QUICK WASH (15' Быстрая стирка)

• Not for heavily soiled clothes
• Great when you're in a hurry
• Use small load only (1–2 items)

📅 DAILY WASH (Ежеднев. стирка)

• Balanced cycle — not too rough, not too gentle
• Good for regular use

🌸 DELICATES (Деликат. ткани)

• Very gentle — slow drum movement
• Low temperature (30°C)
• Prevents stretching and tearing

🖤 DARK CLOTHES (Тёмные вещи)

• Uses cold water to prevent colours fading
• Gentle spin to reduce colour loss
• Keeps dark clothes looking new longer

🛏️ BED LINEN (Постельное бельё)

• Special drum movement to handle large bulky items
• Prevents tangling and ensures even wash

👶 BABY CLOTHES (Детские вещи)

• High temperature (60°C) to kill bacteria and allergens
• Extra rinse to remove all detergent residue
• Safe for sensitive baby skin

🧶 WOOL (Шерсть)

• Very slow and gentle drum movement
• Cold or 30°C only
• Prevents shrinking and matting

🧴 SYNTHETICS (Синтетика)

• Medium temperature (40°C)
• Gentle enough to prevent damage to synthetic fibres

💧 RINSE + SPIN (Полоск. + Отжим)

• No detergent needed
• Just flushes out soap and spins dry

🌀 SPIN ONLY (Отжим)

• No water added — just spins

🥁 DRUM CLEAN ECO (Очистка барабана ECO)

• Run this once a month to clean the drum
• Removes mould, bacteria, and bad smells
• Use a drum-cleaning tablet or just run it empty

🌡️ TEMPERATURE GUIDE (Simple)

⚠️ Rule of thumb: Always check the label on your clothes. If it says 30°C, never go higher — it will shrink or damage the fabric.

🔄 SPIN SPEED GUIDE

Higher spin = clothes come out drier but more wrinkled. Lower spin = gentler on fabric but wetter.

🧴 HOW TO USE IT — Step by Step

1. Load clothes — don't overfill; leave a hand's space at the top of the drum
2. Add detergent to the drawer (pull it out from the top left):
   • Left compartment = pre-wash detergent
   • Middle = main wash detergent
   • Right = fabric softener
3. Turn the dial to your program
4. Adjust settings if needed — temperature, spin speed, rinses
5. Press the Play/Pause button (▶⏸) to start
6. Machine beeps and door locks automatically
7. When done, it beeps — open the door and unload

🔒 SPECIAL BUTTONS EXPLAINED

💡 TOP TIPS

• Never overload — clothes need space to move to get clean
• Use the right amount of detergent — too much = poor rinsing, too little = poor cleaning
• Leave the door open after each wash to prevent mould and smell
• Clean the filter (bottom front panel) every few months — catches lint and coins
• Run Drum Clean once a month to keep it fresh
• Separate colours — wash darks with darks, whites with whites, for the first few washes at least

🧺 QUICK CHEAT SHEET — Cloth Type → Setting

For a Thick/Heavy Bedsheet

Program → Bed Linen (Постельное бельё)

Settings to Choose:

⚠️ Important Tips for Thick Bedsheets

• Wash one at a time — a thick bedsheet alone can already be 2–3 kg. Don't add other items or the machine gets unbalanced and starts shaking violently
• Don't stuff it in — loosely place it in the drum, don't fold it tightly into a ball
• If the machine starts vibrating heavily mid-cycle, it means the sheet has bunched up on one side — pause, open the door, redistribute it evenly, then restart
• After washing, shake it out immediately — thick sheets wrinkle badly if left sitting in the drum

If It's a White Thick Bedsheet