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🏥 ABORTION - Clinical Notes (MBBS Level)

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1. DEFINITION

• Spontaneous abortion (Miscarriage): Expulsion of products of conception (POC) before the fetus becomes viable - before 20 weeks gestation OR fetal weight < 500 g
• Administratively, viability is often set at 28 weeks / ~1000 g (in some countries)
• ~20-40% of all pregnancies abort spontaneously
• 75% occur before 8 weeks

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2. CLASSIFICATION

A. Spontaneous Abortion (Types)

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3. ETIOLOGY / CAUSES

Fetal (most common - ~50-60%)

• Chromosomal abnormalities - most common overall cause (e.g., autosomal trisomies - trisomy 16 most common; monosomy X, polyploidy)

Maternal

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4. CLINICAL FEATURES

• Amenorrhoea (positive UPT)
• Vaginal bleeding - may be spotting to heavy
• Lower abdominal cramping (colicky pain)
• Examine: cervical os (open vs. closed), uterine size vs. dates, adnexal tenderness

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5. INVESTIGATIONS

1. Quantitative serum β-hCG - essential; doubles every 48h in viable IUP
2. Transvaginal USS (TVUS) - gold standard for diagnosis:
   • Discriminatory zone: β-hCG > 1500 mIU/mL → IUP should be visible on TVUS
   • 5 wks: yolk sac; 6 wks: embryo + cardiac activity; 7 wks: embryonic head/torso
3. CBC - assess blood loss / anemia
4. Blood group + Rh factor - critical (RhoGAM indication)
5. Urinalysis - UTI associated with increased fetal wastage
6. Blood cultures - if septic abortion suspected

USS Findings by Gestational Age:

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6. MANAGEMENT

A. Threatened Abortion

• Admit / outpatient with close follow-up
• Pelvic rest (no intercourse, no tampons)
• Bed rest - NOT proven effective
• Progesterone - controversial, not definitively effective
• Prognosis: Majority do NOT miscarry; BUT increased risk of preterm birth (~3x), IUGR, placental abruption later

B. Inevitable Abortion

• Offer medical or surgical management
• If Rh-negative → RhoGAM 300 mcg IM (50 mcg acceptable up to 12 weeks)

C. Incomplete Abortion

• Evacuate uterus - options:
  1. Expectant - wait for spontaneous passage (success ~91%)
  2. Medical - Misoprostol 600 mcg orally OR 800 mcg vaginally
  3. Surgical - Suction curettage / MVA (manual vacuum aspiration) / D&C
• If profuse bleeding: remove visible tissue at cervical os with ring forceps (may stop vasovagal bradycardia)
• If febrile: broad-spectrum antibiotics + arrange evacuation

D. Complete Abortion

• Confirm on USS (empty uterus) + history of passed all POC
• Discharge safely; follow-up in 1-2 weeks

E. Missed Abortion

• Expectant / medical / surgical management (success rates ~76%)
• Medical: Misoprostol (+ mifepristone in combination for better outcomes)
• Monitor β-hCG to zero to rule out GTD

F. Septic Abortion

• Admit + aggressive management:
  • IV fluids (resuscitation)
  • Broad-spectrum IV antibiotics: Ampicillin/sulbactam 3g IV OR Clindamycin 600 mg IV + Gentamicin 1-2 mg/kg IV
  • Urgent uterine evacuation (obstetric consultation)
  • Blood cultures, CBC, Rh, USS

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7. Rh IMMUNOGLOBULIN (RhoGAM) - KEY RULE

• Give to ALL Rh-negative women with vaginal bleeding in pregnancy
• 300 mcg IM (standard dose); 50 mcg acceptable up to 12 weeks
• Must be given within 72 hours of bleeding

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8. MEDICAL (INDUCED) ABORTION

Medication Abortion Regimen (First Trimester, ≤ 70 days from LMP):

• Efficacy: ~97% in early first trimester (95% up to 9 weeks per Park's)
• Side effects: Cramping, bleeding, nausea, vomiting, diarrhea
• Serious adverse events: ~0.3% (hemorrhage needing transfusion, infection)
• Follow-up at 14 days post-mifepristone to confirm complete abortion; if ongoing pregnancy → surgical termination (risk of fetal malformation)

Contraindications to Mifepristone/Misoprostol:

• Suspected ectopic pregnancy
• IUD in situ
• Chronic adrenal failure / inherited porphyria
• Hemorrhagic disorder / anticoagulant therapy
• Hypersensitivity to either drug
• No access to emergency services

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9. SURGICAL METHODS OF ABORTION

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10. COMPLICATIONS OF UNSAFE / SEPTIC ABORTION

• Hemorrhage / shock
• Septicemia → septic shock
• Uterine perforation
• Peritonitis
• Asherman's syndrome (intrauterine adhesions)
• DIC
• Renal failure
• Death (47,000 deaths/year globally from unsafe abortion)

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11. RECURRENT PREGNANCY LOSS (RPL)

Causes to investigate:

1. Antiphospholipid Syndrome (APS) - most important treatable cause
   • Rx: Low-dose aspirin + LMWH (heparin)
2. Uterine anomalies - septum (most common), fibroids
3. Parental chromosomal - balanced translocation (parents' karyotype)
4. Endocrine - thyroid, DM, PCOS
5. Thrombophilias - Factor V Leiden, prothrombin mutation
6. Unexplained - up to 75% of cases

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12. QUICK EXAM MNEMONICS

Threatened, Missed, Inevitable, Incomplete, Complete, Septic

• Single abortion → Chromosomal
• Recurrent abortion → Unexplained (75%) / APS (most treatable)

• Threatened / Missed / Complete → Closed
• Inevitable / Incomplete → Open

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