Spontaneous Abortion

(SAB)
a.k.a Miscarriage

MOHD HAFIS ZUL ARIF BIN AWANG

MBBS 2010 – IMS – MSU
012010050476
 Definition
• Miscarriage = expulsion, dead the product of
conception from the uterus at a stage of pregnancy
when it is incapable of independent survival (between
conception to 24th weeks of gestation)
[Oxford Concise Medical Dictionary]
• Abortus = fetus lost before 20 weeks gestation, less
than 500 g, or less than 25 cm.
 Either dead or incapable of survival
 Abortion Type
Nature of Abortion
a) Induced Abortion – terminated artificially.
• Medical or surgical abortion.
• Ethical (therapeutic) or non-ethical abortion.
b) Spontaneous Abortion (SAB) a.k.a Miscarriage
• The type of SAB is defined by whether any or all of
the products of conception (POC) have passed
and whether or not the cervix is dilated
 SAB Terms:
1. Trimesters
a) First Trimester Mscg – before 13 weeks
b) Second Trimester Mscg – after 13 before 20 weeks.
2. Completeness
a) Complete - when all products of conception have been
expelled. Products of conception may include the trophoblast,
chorionic villi, gestational sac, yolk sac, and fetal pole
(embryo); or later in pregnancy the fetus, umbilical cord,
placenta, amniotic fluid, and amniotic membrane.
b) Incomplete- when tissue has been passed, but some remains
in utero.
Complete vs. Incomplete
c) Missed (Delayed) Mscg - embryo or fetus has died,
but a miscarriage has not yet occurred.
d) Inevitable Mscg - where the cervix has already
dilated open, but the fetus has yet to be expelled.
This usually will progress to a complete abortion.
e) Threatened Mscg - The embryo is usually alive.
The woman will have a crampy pain that gradually
increases in severity. A mild bleeding or blood
stained vaginal discharge can occur. The cervix of
the uterus however remains closed. There is a
possibility of continuation of the pregnancy on
proper and timely management.
4. Complication / Implication
a) Habitual (Recurrent) Mscg - occurrence of three or
more consecutive miscarriages.
b) Septic Mscg- when the tissue from a missed or
incomplete abortion becomes infected. The
infection of the womb carries risk of spreading
infection (septicaemia) and is a grave risk to the life
of the woman.
Interlinking
 Mechanism: Complete Mscg

Expulsion complete.
Haemorrhage occurs in The POC, partly or wholly
The decidua is shed
the decidua basalis detached, acts as a
foreign body and initiates
during the next few
leading to local days in the lochial
uterine contractions. The
necrosis and cervix begins to dilate. flow.
inflammation.
 Causes
a) Embryo – Chromosomal defects or placenta defect.
b) Maternal Environment:
i. Maternal diseases causing high fever.
ii. Infections by toxoplasma (common) or by Listeria
monocytogenes. TORCH.
iii. Hormonal deficiencies as in progesterone deficiency
in corpus luteum defect, or in hyperthyroidism or
hypothyroidism.
iv. Cervical Incompetence
v. Rh-ve pregnancy
 Causes: Continued…
vi. ABO incompatibility
vii. Uterine fibroid causing improper implantation of
the placenta
viii. Physical trauma, e.g. a blow on the abdomen
or that caused by a fall.
ix. Surgical trauma due to any operation.
x. Congenital malformations of the uterus like
hypoplastic uterus, unicornuate, bicornuate
uterus, septate uterus etc.
 Symptoms
• Pelvic Pain – due to uterus contraction to expels
POC.
• Haemorrhage
• Blood clot
 Miscarriage: Management
a) Expectant Management (Watchful Waiting)
• Completed in 2 – 6 weeks
• Appropriate in those women who are not bleeding
heavily.
• Highly effective for women with incomplete
miscarriage
• In women with intact sac, resolution may take several
weeks and may be less effective.
• Patients should be offered surgical evacuation at a
later date if expectant management is unsuccessful.
 Miscarriage: Management
b) Medical Management
• Completed within few days
• Prostaglandin analogues (misoprostol or
gemeprost) are used.
 Administered orally or vaginally.
 With or without priming (mifepristone).
• Bleeding may continue for up to 3 weeks after
medical uterine evacuation.
 Miscarriage: Management
c) Surgical Management
• Fastest way.
• Standard treatment
• Evacuation of retained product of conception
(ERPC) should be performed in patient who:
i) Have excessive or persistent bleeding
ii) Request surgical management
• Suction curettage (or D&C/D&E) should be used
 Ovum Forceps

‘Digital
Curettage’ Curette
 Complication - ERPC
i. Infection
ii. Haemorrhage
iii. Uterine perforation
iv. Retained products of conception
v. Intrauterine adhesions
vi. Cervical tears
vii. Intra-abdominal trauma
• Uterine and cervical trauma can be minimized by administering
prostaglandin before procedure.
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