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Abortion


  • expulsion of dead foetus before 24 weeks gestation

  • up to 12 weeks

    1. haemorrhage into decidua basalis - local necrosis and inflammation

    2. ovum acts as foreign body and uterus contracts, cervix begins to dilate

    3. expulsion completed, decidua shed as lochial flow over next few days

  • between 12 and 24 weeks

    • gestational sac ruptures , expelling foetus

    • placenta may be retained

Causes

  • Abnormal development of ovum

  • Maternal condition

    • pyrexia illness

    • infection

    • severe rhesus iso-immunisation

    • chronic maternal disease

  • Cervical incompetence

    • abortion in mid-trimester

  • Fibroids

  • Congenital abnormality of uterus

Types

  • Threatened abortion

    • any bleeding before 24th week

    • impossible to distinguish from decidual shedding

  • Inevitable abortion

    • bleeding may be slight

    • uterine contractions have started to dilate cervix

    • USS may demonstrate foetal death

  • complete

    • uterine contraction felt

    • cervix dilates

    • foetus and placenta expelled completely

    • bleeding stops

  • incomplete

    • only foetus and some membranes expelled

    • substantial bleeding continues and painful contractions

  • missed abortion

    • death of foetus unnoticed, bleeding ignored as threatened abortion

    • uterus shrinks, pregnancy test becomes negative

    • USS to confirm

Management

  • USS to check for foetal heartbeat

  • bleeding of incomplete abortion may be stopped by 0.5mg ergometrine +/- pethidine, may need blood transfusion

Differential diagnosis

  • tubal pregnancy

  • hydatidiform mole

  • menstrual disorders

Surgical Treatment

  • in theatre

  • 'digital curretage'

  • injection of syntometrine to contract and harden uterus

  • removal of placental tissue with ovum forceps, currette

Retention of dead foetus

  • Forms

    • Carneous mole

    • Macerated foetus

      • skull bones collapse, spine flexed on X-ray (Spalding's sign)

      • mummification (fetus papyraceous), calcification (lithopaedion) rare

  • should be expelled spontaneously

  • risk of coagulation defect - check if evacuating after 4 weeks

 

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