Inevitable abortion (abortion in progress)

Diagnostics: 1. Serum βHCG: Less than 2000 IU/L should be suspicious for threatening. For a potentially viable intrauterine pregnancy (IUP) up to 6-7 weeks gestation the following applies:
- mean doubling time for β-hCG is 1.4-2.1 days
- serial β-hCG rise of at least 66% every 48 hours

1. IUP is usually visible on transvaginal ultrasonography (TVUS) when gestational sac greater than or equal to 3 mm. and a discriminatory zone for β-hCG of 1500-2000 IU/L on TVUS and 6500 IU/L on transabdominal ultasonography (TAUS).

2. Serum progesterone: viable intrauterine pregnancy can be diagnosed if the serum progesterone levels are greater than 25 ng/mL (>79.5 nmol/L). Conversely, finding serum progesterone levels of less than 5 ng/mL (< 15.9 nmol/L) can aid in the diagnosis of a nonviable pregnancy.

3. TVUS and TAUS are also used to determine:

• the fertiliezed ovum in the uterinbe cavity,

• the size of the uterus (term of gestation),

• cardiac motion can sometimes be identified in a 2- to 3-mm embryo but is almost always present when the embryo grows to 5 mm or longer. At 5-6 weeks' gestation, the fetal heart rate ranges from 100-115 beats per minute. At 9 week of gestation the heart rate ranges from 140 bpm.

• Ultrasonography (US) aids identification of retained products of conception, fetal demise, incomplete miscarriage, empty uterus; therefore, it provides a clinically relevant classification of early pregnancy loss. Following spontaneous first-trimester complete miscarriage, TVUS has been found to be 81% sensitive and 94% specific in detection of retained products of conception.US is the most accurate diagnostic modality in the confirmation of a viable pregnancy during the first trimester.Sonographic signs of threatened abortion are as follow:

- Irregular gestational sac

- Nonliving embryo (without a heartbeat)

When threatening abortion, pregnancy can be saved. The management means abstention from sexual intercourse, bed regimen, prescription of progesterone (5-10 mg intramuscularly daily during ten days), dufaston 1-2 tablets daily, utrogestan 200-300 mg orally every day, intravaginal use of progestogel. If indicated (infantilism, ovarian hypofunction), small doses of estrogen can also be administered (microfollin 0.1 mg daily, during 10 days). Papaverine, no-spa can also be used in suppositories, tablets or IM injections.

Inevitable abortion (abortion in progress). This stage is manifested by profuse bleeding, significant cramping pains in the lower abdomen. Due to uterine contractions the conceptus is expelled from the uterine cavity through a dilated cervical canal. The vaginal examination shows that the cervix is dilated, sometimes the lower pole of fertilized ovum can be found in the cervical canal, the uterus size does not correspond to the gestational term (less than in normal gestational term) (Fig. 167).

Fig. 167. Abortion in progress.

Thus, symptoms are:
- spastic pains (regular contractions),
- significant bleeding (with parts of the ovum/embrio),
- uterus size is not correspond to the term of gestation (is less),
- cervix is opened, the ovum , blood clots may be palpable in the canal

The management of this stage means curettage of the uterine cavity to arrest bleeding. Antibiotics should be prescribed to prevent genital inflammation. Uterotonic agents (oxytocin 5UI with 400ml of isotonic crystalloid solution IV by drop) to improve uterine contractions and arrest bleeding.

Incomplete Abortion. If only part of the conceptus has been expelled, while its portion still remains in the uterus, the abortion is incomplete. An incomplete abortion is marked by hemorrhage. The bleeding may be prolonged, moderate or profuse, containing blood clots; parts of the retained membranes can often be discharged together with blood. The uterus is smaller than that at the corresponding gestational age, soft, sometimes painful. The cervical cavity is dilated.

An incomplete miscarriage may demonstrate a variety of sonographic findings as follows:

presence of abnormal hyperechoic material within the uterine cavity; the gestational sac may be misshaped or collapsed, or it may be intact, containing a nonliving embryo.

Management is surgical: instrumental curettage of the uterine cavity for arresting bleeding and prevention of genital inflammation. Medication: Antibiotic agents and uterotonic agents with prophylactic aims.

Complete Abortion. An abortion is complete if the conceptus has been expelled from the uterus in whole. If an abortion is complete, the uterus contracts, the cervical canal closes, woman does not feel pain; there is no bleeding. One can find the uterus normal in size and consistency.

A complete miscarriage may demonstrate the following sonographic findings:

· an empty uterus noted on endovaginal sonogram suggests a complete miscarriage.

It is important to know that the decidual membrane is usually retained in the uterus in an early abortion, and it is the cause of bleeding and infection. So, the curettage of the uterus is necessary in this stage too, even if there is no bleeding and pain.

Clinical features and management of late abortion are the same as in preterm labor.

Preterm Labor. Termination of pregnancy in terms from 22 completed weeks to 36 weeks +6 days is called preterm (premature) labor (PTL) or birth. It is manifested by a low birth weight (1,000-2,500 g), body length of 35–45 cm, physical signs of prematurity and multisystem disorders of a newborn.

There are sub-categories of preterm birth, based on gestational age:

• extremely preterm (

• very preterm (28 to

• moderate to late preterm (32 to

Incidence. Every year, an estimated 15 million babies are born preterm (before 37 completed weeks of gestation), and this number is rising. Preterm birth complications are the leading cause of death among children under 5 years of age, responsible for nearly 1 million deaths in 2015.Three-quarters of them could be saved with current, cost-effective interventions. Across 184 countries, the rate of preterm birth ranges from 5% to 18% of babies born.

Preterm labor risk factors. Maternal habits and behaviors:
- Smoking
- Illicit drug use
- Alcohol use
- Lack of prenatal care

Maternal conditions:
- Low socioeconomic status
- Low prepregnancy weight and low weight gain during pregnancy
- Some infections (chorioamnionatis, bacterial vaginosis, asymptomatic bacteriuria, acute pyelonephritis, cervical/vaginal colonization)
- A short interval (less than 12 to 18 months) between pregnancies (deliveries)
- Extremes of age (40)

- Previous multiple abortions, previous preterm births
- Chronic medical conditions (eg, hypertension, insulin-dependent diabetes, heart failure etc.)
- Moderate to severe anemia early in the pregnancy
- Abdominal surgery during pregnancy
- Uterine causes: leiomyoma, congehital abnormalities of the uterus (septate, bicornuate uterus, cervical incompetence, exposure to DES
- Hormonal changes (eg, mediated by maternal or fetal stress)

Obstetrical complications:
- Multiple gestation ( twins, triplets, or more)
- Cervical incompetence (eg, trauma, cone biopsy)
- Uterine bleeding, especially in the second or third trimester
- Excessive amniotic fluid
- Pregnancy complications (e.g. preeclampsia, antepartum hemorrhage)
- Preterm premature rupture of membranes

Fetal causes:
- Intrauterine fetal death
- Intrauterine growth retardation

Consequences of preterm birth. High incidence of perinatal morbidity is typical feature of preterm birth (PTB). Morbitdity of preterm infants includes respiratory distress syndrome (RDS), bronchopulmonary dysplasia, intraventricular haemorrhage (IVH), necrotizing ente-erocolitis, sepsis, retinopathy, etc. Mortality rate of preterm infants: of all early neonatal deaths (deaths within the first 7 days of life) that are not related to congenital malformations, 28% are due to preterm birth.

The following stages of preterm labor are distinguished:
- threatened preterm labor (TPTL);
- actual preterm labor and delivery (APTL).