| disease | Late Abortion |
| alias | Abortion |
Late abortion (abortion) is a common gynecological disease. If not handled properly or inadequately, it may lead to inflammation of the reproductive organs, endanger the health of the pregnant woman due to heavy bleeding, or even threaten her life. Additionally, late abortion can easily be confused with certain gynecological diseases. Termination of pregnancy before 20 weeks, with a fetal weight of less than 500 grams, is called late abortion (World Health Organization, 1966). Late abortion occurring before 12 weeks of pregnancy is called early late abortion, while that occurring after 12 weeks is called advanced stage late abortion.
bubble_chart Etiology
The causes of late abortion are complex and multifaceted. Common reasons for early late abortion include chromosomal abnormalities, endocrine disorders, and underdeveloped or malformed uterus.
1. **Chromosomal Abnormalities** Chromosomal abnormalities include numerical anomalies such as monosomy, trisomy, and polyploidy, as well as structural anomalies like breaks, deletions, and translocations, all of which can lead to late abortion. Studies on spontaneous and therapeutic late abortions have found that karyotype abnormalities account for 60% of spontaneous late abortions. Those with abnormal karyotypes often exhibit structural abnormalities in the fetus or placenta, whereas fetuses from late abortions with normal karyotypes are usually normal.
2. **Endocrine Disorders** Excessive estrogen and insufficient progesterone are also causes of early late abortion. Between weeks 12 and 14 of pregnancy, when the placenta is forming and taking over the function of the corpus luteum, endocrine imbalances—particularly luteal insufficiency—are likely to occur. Additionally, deficiencies in thyroid hormones, which disrupt cellular oxidation processes, as well as hyperthyroidism and diabetes, can easily lead to late abortion.
3. **Placental Abnormalities and Insufficient Placental Hormones** In early pregnancy, deciduitis can cause bleeding or hyperplasia in the basal decidua, dissolving trophoblast and decidual cells and blocking blood vessels in the villi, impairing nutrient absorption and transport. This can lead to the separation of the fertilized egg from the implantation site, resulting in bleeding and late abortion. Additionally, massive placental infarctions can reduce placental function, threatening fetal survival. Placenta previa and placental villous edema degeneration are also common causes of late abortion. If maternal blood levels of β-hCG, hPL, P, E2, and estrone decline in early pregnancy, there is a 50% chance of late abortion.4. **Blood Type Incompatibility** Due to previous pregnancies or blood transfusions, Rh factor or incompatible ABO blood type factors may produce antibodies in the mother. During this pregnancy, these antibodies enter the fetus via the placenta, causing red blood cell agglutination and hemolysis, leading to late abortion.
5. **Psychological and Neurological Factors** Severe fright or emotional trauma can also cause late abortion. Recent studies suggest that noise and vibration have certain effects on human reproduction.
6. **Maternal Systemic Diseases** (1) **Severe acute infectious and febrile diseases**: Conditions like lobar pneumonia, often accompanied by high fever, can induce uterine contractions or fetal death, resulting in late abortion.
(2) **Chronic diseases**: Severe anemia, heart disease, and heart failure can cause fetal hypoxia and asphyxia, leading to death. Chronic nephritis and severe hypertension can cause placental infarction or premature detachment, resulting in late abortion.
7. **Reproductive Organ Disorders** Uterine malformations, such as a bicornuate uterus or uterine septum, are often causes of late abortion. However, underdeveloped uterus is usually a cause of infertility. Additionally, conditions like uterine fibroids—especially submucosal fibroids protruding into the uterine cavity or ovarian cysts impacted in the pelvic cavity—can affect fetal development and lead to late abortion. Cervical incompetence is one of the common causes of habitual late abortion. Recent studies have found that about 14% of patients with intrauterine adhesions develop the condition after late abortion. Adhesions reduce uterine cavity size, deform it, and harden the endometrium, impairing embryo development.
8. **Immunological Factors** For cases with unexplained causes, recent research has found that most are closely related to immunological factors.
(1) Histocompatibility locus antigen (HLA): The HLA complex is located on a segment of the short arm of the sixth pair of human chromosomes, including at least four gene loci related to transplantation: HLA-A, B, C, D/DR, etc. During normal pregnancy, HLA incompatibility between spouses maintains genetic diversity and prevents the production of lethal homozygotes. However, in couples with habitual late abortion, the frequency of HLA antigen compatibility is higher than in those with normal pregnancy, with a greater likelihood of shared DR antigens. Excessive shared antigens prevent the maternal immune system from recognizing the pregnancy as an alloantigen, failing to stimulate the production of antibodies necessary to sustain the pregnancy. The lack of antibody-mediated regulation makes the maternal immune system prone to mounting immunological attacks against the fetus, leading to late abortion.
(3) Antisperm antibodies: In couples with recurrent spontaneous abortion (RSA), antisperm antibodies have been found in the serum of both or the male partner. Animal experiments have shown that antisperm antibodies have an embryo-killing effect, suggesting a correlation between the presence of these antibodies and RSA. Domestic reports also indicate that antisperm antibodies are more commonly found in females, demonstrating that both the female's alloimmune response to sperm and the male's autoimmune response are associated with RSA.
Late abortion caused by antisperm antibodies mostly occurs within the first three months of pregnancy, i.e., the persistent action of sperm agglutinating antibodies in the mother's body on early embryonic tissue leads to pathological changes, damaging the embryo and resulting in late abortion.
bubble_chart Pathological Changes
Due to the varying timing of late abortion, its pathological processes also differ. For those occurring before 8 weeks of pregnancy, most embryos die first, followed by hemorrhage, necrosis, and thrombosis in the spongy layer of the decidua basalis. At this stage, the chorionic villi are underdeveloped and loosely connected to the maternal body, so during late abortion, the embryo and the entire gestational sac are usually completely detached from the uterine wall and expelled, resulting in minimal bleeding. Such late abortions are often overlooked and mistaken for a delayed menstruation. The typical expelled specimen is a thick, opaque, slightly blood-stained gestational sac. The thickest part of the sac contains proliferating villi, which can be seen floating when placed in water. Upon cutting open the sac wall, a small amount of amniotic fluid is present, and the embryo or absorbed embryonic tissue, about the size of a grain of rice and gray in color, can be seen attached to the gray amniotic membrane. For those occurring between 8 and 12 weeks, the chorionic villi are already well-developed and more firmly attached to the decidua basalis. Often, only the fetus or part of the placenta and villi are expelled, while the remaining tissue is retained in the uterine cavity, impairing uterine contractions and leading to significant bleeding. In some cases, the fetus may die but not be expelled immediately. Repeated minor hemorrhages occur around the embryo, with blood accumulating in the spaces between the decidua basalis and villi, potentially infiltrating the gestational sac. The blood clots after flowing out, and subsequent bleeding may form new clots surrounding the old ones. The embryo becomes encased in multiple layers of blood clots, known as a blood mole. Over time, as hemoglobin is absorbed, it turns into a fleshy mole. Blood clotting between the villi and decidua forms irregular nodular masses protruding into the amniotic sac, compressing and shrinking it. This interrupts placental circulation, leading to fetal absorption and the formation of a nodular mole. Once the placenta is fully formed and firmly attached to the uterine wall, the process of late abortion resembles that of premature labor or full-term delivery. Uterine contractions begin, the cervical os gradually dilates, the amniotic membrane ruptures, the fetus is expelled, and the placenta either detaches and is expelled or remains in the uterine cavity. The amount of bleeding varies depending on the extent of placental detachment. If the fetus dies in utero without infection, it becomes a macerated fetus, with softened skin and umbilical cord, dark red discoloration due to hemoglobin deposition, and amniotic fluid stained with blood, turning brown over time.
Less commonly, the fetus undergoes mummification. The amniotic fluid is absorbed, and the fetal skin adheres to the bones, appearing dry and white, with the body flattened into a paper-like fetus.
bubble_chart Clinical Manifestations
1. The main symptoms of late abortion are bleeding and abdominal pain
(1) Vaginal bleeding: In cases of late abortion within 3 months of pregnancy, bleeding begins when the chorion and decidua separate, opening the blood sinuses. When the embryo is completely detached and expelled, the uterus contracts strongly, closing the blood sinuses and stopping the bleeding. Therefore, the entire process of early late abortion is accompanied by vaginal bleeding. In advanced-stage late abortion, the placenta has already formed, and the bleeding is generally not excessive, similar to premature labor and full-term delivery.
(2) Abdominal pain: In early late abortion, after bleeding starts, the presence of blood, especially clots, in the uterine cavity stimulates uterine contractions, causing persistent lower abdominal pain. In advanced-stage late abortion, there are first paroxysmal uterine contractions, followed by placental detachment, so abdominal pain occurs before vaginal bleeding.
Abdominal pain and bleeding are mostly progressive and related to the clinical course and progression.
2. Clinical classification of late abortion
Late abortion generally follows a certain developmental process, although some stages may not be clinically obvious and may not necessarily occur in sequence. However, the process usually falls into the following clinical types: threatened abortion, inevitable abortion, incomplete abortion, and complete abortion. Missed abortion is another special case in the development of late abortion. Habitual abortion is named for its characteristic of recurrent abortions, but both still fall within the above clinical classifications during the abortion process.
(1) Threatened abortion: Exhibits signs of late abortion, but with appropriate treatment, the pregnancy may continue to full term. It often occurs in early pregnancy, with only slight vaginal bleeding accompanied by mild intermittent uterine contractions. Upon examination, the cervical os is not dilated, the amniotic sac is intact, the uterine size matches the gestational age, and the pregnancy test is positive.
(2) Inevitable abortion: Follows the above process, but as the embryo continues to separate from the uterine wall, the bleeding lasts longer and becomes heavier, exceeding normal menstrual flow, with clots expelled. Paroxysmal lower abdominal pain intensifies, presenting as spasms or a sensation of heaviness. Examination reveals gradual dilation of the cervical os. In more advanced pregnancies, the amniotic sac may bulge or rupture, or embryonic tissue may block the cervical canal or even protrude from the external os. Abortion is inevitable, and the pregnancy cannot continue.
(3) Incomplete abortion: Often occurs in more advanced pregnancies (after 10 weeks), when the placenta is developing or has already formed. During abortion, the fetus and part of the placenta are expelled, but the entire or part of the placenta remains attached to the uterine wall, preventing proper uterine contraction and resulting in significant vaginal bleeding. Retained placental tissue may later form a placental polyp, causing recurrent bleeding and increasing the risk of infection.
(4) Complete abortion: After passing through the threatened and inevitable abortion stages, the embryonic tissue is completely expelled within a short time, and bleeding and abdominal pain cease.
(5) Missed abortion: Also known as overdue abortion or retention of dead fetus. It refers to the retention of a dead embryo in the uterine cavity, with the pregnancy products usually expelled within 1 to 2 months after symptoms appear. Therefore, it is generally defined as a missed abortion if the embryo fails to be expelled naturally within 2 months after its development ceases. Most pregnant women experience early pregnancy threatened abortion symptoms, after which the uterus stops growing and gradually shrinks, losing the typical softness of a normal pregnancy. Pregnancy tests change from positive to negative, and the placenta becomes fibrosed and tightly adhered to the uterine wall, making separation difficult. Additionally, due to insufficient sex hormones, uterine contractions weaken, hindering expulsion and leading to retention. After embryo death, placental dissolution releases hemolytic enzymes into the maternal bloodstream, causing microvascular coagulation and depleting clotting factors. The longer the retention period, the higher the risk of coagulation disorders. With the widespread clinical use of ultrasound, the gestational sac and embryo can be detected as early as 6 to 7 weeks of gestation. If embryonic developmental arrest is suspected, ultrasound can confirm the diagnosis promptly, enabling timely intervention. Some question the continued use of the term "missed abortion," but clinically, cases with subtle symptoms may go unnoticed, leading to prolonged retention of the dead embryo before diagnosis.
(6) Habitual late abortion (habitual abortion): Three or more consecutive spontaneous late abortions are referred to as habitual late abortion, and the late abortion often occurs in the same month. The process of late abortion may follow the clinical subtypes mentioned above.
bubble_chart Auxiliary Examination
Ultrasound technology provides clear image resolution, and transabdominal ultrasound examinations for various early-stage late abortions show high concordance rates, enabling early diagnosis and treatment. Particularly in recent years, vaginal probe examinations for early pregnancy and early late abortion have proven superior to transabdominal examinations. Additionally, basal body temperature (if pregnant, the temperature does not drop again), pregnancy tests, vaginal smears, and cervical mucus crystallization all hold certain diagnostic significance. The level of chorionic membrane gonadotropin has decreased to the normal range.
1. First, determine whether it is a late abortion.
(1) Detailed medical history inquiry: whether there is a history of amenorrhea, vaginal bleeding, the amount and nature of bleeding, and whether it is accompanied by abdominal pain or other discharges.
1. In late abortion, uterine bleeding is generally more significant than in ectopic pregnancy and differs from other abnormal pregnancies. Ectopic pregnancy often presents with spotting vaginal bleeding; bleeding in hydatidiform mole is typically dark red and may recur, sometimes leading to massive vaginal bleeding. Upon careful examination, vesicle-like tissue may occasionally be found in the blood. Dysfunctional uterine bleeding usually occurs at the extremes of reproductive age. In women over 40, it is often accompanied by a history of amenorrhea, with heavy vaginal bleeding but little to no abdominal pain and rarely any other discharges. These conditions, combined with obstetric history and contraceptive use, can usually be distinguished. If in doubt, diagnostic curettage with pathological examination can confirm the diagnosis and guide treatment. Many cases of late abortion are misdiagnosed as dysfunctional uterine bleeding. Patients with uterine fibroids typically have no clear history of amenorrhea but may report hypermenorrhea and infertility. Examination reveals an enlarged uterus, and if fibroids are palpable, the diagnosis is more definitive.
2. Time interval between bleeding and the last menstruation: The duration from the last menstruation to the onset of vaginal bleeding is usually shorter in ectopic pregnancy but longer in late abortion and hydatidiform mole.
3. Color of the discharged blood: In late abortion, the blood is initially bright red, turning dark red or brown over time. Ectopic pregnancy often presents with scant, light red or brown bleeding, while hydatidiform mole typically shows dark red bleeding.
4. Abdominal pain: In late abortion and hydatidiform mole, abdominal pain is generally mild, intermittent, and centered in the lower abdomen. Ectopic pregnancy causes severe unilateral lower abdominal pain, which may spread to the entire abdomen and gradually subside over 1–2 days. Dysfunctional uterine bleeding is rarely accompanied by lower abdominal pain. Uterine fibroids may cause pelvic heaviness or mild pain.
5. Assess whether there were early pregnancy symptoms after amenorrhea and potential triggers for late abortion, such as sexual activity, heavy lifting, or travel.
(2) Bimanual examination: Note the position, size, shape, and firmness of the uterus, whether the isthmus is unusually soft (as if the uterine body and cervix are discontinuous), the presence of masses or tenderness in the adnexa, and whether the cervical os shows erosion, bleeding, or polyps. Confirm that the bleeding originates from the uterus—if it is a late abortion, the bleeding must be uterine in origin.
(3) Auxiliary examinations.
2. Determine the type of late abortion.
Different types of late abortion present with varying labor processes and require different management principles, so the specific type must be identified.
If vaginal bleeding is minimal, the cervical os is not dilated, and the uterine size matches the gestational age, it is a threatened late abortion. If the cervical os is dilated, the amniotic sac is protruding or ruptured, and vaginal bleeding is heavy, it is an inevitable late abortion. Heavy bleeding with partial tissue expulsion and a uterus smaller than the gestational age indicates an incomplete late abortion. A history of threatened late abortion, initially heavy bleeding that rapidly decreases or stops after embryonic tissue expulsion, a closed cervical os, and well-contracted uterus suggest a complete late abortion. If the uterine size is smaller than the gestational age and the pregnancy test is negative, it is a missed late abortion.
Habitual late abortion.
First, identify the cause of late abortion, emphasizing joint evaluation of both partners, not just the female. Male factors should also be considered. Hospitals with the necessary resources often have genetic and eugenics counseling clinics, where the diagnosis and treatment of habitual late abortion is a key focus.
(1) Detailed inquiry into past pregnancy history, medical history, and family genetic history. If a genetic disorder is suspected, a pedigree chart should be constructed.
(2) Conduct a comprehensive physical and gynecological examination.
(3) Perform necessary laboratory and auxiliary tests. For males: semen analysis, blood type, chromosomes, etc. For females: vaginal smear, cervical scoring, basal body temperature, blood type, chromosomes, and ultrasound to assess uterine development and anomalies.
(4) Further tests may be conducted as needed:
1. In addition to ultrasound, suspected uterine malformations can be investigated with hysterosalpingography, hysteroscopy, or laparoscopy.
2. Suspected endocrine abnormalities, check fasting blood glucose. Combined with basal body temperature, perform pathological examination of the uterine membrane and radioimmunoassay for progesterone, LH, FSH, PRL, E2, T3, T4, TSH, 17-OH, 17-Cu, etc. If necessary, cranial CT can be performed to determine whether there are microadenomas in the pituitary gland.
3. Suspected special infections can be checked for cytomegalovirus, toxoplasma, and chlamydia.
4. For those with a history of exposure to adverse environments, perform SLE, micronucleus, and chromosome aberration rate tests.
5. For suspected ABO blood type incompatibility, further check antibody titers. If checked intermittently during pregnancy, observe whether the antibody titer changes. After treatment, check whether the titer decreases.
III. Whether there are complications of late abortion (details follow).
bubble_chart Treatment Measures
1. Threatened Late Abortion The clinical treatment principle is to preserve the fetus. Approximately 60% of threatened late abortions can be effectively managed with appropriate treatment. First, confirm embryo viability via ultrasound. Absolute bed rest is required until symptoms subside, followed by moderate activity. Avoid all stimuli that may induce uterine contractions, such as vaginal examinations or sexual intercourse. Minimize unnecessary anxiety and concerns in patients. Educate patients from a eugenic perspective: most early late abortions are due to abnormal embryos caused by various factors, and late abortion is a natural selection process that should not be regretted.
Ensure adequate nutrition. Use sedatives that are harmless to the fetus, such as Luminal 0.03–0.06g, three times daily. Maintain regular bowel movements. For constipation, mild laxatives like Tongbian Ling (containing aloe and amber, etc.), 1–2 capsules, are preferable, as they are easier to dose compared to Phenolphthalein or Bisacodyl, and effectively soften stools.
For endocrine therapy, such as in cases of luteal insufficiency, administer progesterone 20mg intramuscularly once or twice daily to promote decidual growth and inhibit uterine muscle activity. Treatment should be monitored via ultrasound.
Regarding estrogen use, recent studies by many scholars report an increased risk of vaginal adenosis or even adenocarcinoma in female infants.
Early application of chorionic gonadotropin promotes progesterone synthesis. Vitamin E (tocopherol) benefits embryonic development; take 100mg orally daily. Some authors suggest Vitamin E has a progesterone-like effect on the uterus and acts on the central nervous system; take 200mg twice daily.
For low basal metabolic rate, administer thyroid tablets 0.03g/d orally.
Monitor embryo status via ultrasound to avoid unnecessary fetal preservation.
**Chinese Medicine and Herbs**: Chinese medicine attributes threatened late abortion to qi and blood deficiency, weakened kidney qi, and instability of the fetal origin, leading to disharmony of qi and blood, instability of the Chong and Ren meridians, and impaired embryo implantation and development, resulting in late abortion.
(1) **Qi and Blood Deficiency**: In the early stage of pregnancy, symptoms include vaginal bleeding, sore waist, abdominal heaviness, or in the intermediate stage, threatened abortion, vaginal bleeding, mental fatigue, lack of strength, pale tongue, and weak, slippery pulse.
**Treatment**: Tonify qi, nourish blood, and calm the fetus.
**Prescription**: Modified Taishan Panshi Decoction: Codonopsis Root 10g, White Atractylodes Rhizome 10g, Astragalus Root 10g, Peony Root 10g, Skullcap Root 10g, Dipsacus 10g, Tangerine Peel 6g, Prepared Rehmannia Root 10g, Villous Amomum Fruit 10g.
(2) **Kidney Deficiency**: Symptoms include sore waist, weak legs, or a history of late abortion, threatened pregnancy, severe sore waist, abdominal pain, fetal descent with bleeding, frequent urination, deep and weak pulse, pale red tongue with scant coating.
**Treatment**: Tonify the kidney to calm the fetus.
**Prescription**: Modified Fetus-Preserving Pill: Dodder Seed 30g, Chinese Taxillus Herb 10g, Dipsacus 10g, Eucommia Bark 10g, Prepared Rehmannia Root 10g, Donkey-hide Gelatin 10g (infused), Prepared Liquorice Root 3g.
(3) **Blood Heat**: Threatened abortion, descent sensation, bright red vaginal bleeding, dry mouth, irritability, feverish palms, dark urine, red tongue with thin yellow coating, slippery and rapid pulse.
**Treatment**: Clear heat to calm the fetus.
**Prescription**: Unprocessed Rehmannia Root 10g, Hangshao (Peony Root) 10g, Skullcap Root 10g, Dipsacus 10g, Chinese Yam 10g, Yerbadetajo Herb 10g.
2. **Inevitable Late Abortion** The treatment principle is to remove embryonic tissue from the uterine cavity. For early pregnancy, perform suction curettage. For heavy bleeding, immediately inject 10U of posterior pituitary (or oxytocin) to promote uterine contractions and expel tissue, preparing for suction curettage. For intermediate-stage pregnancy, induce labor with posterior pituitary (or oxytocin). Methods: ① Posterior pituitary (or oxytocin) 5U intramuscularly every 30 minutes for 4–6 doses to await spontaneous expulsion. Caution or avoid in cases of uterine trauma or infection history to prevent uterine rupture. ② High-concentration oxytocin induction: administer 1–5% oxytocin (1–5U per 100ml) intravenously, starting at a low concentration and gradually increasing to an effective level (inducing strong uterine contractions), maintaining until embryonic tissue is expelled.
Bleeding for a long time, the uterine orifice is dilated, and the embryo can be removed surgically.
III. Incomplete late abortion: The uterine cavity should be evacuated. If there is heavy bleeding or signs of shock, intravenous fluids and blood transfusions should be administered to correct the shock, while simultaneously administering 10U of oxytocin intravenously or intramuscularly, and preparing to evacuate the uterine cavity. Once the shock is corrected, placental tissue should be removed with forceps or suction to stop the bleeding.
Postoperative infection prevention is necessary. Iron supplements and Chinese medicinals should also be given to correct anemia.
IV. Complete late abortion: After the expulsion of embryonic tissue, bleeding stops and abdominal pain disappears. Apart from advising the patient to rest and pay attention to postpartum care, no special treatment is required. However, it is essential to accurately determine whether all embryonic tissue has been expelled. If examination confirms the presence of a complete gestational sac, decidua, or fetal placenta, combined with symptoms and further tests such as ultrasound if necessary, a diagnosis of complete late abortion can be made. If uncertainty remains, the case should be managed as an incomplete late abortion, and another curettage is advisable.
V. Missed late abortion: There is no consensus on management, with opinions even being completely antagonistic. Some believe no intervention is necessary, allowing natural expulsion. Others argue for surgical evacuation immediately after diagnosis. Current principles of management are as follows: If pregnancy is within 3 months and fetal death is confirmed, the uterine cavity should be evacuated promptly. For pregnancies beyond 3 months, high doses of estrogen are administered first, followed by oxytocin to induce labor. If unsuccessful, surgical intervention may be considered. In missed late abortion, the longer the fetal death persists, the more difficult curettage becomes due to tissue organization. Recent clinical and literature reports suggest that emetic therapy for missed late abortion beyond 16 weeks may lead to coagulation disorders and severe bleeding. Therefore, active management after diagnosis is recommended.
Preoperatively, estrogen or diethylstilbestrol 5mg should be given four times daily for 3–5 days to sensitize the uterus to oxytocin. Preoperative blood tests, including coagulation time and, if possible, fibrinogen levels, should be performed, with blood transfusion preparations made.
For pregnancies within 3 months, suction or cervical canal insertion 12 hours before forceps curettage may be performed.
For later pregnancies, ultrasound should first be performed to assess fetal size and the presence of amniotic fluid. If amniotic fluid is present, amniocentesis with 80–100mg of rivanol injected into the amniotic cavity can induce labor. Oxytocin may also be used if necessary, though the former method is more convenient and safer.
VI. Habitual late abortion: Patients with a history of habitual late abortion should regularly monitor basal body temperature. If the menstrual cycle is slightly prolonged and basal temperature does not drop, treatment should begin upon suspicion of pregnancy. Avoid physical exertion and stress, abstain from intercourse, and start oral vitamin E (100mg/day) along with vitamins B and C. Early β-hCG testing and ultrasound should confirm the diagnosis. Identify the cause and treat accordingly:
1. Chromosomal abnormalities: Prenatal diagnosis is required. If the male partner has chromosomal abnormalities, artificial insemination by donor (AID) may be considered with spousal consent. For other genetic factors, management depends on inheritance patterns. If there is a clear genetic predisposition and no reliable prenatal diagnostic method, termination of pregnancy should be advised.
2. ABO Blood Type Incompatibility: For those with IgG antibody titers in Zone II or above, administer Virgate Wormwood Decoction (Virgate Wormwood 10g, Prepared Rhubarb Rhizoma 3g, Skullcap Root 12g, Liquorice Root 10g), 10 doses each during early, middle, and late pregnancy. Motherwort Pill (motherwort herb 500g, Chinese Angelica 250g, Sichuan Lovage Rhizome 250g, Peony Root 300g, Guang Aucklandia Root 12g. Grind into fine powder and mix with honey to form pills, each weighing 10g), take 1 pill each time, 2-3 times daily. Regular follow-ups are also required to monitor changes in antibody titers, in addition to obstetric conditions. Among 228 cases of maternal-fetal blood type incompatibility at Shandong Provincial Hospital, 214 cases were ABO incompatibility with IgG anti-A(B) antibodies detected in the serum, and 12 cases were Rh incompatibility. After subsequent pregnancies, 88 cases were followed up and treated regularly at the hospital: 17 cases had compatible maternal-fetal blood types, while 71 cases were incompatible. Among these, 58 cases showed IgG anti-A(B) antibodies in umbilical cord blood, including 10 cases of severely affected newborns who all survived after treatment. Of the 12 Rh incompatibility cases, 9 became pregnant again, and 5 survived after treatment. In addition to the aforementioned Chinese medicinals, Shandong Provincial Hospital also administered a 10-day therapy for cases with antibody titers in Zone III or above during early, middle, and advanced pregnancy: intravenous injection of 40ml 50% glucose plus 500mg vitamin C, once daily; oxygen inhalation for 30 minutes daily for 10 consecutive days; and 100mg vitamin E once daily. Chinese herbal medicine possesses blood type substance characteristics, enabling it to specifically bind with corresponding antibodies, thereby inhibiting the antibodies, reducing titers, and preventing ABO neonatal hemolytic disease and late abortion.
Newborns with Rh hemolytic disease undergo exchange transfusion, and preventing post-exchange complications is key to successful treatment. For pregnant women carrying fetuses with severe Rh hemolytic disease, prenatal plasma exchange can reduce the amount of antibodies in the mother, lower antibody titers, mitigate antigen-antibody binding, lessen fetal damage, and improve the chances of neonatal survival.
3. Uterine abnormalities: For confirmed cases of bicornuate uterus, double uterus, or septate uterus in non-pregnant women, uterine reconstruction surgery can be performed. Zhang Peisheng from Liaocheng, Shandong, reported that two cases of bicornuate uterus (one with infertility and one with habitual late abortion) both resulted in live births shortly after uterine reconstruction. The surgery avoided the asynchronous hormonal response of the original double uterus, thereby eliminating the foreign body stimulation of the non-pregnant uterus on the pregnant uterus and increasing the chances of embryo implantation. Post-surgery contraception is advised for three months. If pregnancy reaches full term, a cesarean section should be performed before labor. For those eager to have children, one additional pregnancy may be permitted. Since there is little difference in pregnancy maintenance rates between pregnancies occurring within six months post-surgery and those occurring after six months, and no significant difference in uterine scar observation during cesarean section, prolonged contraception is unnecessary.
For habitual late abortion caused solely by uterine fibroids without other reasons, myomectomy can be performed during the non-pregnant period, but the patient and family should be informed that late abortion may still occur. Uterine adhesions can be treated with adhesion separation. Cervical incompetence will be discussed later.
4. Luteal phase defect: Treatment includes progesterone, chorionic gonadotropin, clomiphene, etc.
5. Immunotherapy: Used for habitual late abortion with no clear cause, where the wife lacks HLA antibodies against the husband. The method involves aseptically isolating lymphocytes from the husband’s venous blood at a concentration of 3000–4000×104/ml and injecting them intradermally into the wife every 3–4 weeks for a total of 3–5 immunizations. Some authors report good efficacy with immunotherapy using the husband’s lymphocytes: out of 311 cases, 200 achieved pregnancy, including 124 live births and 23 ongoing pregnancies beyond 24 weeks, totaling 73.5%. Shandong Provincial Hospital reported a success rate of 87.5% (28 out of 32 cases) after immunotherapy.
Traditional Chinese Medicine (TCM):
1. Qi and blood deficiency: Treatment follows the approach for threatened late abortion. After symptom improvement, take one dose every 3–5 days until the fourth month. For morning heat, double Skullcap Root and reduce Villous Amomum Fruit; for stomach cold, increase Villous Amomum Fruit and reduce Skullcap Root. For vaginal bleeding, combine with Donkey-hide Gelatin and Artemisia Decoction, sometimes adding Eucommia Bark and Chinese Taxillus Herb. For excessive fetal fire, add Phellodendron Bark and Anemarrhena.
2. Kidney qi insecurity:
Treatment: Tonify the kidney and secure the Chong meridian.
Prescription: Kidney-Securing Chong Pill: Dodder Seed 75g, Dipsacus 30g, Donkey-hide Gelatin 45g, Degelatined Deer-horn 30g, Prepared Rehmannia Root 45g, White Atractylodes Rhizome 30g, Eucommia Bark 30g, Barbary Wolfberry Fruit 30g, Villous Amomum Fruit 10g, Chinese Angelica (body) 24g, Morinda 30g, Chinese Date (flesh) 20 pieces. Grind into fine powder and form into honeyed pills, each weighing 10g. Dosage: Take one pill three times daily. Discontinue during menstruation. Two months constitute one course. If pregnancy occurs, take the modified Kidney-Tonifying Fetus-Calming Decoction: Tangshen 12g, White Atractylodes Rhizome 10g, Eucommia Bark 12g, Sichuan续断12g, Cibot Rhizome 12g, Donkey-hide Gelatin 10g, Mugwort炭10g, Dodder Seed 10g, Chinese Taxillus Herb 10g, Sharpleaf Galangal Fruit 10g, Psoralea 10g.
Begin taking two weeks before the habitual late abortion month, one dose every other day, and continue past the habitual late abortion month.
1. Massive blood loss Sometimes, inevitable late abortion or incomplete late abortion can cause severe massive blood loss, even shock. Therefore, active management is essential. Various measures can be taken simultaneously. Administer 10U of oxytocin or posterior pituitary hormone intravenously or intramuscularly. Strive to provide the patient with a blood transfusion. In the absence of a blood bank, medical staff or family members may be mobilized to donate blood. If blood is truly unavailable for the time being, intravenous dextran infusion can be temporarily administered. Simultaneously, perform curettage; bleeding often stops after the removal of embryonic tissue, and even in the presence of infection, large pieces of embryonic tissue should be removed. Subsequently, active efforts should be made to arrange for a blood transfusion.
2. Infection All types of late abortion mentioned above can be complicated by infection, with incomplete late abortion being the most common. Infection often occurs due to the use of inadequately sterilized instruments during late abortion procedures, cervical injury caused by instruments, or pre-existing intrauterine infections that may spread after surgical or spontaneous late abortion. Additionally, poor hygiene after late abortion (whether spontaneous or induced) or engaging in sexual intercourse too early can lead to infection. The pathogens involved are often mixed infections of various bacteria, including both anaerobic and aerobic bacteria. Recent reports indicate that anaerobic bacteria account for the majority (60–80%).
The infection may be confined to the uterine cavity or spread to surrounding areas, leading to salpingitis, salpingo-oophoritis, pelvic connective tissue inflammation, or even extending beyond the reproductive organs to cause peritonitis or sepsis.
Patients may experience chills, fever, abdominal pain, vaginal bleeding, and sometimes foul-smelling discharge. Tenderness in the uterus and adnexa, poor uterine involution, and elevated white blood cell count are common inflammatory manifestations. Severe cases may develop septic shock. Blood, cervical, or intrauterine secretion smears and cultures (for both aerobic and anaerobic bacteria) can be performed. Ultrasound can check for retained tissue in the uterine cavity.
Treatment:
1. Rapidly control the infection with intravenous metronidazole and antibiotics. The type, dose, and route of administration should be determined based on the severity of the condition. If culture and sensitivity results are available, targeted treatment can be selected.
2. Remove infected tissue from the uterine cavity as soon as possible. Curettage can be performed 6 hours after intravenous medication to extract large tissue fragments.
3. Supportive therapy, including fresh blood transfusion if necessary, and various vitamins.
4. For traditional Chinese medicine treatment, refer to the chapter on pelvic inflammatory diseases.
3. Poor uterine involution Uterine contraction agents such as ergot liquid extract or motherwort herb liquid extract can be administered. If placental retention is suspected, curettage can be performed after the infection is controlled. However, in cases of massive bleeding, immediate curettage is necessary.
4. Acute renal failure Acute renal failure may occur after late abortion due to massive blood loss and severe infection leading to shock.
5. Placental polyp Compared to full-term pregnancy, placental polyps occur more frequently after late abortion. They can cause severe uterine bleeding, usually within a few weeks after late abortion. Examination may reveal a slightly enlarged and softer uterus with mild cervical dilation. Sometimes, pregnancy tests may still be positive. Cervical dilation and curettage should be performed to remove the polyp. Pathological examination is mandatory, which may show intact or degenerated villi surrounded by blood clots.
(1) Ultrasonic diagnosis: Generally, the gestational sac can be seen at 5-6 weeks of pregnancy, and the fetal bud can be seen at 6-7 weeks of pregnancy. The vaginal probe is earlier than the abdominal probe. When there are no clinical signs of {|###|}late abortion{|###|}, a blighted ovum can be detected by ultrasound. A gestational sac >20mm without an {|###|}egg yolk{|###|} sac or a gestational sac >25mm without a fetal bud is considered a blighted ovum. The image shows only a larger gestational sac with an anechoic area inside.
The following types of {|###|}late abortion{|###|} can be diagnosed:
1. Threatened {|###|}late abortion{|###|}: In mild cases, ultrasound shows a small amount of bleeding, with the gestational sac surrounded by an anechoic area on one side, which is minimal but clear. In severe cases, there is a large amount of blood accumulation in the uterine cavity, and sometimes the separation of the fetal {|###|}membrane{|###|} from the uterine wall can be seen, with an anechoic area behind the fetal {|###|}membrane{|###|}. Depending on the stage of pregnancy, the fetal bud and primitive fetal heartbeat may be visible.
2. Inevitable {|###|}late abortion{|###|}: Ultrasound findings: ① Deformation of the gestational sac, downward displacement of the gestational sac, or leakage of amniotic fluid; ② The internal os or cervical canal is dilated, and embryonic products have descended and are obstructing the internal os or cervical canal. If the fetal {|###|}membrane{|###|} is intact, a cystic dark area may be seen in the cervical canal or {|###|}vagina{|###|}; ③ The fetus is mostly dead, with no fetal heartbeat.
3. Incomplete {|###|}late abortion{|###|}: Ultrasound findings: ① The {|###|}uterus{|###|} is slightly enlarged; ② There are irregular echogenic masses or small dark areas in the uterine cavity.
4. Complete {|###|}late abortion{|###|}: Ultrasound image: ① The {|###|}uterus{|###|} is normal in size or slightly enlarged; ② Regular uterine cavity waves are seen in the uterine cavity, with no irregular echogenic masses.
5. Missed {|###|}late abortion{|###|}: In recent years, ultrasound has been used to promptly detect embryonic death without waiting two months for diagnosis. Therefore, some have proposed the term "intrauterine fetal death." Ultrasound findings: ① The {|###|}uterus{|###|} is smaller than the gestational age; ② No fetal heartbeat or movement is observed; ③ The echoes in the {|###|}uterus{|###|} are disordered, making it difficult to distinguish placental or fetal structures.
(2) Vaginal cytology
1. The appearance of chorionic syncytial cells in smears tends to indicate {|###|}late abortion{|###|}. Chorionic syncytial cells are cell clusters of varying sizes, with basophilic cytoplasm containing different numbers of deeply stained large nuclei, often surrounded by red and white blood cells, which is characteristic.
2. Pyknotic index: An elevated pyknotic index in vaginal smears during {|###|}pregnancy{|###|} indicates progesterone deficiency. The reasons for this are: first, ovarian luteal insufficiency, leading to poor development of the endometrial and decidual membranes, resulting in defective trophoblast; second, defects in the trophoblast itself. Luteal insufficiency may recover naturally or after treatment. If the trophoblast shows extensive abnormalities, whether due to primary defects in the fertilized egg or secondary to trophoblast separation or decidual defects, {|###|}late abortion{|###|} will be inevitable. The prognosis differs in these two cases, but the pyknotic index is elevated in both, so it cannot distinguish between them. Only continuous observation of pyknotic changes is meaningful.
(3) Cervical mucus crystallization: Estrogen can produce cervical mucus crystallization, while progesterone inhibits crystallization. Therefore, examining cervical mucus crystallization during pregnancy can predict the prognosis of {|###|}late abortion{|###|}.
(4) Basal body temperature: Early {|###|}pregnancy{|###|} should maintain a high-temperature curve for about 16 weeks, gradually normalizing. In cases of threatened {|###|}late abortion{|###|}, if the basal body temperature is the same as in normal {|###|}pregnancy{|###|}, the prognosis is good; if it is lower than normal {|###|}pregnancy{|###|}, the prognosis is poor.
(5) Hormone measurement: For {|###|}late abortion{|###|} caused by endocrine abnormalities, hormones can be measured based on different conditions. For example, if luteal insufficiency is suspected, pregnanediol can be measured to observe dynamic changes and select appropriate treatment methods.
