Types of Abortion

Abortions, which are referred to as “abortus” in the medical literature, are termination of pregnancy for various reasons in the first half of pregnancy, that is before the twentieth week of pregnancy, or before the fetus reaches a weight of 500 grams.

The intra uterine content consisting of a fetus, placenta, amniotic sac and decidua during this period is called “pregnancy materials” or “pregnancy products”.

Whereas deliveries that take place between the 20th and 37th weeks of pregnancy are defined as “preterm delivery” rather than abortion.

Types of Abortion

Early abortion: Abortions that occur in the first 12 weeks of pregnancy.

Late abortion: Abortions that take place between the 12th and 20th weeks of pregnancy.

Spontaneous abortion: Throwing of the pregnancy out of the uterus directly without any interventions.

Imminent Abortion: Occurrence of vaginal bleeding despite the existence of a fetus living in the uterus in the first half of the pregnancy. In this case, abortion has not taken place yet, an imminent abortion or abortion risk is in question.

The color of bleeding in vaginal bleedings can be in different colors ranging from brown to light red. Bright bleedings imply a fresh (recent) bleeding and are more dangerous.

Brown bleedings, on the other hand, are related to the drainage of previous bleedings from inside to outside in the later periods.

Cramp-like aches might accompany bleedings. However, an openness does not exist in the uterine cervix in imminent abortion.

90% of the bleedings in the first weeks in pregnancies heal spontaneously and does not lead to a disability (anomaly) in the fetus. However, 10% might result in inevitable abortion (abortus insipiens) due to the increasing spasms.
The things you must do if imminent abortion (Abortus imminens) is identified in the ultrasound scan when you apply to your doctor due to vaginal bleeding during your pregnancy are as follows and extremely important:

• Definitely be on bed rest (according to the suggestions of the doctor)
• Avoid sexual intercourse
• Avoid lifting heavy load and doing hard work
• Stay away from stress
• Consider the suggestions of your doctor into consideration and take the necessary medication
• Inform your doctor again if your bleeding increases and if you drop a piece of the fetus.

Abortus insipiens (Inevitable Abortion): An opening in the cervix accompanied by bleeding and intense pain results in an inevitable abortion.

Pregnancies of pregnant women diagnosed with abortus insipiens must be terminated with an abortment in a controlled manner because a person in this situation is laboring and maintenance of pregnancy is impossible.

Incomplete Abortion: Failure to throw the “pregnancy materials”, which consists of the fetus, placenta, amniotic sac and decidua outside the uterus completely. Some material remains inside the uterus.

In this situation, the gestational sac is destroyed when a part of the pregnancy materials is thrown out with bleeding and contractions of the uterine (uterus spasms) but the material which cannot be thrown out remains inside.

Curettage must be performed on patients with residual material (rest) inside the uterus, that is the intra uterine must be cleaned out.

Residual materials:  Pregnancy material that remains in the intra uterine for days and even weeks after abortion or sometimes abortment is called “rest” and the residual material might force the patient to consult a doctor by causing bleeding.

When residual materials are identified, the pregnancy material inside the uterus must be cleaned out with abortion.

As the probability that a part of the fetus has been left inside after abortion in pregnancies that are older than 6-7 weeks is high, the patient must undergo an abortion to make sure that no parts are left inside.

Complete abortion: Products relating to pregnancy are thrown out of the body as a whole through bleeding and uterus contractions and no tissues relating to pregnancy have been left in the uterus in this situation.

Pregnancy materials can be completely thrown out of the body through uterus contractions as the volume of tissues inside the uterus is low especially in very early pregnancies that are 4-5 weeks old. This can be identified with vaginal ultrasound and an intervention is usually not necessary anymore as no materials relating to pregnancy are left inside the uterus. Bleeding of the women also starts decreasing of its own accord. 

Blighted ovum, un-embryonic pregnancy: In this situation which people also call “blighted ovum”, “un-embryonic pregnancy” or “empty water bag”, a fetus is not available in the amniotic sac and placenta which make up the gestational sac while these structures are being formed.

Controlled termination of the pregnancy, that is abortion, is a must as a healthy pregnancy does not exist in the uterus although the pregnancy test results are positive when the individual has a blood or urine test.

Otherwise, the pregnancy will come to an end by its own Accord in and out of season. This sudden situation might lead to panic in the individual.

Missed abortus: Intrauterin exitus is a frequently used term which implies the death of the fetus in the uterus.

Abortus cannot fully take place as no uterus spasms are present although the fetus has died inside the uterus, that is although missed abortus, intrauterin exitus has taken place, and the situation might not be noticed even though a long period of time has passed.

The fact that the fetus has remained death in the uterus for a long time might lead to dirty brown bleeding. The prevalence of missed abortus has decreased a lot thanks to the routine ultrasound controls performed in the first period today.

Fetus’s remaining dead inside the uterus for a long time without being thrown out is extremely important as it might lead to blood coagulation problems that might threaten the life of the expectant mother.

Elective abortus: Termination of the pregnancy with the consent of the expectant mother and father although there are no complications.

Elective abortion is usually referred to by people as “abortion”. However, the term abortion covers all the procedures relating to the cleaning up of the intra uterine.

Chemical pregnancy: I believe that it will be beneficial to provide information relating to the commencement of the pregnancy in order to be able to fully understand chemical pregnancy.

Pregnancy, which is a 40-week marathon, begins when the ovule (oosphere) from the mother and the sperm cell from the father unite in the tubes. The ovule, which is inseminated after this stage, reproduces via mitosis. Cells contained by the new living being (zygote) formed increase in number on the one hand and nidate by holding onto the intrauterine membrane (endometriuma) at the “blastocyst” stage going further into the tube on the other (implantation).

At the blastocyst stage, the embryo has already reached the uterine, and the hormone specific to pregnancy which is called human chorionic gonadotropin (HCG) has started being secreted. The amount of this hormone increases first in the blood and then in the urine as pregnancy progresses. Blood levels need to reach high values so that it can be identified in the urine.

The gestational sac can be seen via a “vaginal ultrasonography” performed from the vagina when HCG hormone level usually reaches up to 500-1000 IU/mL.

Pregnancy can be seen at a later stage via an ultrasound performed from the abdomen and in this case, the pregnancy test (Beta HCG) level in the blood has to rise up to 5000 IU/ml.

Identification of pregnancy in the uterus via vaginal or abdominal ultrasounds is called “clinical pregnancy”.

However, in some cases, an increase in the HCG level might be detected via a pregnancy test performed in the blood 1-2 days before menstrual bleeding even when the menstrual bleeding is not delayed. However, when pregnancy loses its aliveness due to any reason whatsoever, the pregnancy sometimes comes to an end without any delays in the menstrual bleeding or with a bleeding delayed for 1-2 days. This is called “chemical pregnancy”.  In other words, pregnancy has been identified via examination of the blood but is over before it reaches a stage, in which it can be identified clinically.

That is, in chemical pregnancy, “blastocyst” formed after the ovule and the sperm cell unite in tubes is thrown out of the body and disappears without being able to hold on to the intra uterine or a few days it has held on to it. 50% of all pregnancies formed end up in chemical pregnancy and therefore abortion. The reason why the blastocyst is thrown out of the body is the mistakes that occur at the formation stage of the fetus.

Habituel abortus (recurrent abortus): Recurrent abortus (habitual abortus) is in question when two or more successive pregnancies end up in abortion. Reasons for recurrent abortions are different from “spontaneous abortions” which happen only once.

Septic Abortion (Criminal Abortion): Abortion with complicated infections. Septic abortion is most often seen after abortion performed by unlicensed people through illegal means especially at an advanced stage of the pregnancy and in unsterile environments.

It can sometimes be seen after the person herself destroys her gestational sac during an attempt at aborting the fetus by inserting unsterile objects through her own vagina. Criminal abortions are among the leading reasons of maternal mortality.

Prevalence of Abortions

About 50-60% of chemical pregnancies come to an end by themselves and are perceived as just a short delay in menstrual bleeding going unnoticed most of the time.

Prevalence of abortions reported in scientific studies, on the other hand, is about 20%, which is far beyond estimations. The first 3 months are usually the risky period. Probability of an abortion decreases as pregnancy progresses.

More than 80% of abortions occur within the first trimester, that is during the first 13 weeks. The highest risk being during the first 8 weeks, probability of an abortion gradually decreases after the 8th week.

Why Does Abortion Occur?

Reasons relating to the embryo constitute 90% of abortions in the early period. The most important one among these is the “chromosome abnormalities” of the fetus. Chromosome anomalies relating to the fetus are identified in more than half of the early period abortions.

Chromosome abnormalities, which are the most significant reasons of abortions, do not pass from generation to generation and appear completely by chance and coincidentally. In other words, abortion is the termination of a pregnancy by itself resulting from a defective production.

Therefore, abortion is, in fact, not a life experience that requires too much aggrievement. It is just a small part of the great effort made by the nature for your fetus to be healthy and free of problems.

Medications taken during the early periods of pregnancy, radiation or similar environmental factors can be listed among the other known reasons of abortion.
Some genetic anomalies in the mother or the father cause recurrent abortions in 3% of cases.

Inborn malformations in the uterus or some diseases of the immune system also cause abortions through different mechanisms.

Causes of Abortion

• Chromosome anomalies relating to the embryo
• Problems relating to the embryo often appear in expectant mothers especially those with advanced age causing abortion
• For example, whereas probability of abortion is 13% when a 20-year-old woman becomes pregnant, such probability is 50% after the age of 42. This is because of the aging of the ovaries of the mother.
• Multiple pregnancies
• Risk of abortion increases as the number of pregnancies increase. Multiple pregnancies have increased recently especially due to the increase in the supportive reproduction techniques.
• Teratogenetic or mutagenic effects (medications, radiation etc.)
• Genetic reasons (A genetic disorder that belongs to the mother or the father. While these disorders do not cause any problems to the mother, they might lead to an abortion due to a problem they cause.)
• Structural anomalies in the reproductive system
• Inborn uterus anomalies (Double uterus, a narrow intra uterine, blinds in the uterus etc.)
• Myoma
• Cervical incompetence (cervix incompetency)
• Corpus luteum incompetence
• Some infections seen in the mother
• Active infections (Rubella, Sitomegalovirus, Listeria, toxoplasma etc.)
• High fever
• Asherman syndrome
• Systemic diseases observed in the mother
• Systemic lupus (SLE)
• Some thyroid diseases (Hashimato, thyroiditis, graves etc.)
• Polycystic ovarian syndrome (pCOS)
• Uncontrolled diabetes (diabetes mellitus)
• Kidney diseases 
• Endometriosis
• Severe high blood pressure
• Heart diseases
• Chronic asthma
• Antrophospholipid syndrome (thrombophilia)
• Bad habits
• Smoking
• Alcohol
• Drugs
• High dose caffeine
• Reasons for recurrent abortions, on the other hand, are completely different.

Symptoms of Abortion

Existence of vaginal bleeding from the beginning to the end of pregnancy  cannot be accepted as normal and might lead to serious problems both for the mother and the fetus. You must definitely call your doctor if you have vaginal bleeding!!

Bleeding is the most significant symptom of abortion as there can be no abortion without bleeding. Some pregnant women might be seized with fear that they might be suffering a miscarriage when they have inguinal pain during the first period of their pregnancy. The reason for such inguinal pain is the stretching of the ligaments that hold the uterus from sidewalls due to the growing pregnancy (round ligament pain) and this is not something to be feared.

An ultrasound assessment and sometimes a vaginal speculum examination are definitely required when there is vaginal bleeding. Vaginal bleeding accompanied by intense pain in the inguen implies that the risk of abortion has increased.

Whether the person has dropped blood-soaked clots in the form of pieces of white meat alongside pain and bleeding is significant for diagnosis. These pieces should not be thrown away, if possible, and they should be taken to the doctor in a plastic bag to make diagnosis easier.

What Problems Does Abortion Cause?

The most frequent complications are bleeding and infection.

Findings of anemia or hypovolemic shock might develop if bleeding is too much. A shock occurs mostly in the advanced weeks of pregnancy or is apparent in patients who have arrived at the hospital too late. Amount of bleeding is also higher in the advanced weeks of pregnancy.

Life threatening serious problems (such as a shock) might be encountered if the bleeding is too heavy and the intervention is delayed. Another complication of bleeding is anemia. If there is heavy bleeding, vascular access is established and transfusion and even a blood return in some cases might be required.

Infection, on the other hand, occurs most often when a piece of the fetus is left in the uterus as tissues, which have lost their aliveness, create an ideal environment for reproduction of bacteria.

Infection is a serious threat to the life of the mother especially in septic abortus.

Is Abortment Required After All Miscarriages?

Abortment after miscarriage is required when a “complete” abortion is not in question. This is because the pieces left inside might lead to bleeding or infection.

When Does the Woman Menstruate for the First Time After Miscarriage?

You will menstruate for the first time 4-6 weeks after the abortment performed after miscarriage.

How Long Should you Wait for Another Pregnancy After a Miscarriage?

Medicinally, there is a chance of becoming pregnant after the first menstrual bleeding following miscarriage and there are no disadvantages of becoming pregnant.

What is Implantation Bleeding?

Mild bleeding (a few drops) developing during the homing of the blastocyst, which is formed by the union of the sperm and the ovule (that is, in the first week of pregnancy) and is quite normal.

Some may consider such bleeding as menstrual bleeding because it takes place on the expected period cycle and  do not even realize that they have become pregnant.

In this situation, the fetus appears to be older than it should in the ultrasound measurements performed in the first months as the ultrasound measurement results are based on the last date of menstrual bleeding. 

What is Intra Uterine Exitus?

Intra uterine exitus is a term that refers to the death of the fetus within the uterus. It is derived by the combination of the words intra (which means inner), uterine (which means uterus) and exitus (death) and is frequently used in the medical terminology.

There is the risk of losing the baby inside the uterus throughout the 40-week pregnancy marathon due to many reasons that are identified or cannot be identified. The dead fetus in the uterus is called “intrauterin ex”.

Death of the fetus in the uterus especially in the first months will lead to abortus (miscarriage). However, sometimes the uterus do not contract enough and the dead fetus stays in the uterus for weeks without being realized (missed abortus).

Does a Pregnant Woman Menstruate?

A woman does not menstruate throughout her pregnancy. Bleedings during pregnancy are misinterpreted by some patients as menstrual bleeding. However, these bleedings might develop due to threatened abortion, threatened preterm labor or placental pathologies. This might be extremely risky for both the mother and the fetus.

Consult your doctor in the event of all kinds of bleedings low or intense throughout your pregnancy.

Suggestions for Those Having Vaginal Bleeding During Pregnancy

All bleedings from the beginning of your pregnancy to the end poses risks for the lives of you and your baby. Therefore, consult you gynecologist in all kinds of bleedings low or intense throughout your pregnancy.

If you depose a piece together with the bleeding, put such piece in a plastic bag and take it to your doctor. Inspection of this piece visually and pathologically (under a microscope) might provide information about the miscarriage.

Results of the pregnancy tests performed in blood and urine are positive although your baby is not alive. Even your pregnancies symptoms might continue although your baby is not alive and you might not have any bleeding at the beginning.

However, transvaginal ultrasounds performed starting from the fifth and a half week of your pregnancy will provide more information as to whether your baby is healthy and alive. Therefore, do not ignore the ultrasound controls performed in the first period of your pregnancy.

There is no need to examine the situation in detail after you have miscarried once. However, it might provide detailed information on the following pregnancies of a woman who have miscarried twice or more if some tests are performed in detail.

Some psychological problems may arise in people who have miscarried. However, we should not forget that “miscarriage is actually not a life experience that we should worry about too much.” Losing the baby in the first months of pregnancy should be considered as a better result than delivering a disabled child.

Post-abortion Tests and Follow-ups

Attempts at bringing light to the situation with some blood tests performed on people who have miscarried once are made. You are usually advised to be regularly monitored by a doctor after a new pregnancy develops and take the required medications.

 It will be extremely useful if you try to become pregnant again after you reach your ideal weight, stop smoking and drinking, take under your systemic diseases, if any, (diabetes, asthma, heart diseases etc.) under control and obtain the approval of your doctor.