In threatened abortion, painful or painless bleeding occurs, the cervical os is closed and ultrasound will define a live fetus when conservative treatment such as bed rest is advised. The outcome may be resolution and continuance of the pregnancy or proceed to an inevitable abortion.

A diagnosis of inevitable abortion is made on the fact that the cervical canal is open; ultrasound will define if the fetus is alive. Blood loss may be heavy and cause maternal collapse with increasing abdominal pain. The uterus may spontaneously evacuate its contents or surgical or medical removal with mifepristone (RU4B6) may be necessary to remove retained products. Expectant management is sometimes an alternative to operative measures for removing retained products of conception. Ultrasound measures endometrial thickness and the presence of a gestational sac. If left to nature, most women will lose the retained products naturally. This management requires regular follow-up as an outpatient and access to the clinic by phone (Cahill 2001, Luise et al 2002).

This is now termed early fetal demise (Cahill 2001). A blood-stained or brown loss may be evident, the woman may or may not still feel pregnant and the signs of pregnancy may disappear. Low levels of human chorionic gonadotrophin (hCG) may be found, in which case the conceptus has died or ultrasound confirms fetal death. A suction curette or oral mifepristone may be used. If the uterus is larger than 13 weeks, a combination of vaginal prostaglandins and intravenous Syntocinon (oxytocin) may be prescribed. Although the uterus would eventually expel the mole, there is a risk of disseminated intravascular coagulation because of the toxins produced by a dead fetus.

Recurrent abortion is the term used for three or more consecutive abortions. Only 0.4% of women suffer in this way but they have a 55% increased risk of having a fourth miscarriage (Eblen et al 2000). In some women the cause is unknown but there is a specific group of women who suffer from antiphospholipid antibodies (Hughes syndrome), some 10–16% who will continually abort. In other words, the mother produces antibodies against the fetus. These antibodies also affect clotting factors and the process of abortion is thought to involve the activation of clotting mechanisms on the endothelial decidual cell surface (Singh 2001).

Therapeutic abortions have been available in the UK since 1967 but there are other countries where the procedure is illegal. The lack of an abortion law leads to the risk of women seeking illegal abortions, often carried out in unfavourable conditions by unskilled practitioners. In the past this often resulted in a septic abortion, which occurred because of infection, and the woman suffered from septicaemia, endotoxic shock and disseminated intravascular coagulation. Infection leads to the development of adhesions, and infertility. Fatalities were common. As for long-term health problems, there seems to be no connection between induced abortion and later early pregnancy loss or the incidence of ectopic pregnancy, but the risk of preterm birth and placenta praevia in subsequent pregnancies is increased (Thorp et al 2003).

It should be considered that, if a woman is pregnant and the pregnancy is unwanted, then she may choose the route to abort the baby. Other women abort because of fetal abnormality and this in itself is difficult for the woman and her partner. Some women are treated as outpatients using mifepristone or prostaglandins followed by a suction evacuation under a general anaesthetic if deemed necessary.

There are wide variations in incidence: 2:1000 in Japan; 1:1000 in Europe and North America; and 1:1945 in Ireland. It is suggested that diet and socioeconomic factors may play a role, particularly the lack of carotene and animal fats (Berkowitz & Goldstein 1996). Women over 35, and who have had a previous mole, have an increased risk of a complete mole.

Complete emptying of the uterus by suction and then curettage to eliminate all diseased tissue is essential. The molar tissue always expresses the RhD factor; therefore Rh-negative women require rhesus immunoglobulin following evacuation (Berkowitz & Goldstein 1996). Follow-up at one of the three centres in the UK for the measurement of hCG until hCG levels are normal (urine hCG 0–24 IU/L; serum hCG 0–4 IU/L) will be routine. Follow-up will continue for life with an incidence of recurrence of a molar pregnancy being 1:75 (http://www.Hmole-chorio.org.uk, accessed June 2008). Hormonal contraception should be avoided, as it increases the chance of developing malignant disease.

Choriocarcinoma in all its presentations responds very well to chemotherapy. To assist in the treatment process a scoring system is used: women scoring 0–8 are low risk and are administered methotrexate and folinic acid; those scoring above 8 receive etoposide, methotrexate, cyclophosphamide and vincristine (McNeish et al 2002). The problem of toxicity is as for every use of cytotoxic drugs with malaise, stomatitis, pharyngitis, diarrhoea, leucopenia and alopecia occurring. Follow-up treatment will continue for life with some women opting for hysterectomy.

Risk factors for tubal pregnancy include (Tay et al 2000):

Implantation may occur in various sites along the genital tract (Table 31.2).

The outcome varies depending on where in the tube implantation occurs, the ability of the tube to distend and the size of blood vessels eroded. If the pregnancy occurs in the fimbriated end or the ampulla, the conceptus may continue to grow until 10 weeks. The gestation sac may be expelled into the abdominal cavity as a tubal abortion (Fig. 31.5). Blood clot may be organised around the separated sac to form a tubal mole, which may remain in the uterine tube or be expelled from the fimbriated end as a tubal abortion. Tubal rupture (Fig. 31.6) may lead to devastating haemorrhage. The most severe haemorrhage occurs if the zygote implants at the level of the isthmus where the mucosa is thinner and the blood vessels larger. Tubal rupture is likely to occur between the 5th and 7th weeks of pregnancy.

The condition may be subacute or acute with signs of shock and collapse. The condition is serious and should always be suspected in women of childbearing age, especially if there is a history of amenorrhoea or previous salpingitis. The likely signs and presenting history of ectopic pregnancy are given in Table 31.3 (Tay et al 2000).