Abortus William

Williams ObstetricsWilliams Obstetrics

Chapter 9 Abortion Chapter 9 Abortion

OBGY R1 Lee Eun SukOBGY R1 Lee Eun Suk

AbortionAbortion

Spontaneous abortionSpontaneous abortion PathologyPathology EtiologyEtiology Fetal FactorsFetal Factors Maternal FactorsMaternal Factors Paternal FactorsPaternal Factors Categories of Spontaneous AbortionCategories of Spontaneous Abortion

Induced abortionInduced abortion History of abortionHistory of abortion IndicationsIndications Elective (Voluntary) AbortionElective (Voluntary) Abortion

Presumption of ovulation after abortionPresumption of ovulation after abortion

AbortionAbortion

Termination of pregnancy, either spontaneously or Termination of pregnancy, either spontaneously or intentionallyintentionally

Pregnancy termination prior to 20 weeksPregnancy termination prior to 20 weeks’’ gestation gestation or less than 500-g birthweight or less than 500-g birthweight

Definition vary according to state laws for reporting Definition vary according to state laws for reporting abortions, fetal deaths, and neonatal deathsabortions, fetal deaths, and neonatal deaths

Spontaneous abortionSpontaneous abortion

Abortion occurring without medical or mechanical Abortion occurring without medical or mechanical means to empty the uterus is referred to as means to empty the uterus is referred to as spontaneousspontaneous

Another widely used term is Another widely used term is miscarriagemiscarriage

Pathology Pathology Hemorrhage into the decidua basinalis, followed by necrosis of Hemorrhage into the decidua basinalis, followed by necrosis of

tissues adjacent to the bleedingtissues adjacent to the bleeding If early, the ovum detaches, stimulating uterine contractionsIf early, the ovum detaches, stimulating uterine contractions

that result in its ovulationthat result in its ovulation Gestational sac is opened , fluid surrounding a small maceratedGestational sac is opened , fluid surrounding a small macerated

fetus or alternatively no fetus is visible → fetus or alternatively no fetus is visible → blighted ovumblighted ovum


Pathology Pathology

In later abortion, the retained fetus may undergo In later abortion, the retained fetus may undergo macerationmaceration

The skull bones collapse, the abdomen distends with bloodThe skull bones collapse, the abdomen distends with blood--

stained fluid, and the internal organs degeneratestained fluid, and the internal organs degenerate The skin softens and peels off in utero or at the slightest The skin softens and peels off in utero or at the slightest

toughtough

When amnionic fluid is absorbed, the fetus may become When amnionic fluid is absorbed, the fetus may become

compressed and desiccated → compressed and desiccated → fetal compressusfetal compressus

The fetus become so dry and compressed that it The fetus become so dry and compressed that it resembles parchment - resembles parchment - a fetus papyraceousa fetus papyraceous


Etiology Etiology

More than 80 percent of abortions occur in the first 12 More than 80 percent of abortions occur in the first 12 weeks of pregnancyweeks of pregnancy

At least half result from chromosomal anomaliesAt least half result from chromosomal anomalies

After the first trimester, both the abortion rate & the After the first trimester, both the abortion rate & the incidence of chromosomal anomalies decreaseincidence of chromosomal anomalies decrease

F9-1F9-1


EtiologyEtiology

The risk of spontaneous abortion increases with parity The risk of spontaneous abortion increases with parity as well as with maternal and paternal ageas well as with maternal and paternal age

The frequency of abortion increases from 12 percent in The frequency of abortion increases from 12 percent in women younger than 20 years to 26 percent in those women younger than 20 years to 26 percent in those older than 40 yearsolder than 40 years

If a woman conceives within 3 months following a term If a woman conceives within 3 months following a term birthbirth

→ → incidence of abortion ↑incidence of abortion ↑

F9-2F9-2


EtiologyEtiology

The exact mechanism responsible for abortion are not The exact mechanism responsible for abortion are not apparentapparent

In the first 3 months of pregnancyIn the first 3 months of pregnancy Death of the embryo or fetus nearly always precedes Death of the embryo or fetus nearly always precedes

spontaneous expulsion of the ovumspontaneous expulsion of the ovum Finding of the cause of early abortion involves ascertaining Finding of the cause of early abortion involves ascertaining

the cause of fetal deaththe cause of fetal death

In subsequent months In subsequent months The fetus frequently does not die before expulsionThe fetus frequently does not die before expulsion

Other explanations for its expulsion should be soughtOther explanations for its expulsion should be sought

Spontaneous abortion - Fetal factorsSpontaneous abortion - Fetal factors

Abnormal zygotic developmentAbnormal zygotic development

Early spontaneous abortion commonly display a Early spontaneous abortion commonly display a developmental abnormality of the zygote, embryo, early developmental abnormality of the zygote, embryo, early fetus, or placentafetus, or placenta

1000 spontaneous abortions analyzed by Hertig and 1000 spontaneous abortions analyzed by Hertig and SheldonSheldon

Half demonstrated degenerated or absent embryos, that is,Half demonstrated degenerated or absent embryos, that is,

blighted ovablighted ova

F9-3F9-3


Aneuploid abortionAneuploid abortion

Approximately 50 to 60 percent of embryos and early Approximately 50 to 60 percent of embryos and early fetuses fetuses

that are spontaneously aborted contain chromosomal that are spontaneously aborted contain chromosomal abnor-malities accounting for most of early pregnancy abnor-malities accounting for most of early pregnancy wastagewastage

Jacobs and Hassold Jacobs and Hassold (1980)(1980)

95 percent of chromosomal abnormalities 95 percent of chromosomal abnormalities d/t maternal gametogenesis error d/t maternal gametogenesis error

5 percent → d/t paternal error5 percent → d/t paternal error

T9-1T9-1


Aneuploid abortion - Aneuploid abortion - Autosomal trisomyAutosomal trisomy

The most frequently identified chromosomal anomaly The most frequently identified chromosomal anomaly associated with first-trimester abortionsassociated with first-trimester abortions

Most trisomies result from Most trisomies result from isolated nondisjunction , isolated nondisjunction , balanced structural chromosomal rearrangements are balanced structural chromosomal rearrangements are present in one partner in 2 to 4 percent of couples with present in one partner in 2 to 4 percent of couples with a history of recurrent abortionsa history of recurrent abortions

Autosomes 13, 16, 18, 21, and 22 Autosomes 13, 16, 18, 21, and 22 –– most commom most commom


Monosomy XMonosomy X

The second frequent chromosomal abnormalityThe second frequent chromosomal abnormality Usually results in abortionUsually results in abortion Much less frequently in liveborn female infant (Turner Much less frequently in liveborn female infant (Turner

syndrome) syndrome)

TriploidyTriploidy

Associated with hydropic placental (molar) degenerationAssociated with hydropic placental (molar) degeneration Incomplete (partial) hydatidiform moles may contain Incomplete (partial) hydatidiform moles may contain

triploidy or trisomy for only chromosome 16triploidy or trisomy for only chromosome 16


Tetraploid abortusesTetraploid abortuses

Rarely are liveborn and most often are aborted early in Rarely are liveborn and most often are aborted early in gestationgestation

Chromosomal structural abnormalitiesChromosomal structural abnormalities

Identified only since the development of banding Identified only since the development of banding techniques, infrequently cause abortiontechniques, infrequently cause abortion


Euploid abortionEuploid abortion

Abort later in gestational than aneuploid Abort later in gestational than aneuploid

Three fourths of aneuploid abortions occurred before8 weeksThree fourths of aneuploid abortions occurred before8 weeks

Euploid abortions peak at about 13 weeksEuploid abortions peak at about 13 weeks

The incidence of euploid abortions increased dramatically after The incidence of euploid abortions increased dramatically after maternal age exceeded 35 yearsmaternal age exceeded 35 years

Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors

InfectionsInfections

Uncommon causes of abortion in humanUncommon causes of abortion in human

Listeria monocytogenes Listeria monocytogenes Clamydia trachomatisClamydia trachomatis Mycoplasma hominis Mycoplasma hominis Ureaplasma urealyticumUreaplasma urealyticum Toxoplasma gondiiToxoplasma gondii


Chronic debilitating diseasesChronic debilitating diseases

In early pregnancy, fetuses seldom abort secondary to In early pregnancy, fetuses seldom abort secondary to chronic wasting disease such as tuberculosis or chronic wasting disease such as tuberculosis or carcinomatosiscarcinomatosis

Celiac sprue Celiac sprue

Cause both male and female infertility and recurrent Cause both male and female infertility and recurrent abortionsabortions


Endocrine abnormalitiesEndocrine abnormalities

Hypothyroidism Hypothyroidism Iodine deficiency associated with excessive miscarriagesIodine deficiency associated with excessive miscarriages Thyroid autoantibodies → incidence of abortion↑Thyroid autoantibodies → incidence of abortion↑

Diabetes mellitusDiabetes mellitus The rates of spontaneous abortion & major congenital The rates of spontaneous abortion & major congenital

malformationsmalformations Poor glucose control → incidence of abortion↑Poor glucose control → incidence of abortion↑

Progesterone deficiencyProgesterone deficiency Luteal phase defectLuteal phase defect Insufficient progesterone secretion by the corpus luteum or Insufficient progesterone secretion by the corpus luteum or

placentaplacenta Poor glucose control → incidence of abortion↑Poor glucose control → incidence of abortion↑


NutritionNutrition Dietary deficiency of any one nutrients → not important Dietary deficiency of any one nutrients → not important

causecause

Drug use and environmental factorDrug use and environmental factor TobaccoTobacco

↑ ↑ Risk for euploid abortionRisk for euploid abortion More than 14 cigarettes a day → the risk twofold greater ↑More than 14 cigarettes a day → the risk twofold greater ↑

AlcoholAlcohol Spontaneous abortion & fetal anomalies → result from frequent Spontaneous abortion & fetal anomalies → result from frequent

alcohol use during the first 8 weeks of pregnancyalcohol use during the first 8 weeks of pregnancy Drinking twice a week → abortion rates doubled ↑Drinking twice a week → abortion rates doubled ↑ Drinking daily → abortion rates tripled ↑Drinking daily → abortion rates tripled ↑

CaffeineCaffeine At least 5 cups of coffee per day → slightly increased risk of At least 5 cups of coffee per day → slightly increased risk of

abortion abortion


Drug use and environmental factorDrug use and environmental factor

RadiationRadiation In sufficient doses → abortifacientIn sufficient doses → abortifacient

ContraceptivesContraceptives When intrauterine devices fail to prevent pregnancy → When intrauterine devices fail to prevent pregnancy →

abortion↑abortion↑ Environmental toxinsEnvironmental toxins

Anesthetic gases : exact fetal risk of chronic maternal Anesthetic gases : exact fetal risk of chronic maternal exposure is unknownexposure is unknown

Arsenic, lead, formaldehyde, benzene, ethylene oxide → Arsenic, lead, formaldehyde, benzene, ethylene oxide → abortifacientabortifacient

Video display terminal & accompanying electromagnetic fieldsVideo display terminal & accompanying electromagnetic fields

short waves & ultrasound do not increase the risk of abortionshort waves & ultrasound do not increase the risk of abortion


Immunological factors Immunological factors –– autoimmune factors autoimmune factors Recurrent pregnancy loss patients : 15%Recurrent pregnancy loss patients : 15% Antiphospholipid antibody : most significantAntiphospholipid antibody : most significant

LCA (lupus anticoagulant), ACA (anticardiolipin Ab)LCA (lupus anticoagulant), ACA (anticardiolipin Ab) Reduce prostacyclin productionReduce prostacyclin production

→ → facilitating thromboxane dominant milieu → thrombosisfacilitating thromboxane dominant milieu → thrombosis Prostacyclin : produced by vascular endothelial cellProstacyclin : produced by vascular endothelial cell

→ → potent vasodilator & inhibit platelet aggregationpotent vasodilator & inhibit platelet aggregation Thromboxane A2 : produced by plateletsThromboxane A2 : produced by platelets

→ → vasoconstrictor & platelet aggregatorvasoconstrictor & platelet aggregator Strong association withStrong association with

Decidual vasculopathy , placental infarction, fetal growth Decidual vasculopathy , placental infarction, fetal growth restrictionrestriction

Early-onset preeclampsia, recurrent abortion, fetal deathEarly-onset preeclampsia, recurrent abortion, fetal death


Immunological factors Immunological factors –– autoimmune factors autoimmune factors

Therapy of antiphopholipid antibody syndrome Therapy of antiphopholipid antibody syndrome

: low dose aspirin, prednisone, heparin, intravenous Ig: low dose aspirin, prednisone, heparin, intravenous Ig

→ → affect both immune & coagulation systemaffect both immune & coagulation system

→ → counteract the adverse action of antibodiescounteract the adverse action of antibodies


Immunological factors Immunological factors –– alloimmune factors alloimmune factors

Allogeneity Allogeneity Genetic dissimilarities between animals of the same Genetic dissimilarities between animals of the same

speciesspecies Human fetus is allogenic transplant tolerated by motherHuman fetus is allogenic transplant tolerated by mother

Several test for diagnosis of alloimmune factorsSeveral test for diagnosis of alloimmune factors Maternal & paternal HLA comparisonMaternal & paternal HLA comparison Maternal serum test for blocking antibodies Maternal serum test for blocking antibodies

: blocking antibodies to paternal antigens : blocking antibodies to paternal antigens

: ig G origin: ig G origin Maternal serum test for antipaternal antibodiesMaternal serum test for antipaternal antibodies

: cytotoxic antibodies to paternal leukocyte: cytotoxic antibodies to paternal leukocyte


Inherited thrombophiliaInherited thrombophilia Many studies of aggregated thrombophiliasMany studies of aggregated thrombophilias

→ → excessive recurrent abortionsexcessive recurrent abortions

LaparotomyLaparotomy Surgery performed during early pregnancySurgery performed during early pregnancy

→ → no evidence of tncreased abortionno evidence of tncreased abortion Peritonitis increases the likelihood of abortionPeritonitis increases the likelihood of abortion

Physical traumaPhysical trauma Major abdominal trauma → abortion↑Major abdominal trauma → abortion↑


Uterine defects Uterine defects –– acquired uterine defects acquired uterine defects Uterine leiomyoma : usually do not cause abortionUterine leiomyoma : usually do not cause abortion

Placental implantation over or in contact with myomaPlacental implantation over or in contact with myoma

→ → placental abruption, abortion, preterm labor ↑placental abruption, abortion, preterm labor ↑

→ → location is more important than sizelocation is more important than size

Uterine synechiae (Asherman syndrome)Uterine synechiae (Asherman syndrome) Partial or complete obliteration of the uterine cavity by Partial or complete obliteration of the uterine cavity by

adherence of uterine walladherence of uterine wall Cause : destruction of large areas of endometrium by Cause : destruction of large areas of endometrium by

curettagecurettage

→ → insufficient endometrium to support implantation & insufficient endometrium to support implantation & menstruationmenstruation

→ → recurrent abortion, amenorrhea, hypomenorrhearecurrent abortion, amenorrhea, hypomenorrhea


Uterine defects Uterine defects –– acquired uterine defects acquired uterine defects

Diagnosis of uterine synechiaeDiagnosis of uterine synechiae Hysterosalpingogram → characteristic multiple filling Hysterosalpingogram → characteristic multiple filling

defectsdefects Hysteroscopy → most accurate & direct diagnosisHysteroscopy → most accurate & direct diagnosis

Treatment of uterine synechiaeTreatment of uterine synechiae Lysis of adhesions via hysteroscopyLysis of adhesions via hysteroscopy Prevention of adherence : IUDPrevention of adherence : IUD Promotion of endometrial proliferationPromotion of endometrial proliferation

: Continuous high-dose estrogen (60-90 days) : Continuous high-dose estrogen (60-90 days)


Uterine defects Uterine defects –– developmental uterine defects developmental uterine defects

Consequence of abnormal mullerian duct formation or Consequence of abnormal mullerian duct formation or fusionfusion

SpontaneouslySpontaneously Induced by in utero exposure to DES (diethylstilbestrol)Induced by in utero exposure to DES (diethylstilbestrol)


Incompetent cervixIncompetent cervix Painless dilatation of cervix in the 2Painless dilatation of cervix in the 2ndnd or early in the 3 or early in the 3rdrd

trimestertrimester

→ → prolapse & ballooning of membranes into vaginaprolapse & ballooning of membranes into vagina

→ → rupture of membrane & expulsion of immature fetusrupture of membrane & expulsion of immature fetus Unless effectively treated, tends to repeat in each pregnancyUnless effectively treated, tends to repeat in each pregnancy

Diagnosis in nonpregnant womenDiagnosis in nonpregnant women HysterographyHysterography Pull-through techniques of inflated Foley catheter balloonsPull-through techniques of inflated Foley catheter balloons Acceptance without resistance at the internal os of specifically sized Acceptance without resistance at the internal os of specifically sized

cervical dilatorscervical dilators The use of transvaginal ultrasound in pregnant womenThe use of transvaginal ultrasound in pregnant women

Cervical length - shorteningCervical length - shortening Funneling Funneling


Incompetent cervix Incompetent cervix –– Etiology Etiology

Previous trauma to the cervixPrevious trauma to the cervix Dilatation & curettage Dilatation & curettage ConizationConization CauterizationCauterization

Abnormal cervical developmentAbnormal cervical development Exposure to DES in uteroExposure to DES in utero


Incompetent cervix Incompetent cervix –– Treatment Treatment

The operation is performed to surgicallyThe operation is performed to surgically Reinforcement of weak cervix by some type of purse string suture Reinforcement of weak cervix by some type of purse string suture

( Cerclage )( Cerclage )

Prophylactic surgeryProphylactic surgery : generally performed between 12 & : generally performed between 12 & 16weeks16weeks

Should be delayed until after 14 weeksShould be delayed until after 14 weeks ’’ gestation gestation → → Early abortion due to other factors will be completedEarly abortion due to other factors will be completed

The more advanced the pregnancy, the more likely the risk that The more advanced the pregnancy, the more likely the risk that surgical intervention stimulate preterm labor or membrane surgical intervention stimulate preterm labor or membrane rupturerupture

Usually do not perform after about 23 weeksUsually do not perform after about 23 weeks


Incompetent cervix Incompetent cervix –– Preoperative evaluation Preoperative evaluation

SonographySonography

: : Confirm living fetus & exclude major fetal anomaliesConfirm living fetus & exclude major fetal anomalies

Cervical cytology Cervical cytology

Cultures for gonorrhea, chlamydia, group B streptococciCultures for gonorrhea, chlamydia, group B streptococci Obvious cervical infections → treatment is givenObvious cervical infections → treatment is given For at least a week before & after surgery → sexual intercourse For at least a week before & after surgery → sexual intercourse

should be restrictedshould be restricted


Incompetent cervix Incompetent cervix –– Cerclage procedures Cerclage procedures

Types of operations commonly usedTypes of operations commonly used

McDonald McDonald

Modified Shirodkar Modified Shirodkar

→ → 85~90% success rate85~90% success rate


Incompetent cervix Incompetent cervix –– Transabdominal cerclage Transabdominal cerclage

Requries laparotomy forRequries laparotomy for Placement of cerclage at uterine isthmus levelPlacement of cerclage at uterine isthmus level Cerclage removal, delivery, or bothCerclage removal, delivery, or both

Indications Indications Anatomical defects of cervix Anatomical defects of cervix Failed transvaginal cerclageFailed transvaginal cerclage


Incompetent cervix Incompetent cervix –– Complications Complications

High incidence when performed much after 20 weeksHigh incidence when performed much after 20 weeks Membranes rupturesMembranes ruptures ChorioamnionitisChorioamnionitis Intrauterine infectionIntrauterine infection

Urgent removal of sutureUrgent removal of suture Operation failsOperation fails Signs of imminent abortion or deliverySigns of imminent abortion or delivery

Spontaneous abortion Spontaneous abortion –– Paternal Paternal factorsfactors

Little is known in the genesis of spontaneous Little is known in the genesis of spontaneous abortionabortion

Chromosomal translocations in sperm can lead to Chromosomal translocations in sperm can lead to abortionabortion

Categories of spontaneous abortionCategories of spontaneous abortion

Threatened abortionThreatened abortion

Inevitable abortionInevitable abortion

Complete or incomplete abortionComplete or incomplete abortion

Missed abortionMissed abortion

Recurrent abortionRecurrent abortion


Definition Definition Any bloody vaginal discharge or bleeding during 1Any bloody vaginal discharge or bleeding during 1stst half of half of

pregnancypregnancy Bleeding is frequently slight, but may persist for days or weeksBleeding is frequently slight, but may persist for days or weeks

FrequencyFrequency Extremely common (one out of four or five pregnant women)Extremely common (one out of four or five pregnant women)

PrognosisPrognosis Approximately Approximately ½½ will abort will abort Risk of preterm delivery, low birthweight, perinatal death↑ Risk of preterm delivery, low birthweight, perinatal death↑ Risk of malformed infant does not appear to be increased Risk of malformed infant does not appear to be increased

Categories of spontaneous Categories of spontaneous abortionabortion

Symptoms Symptoms Usually bleeding begins firstUsually bleeding begins first Cramping abdominal pain follows a few hours to several days Cramping abdominal pain follows a few hours to several days

laterlater Presence of bleeding & painPresence of bleeding & pain

→ → Poor prognosis for pregnancy continuationPoor prognosis for pregnancy continuation

Treatment Treatment Bed rest & acetaminophen-based analgesia Bed rest & acetaminophen-based analgesia Progesterone Progesterone (IM)(IM) or synthetic progestational agent or synthetic progestational agent (PO or IM)(PO or IM)

Lack of evidence of effectivenessLack of evidence of effectiveness Often results in no more than a missed abortionOften results in no more than a missed abortion

D-negative women with threatened abortionD-negative women with threatened abortion Probably should receive anti-D immunoglobulinProbably should receive anti-D immunoglobulin




TreatmentTreatment : slight bleeding persists for weeks : slight bleeding persists for weeks Vaginal sonographyVaginal sonography Serial serum quantitative hCGSerial serum quantitative hCG Serum progesteroneSerum progesterone

→ → can help ascertain if the fetus is alive & its locationcan help ascertain if the fetus is alive & its location

Vaginal sonography Vaginal sonography Gestational sac(+) & hCG < 1000mIU/mlGestational sac(+) & hCG < 1000mIU/ml

→ → gestation is not likely to survivegestation is not likely to survive

→ → If any doubt(+), check the serum hCG level at intervals of 48hrsIf any doubt(+), check the serum hCG level at intervals of 48hrs

→ → if not increase more than 65%, almost always hopelessif not increase more than 65%, almost always hopeless Serum progesterone value < 5 ng/mlSerum progesterone value < 5 ng/ml

→ → dead conceptusdead conceptus



Treatment : after death of conceptusTreatment : after death of conceptus

Uterus should be emptiedUterus should be emptied

→ → examination of all passed tissue whether the abortion is completeexamination of all passed tissue whether the abortion is complete

Ectopic pregnancy should be considered if gestational Ectopic pregnancy should be considered if gestational sac or sac or

fetus are not identified fetus are not identified


Inevitable abortionInevitable abortion

Gross rupture of membrane,evidenced by leaking Gross rupture of membrane,evidenced by leaking amnionic fluid, in the presence of cervical dilatation, amnionic fluid, in the presence of cervical dilatation, but no tissue passed during 1but no tissue passed during 1stst half of pregnancy half of pregnancy

Placenta (in whole or in part) is retained in the uterusPlacenta (in whole or in part) is retained in the uterus

→ → Uterine contractions begin promptly or infection Uterine contractions begin promptly or infection developsdevelops

The gush of fluid is accompanied by bleeding, pain, or The gush of fluid is accompanied by bleeding, pain, or fever, abortion should be considered inevitablefever, abortion should be considered inevitable


Complete abortionComplete abortion Following complete detachment & expulsion of the conceptusFollowing complete detachment & expulsion of the conceptus The internal cervical os closesThe internal cervical os closes

Incomplete abortionIncomplete abortion Expulsion of some but not all of the products of conception Expulsion of some but not all of the products of conception

during 1during 1stst half of pregnancy half of pregnancy The internal cervical os remains open & allows passage of The internal cervical os remains open & allows passage of

bloodblood The fetus & placenta may remain entirely in utero or may The fetus & placenta may remain entirely in utero or may

partially extrude through the dilated os partially extrude through the dilated os

→ → Remove retained tissue without delay Remove retained tissue without delay

Complete or incomplete abortionComplete or incomplete abortion


Retention of dead products of conception in utero for Retention of dead products of conception in utero for several weeksseveral weeks

Many women have no symptoms except persistent amenorrheaMany women have no symptoms except persistent amenorrhea

Uterus remain stationary in size, but mammary changes usuallyUterus remain stationary in size, but mammary changes usually

regress → uterus become smallerregress → uterus become smaller

Most terminates spontaneouslyMost terminates spontaneously

Serious coagulation defect occasionally develop after prolonged Serious coagulation defect occasionally develop after prolonged retention of fetus retention of fetus

Missed abortionMissed abortion


Definition : Three or more consecutive spontaneous Definition : Three or more consecutive spontaneous abortionsabortions

Clinical investigation of recurrent miscarriageClinical investigation of recurrent miscarriage Parental cytogenetic analysisParental cytogenetic analysis Lupus anticoagulant & anticardiolipin antibodies assaysLupus anticoagulant & anticardiolipin antibodies assays

Postconceptional evaluationPostconceptional evaluation Serial monitoring of Serial monitoring of ß–ß–hCGhCG from missed mens period from missed mens period

ß–ß–hCG>1500mIU/ml → USGhCG>1500mIU/ml → USG Maternal serum Maternal serum αα-fetoprotein assessment -fetoprotein assessment (GA16-18wks)(GA16-18wks) Amniocentesis → fetal karyotype Amniocentesis → fetal karyotype

PrognosisPrognosis Depends on potential underlying etiology & number of prior lossesDepends on potential underlying etiology & number of prior losses

Recurrent abortionRecurrent abortion


INDUCED ABORTIONINDUCED ABORTION

The medical or surgical termination of pregnancy The medical or surgical termination of pregnancy before the time of fetal viabilitybefore the time of fetal viability

Therapeutic abortionTherapeutic abortion

Termination of pregnancy before of fetal viability for Termination of pregnancy before of fetal viability for the purpose the purpose

of saving the life of the motherof saving the life of the mother

Induced abortionInduced abortion


IndicationIndication

Continuation of pregnancy may threaten the life of Continuation of pregnancy may threaten the life of women or seriously impair her healthwomen or seriously impair her health

Persistent heart disease after cardiac decompensationPersistent heart disease after cardiac decompensation Advanced hypertensive vascular diseaseAdvanced hypertensive vascular disease Invasive carcinoma of the cervixInvasive carcinoma of the cervix

Pregnancy resulted from rape or incestPregnancy resulted from rape or incest

Continuation of pregnancy is likely to result in the birth Continuation of pregnancy is likely to result in the birth of child with severe physical deformities or mental of child with severe physical deformities or mental retardationretardation


Elective (voluntary) abortionElective (voluntary) abortion

Interruption of pregnancy before viability at the Interruption of pregnancy before viability at the request of the women, but not for reasons of impaired request of the women, but not for reasons of impaired maternal health ormaternal health or

fetal diseasefetal disease

Counseling before elective abortionCounseling before elective abortion

Continued pregnancy with its risks & parental responsibilitiesContinued pregnancy with its risks & parental responsibilities Continued pregnancy with its risks & its responsibilities of Continued pregnancy with its risks & its responsibilities of

arranged adoptionarranged adoption The choice of abortion with its risksThe choice of abortion with its risks

Surgical techniques for abortionSurgical techniques for abortion

Dilatation and curettageDilatation and curettage

Performed first by dilating the cervix & evacuating the Performed first by dilating the cervix & evacuating the product of conceptionproduct of conception

Mechanically scraping out of the contents (sharp curettage)Mechanically scraping out of the contents (sharp curettage) Vacuum aspiration (suction curettage)Vacuum aspiration (suction curettage) BothBoth

Before 14 weeks, D&C or vacuum aspiration should be Before 14 weeks, D&C or vacuum aspiration should be performedperformed

After 16 weeks, dilatation & evacuation (D&E) is performedAfter 16 weeks, dilatation & evacuation (D&E) is performed Wide cervical dilatationWide cervical dilatation Mechanical destruction & evacuation of fetal partsMechanical destruction & evacuation of fetal parts


Dilatation and curettageDilatation and curettage Hygroscopic dilatorsHygroscopic dilators

: swell slowly & dilate cervix → cervical trauma can be : swell slowly & dilate cervix → cervical trauma can be minimizedminimized

Laminaria tentsLaminaria tents

: : stem of brown seaweed ( Laminaria digitata or japonica)stem of brown seaweed ( Laminaria digitata or japonica)

→ → drawing water from proteoglycan complexes of cervixdrawing water from proteoglycan complexes of cervix

→ → dissociation allow the cervix to soften & dilatedissociation allow the cervix to soften & dilate Insertion technique : tip rests just at the level of internal osInsertion technique : tip rests just at the level of internal os Usually after 4-6hours, laminaria dilate the cervix sufficiently to Usually after 4-6hours, laminaria dilate the cervix sufficiently to

allow easier mechanical dilation & curettageallow easier mechanical dilation & curettage May cause cramping pain May cause cramping pain

→ → easily managed with 60 mg codeine every 3-4 hourseasily managed with 60 mg codeine every 3-4 hours


Technique for dilatation & curettage Technique for dilatation & curettage

Remove laminaria → Uterus is sounded carefully toRemove laminaria → Uterus is sounded carefully to

Identify the status of the internal osIdentify the status of the internal os

Confirm uterus size & positionConfirm uterus size & position

Further dilation of cervix with Hegar dilatorFurther dilation of cervix with Hegar dilator


Complications : uterine perforationComplications : uterine perforation 2 important determinants2 important determinants

Skill of the physicianSkill of the physician Position of the uterus (retroverted)Position of the uterus (retroverted)

Small defects by uterine sound or narrow dilatorSmall defects by uterine sound or narrow dilator

→ → often heal without complicationoften heal without complication Suction & sharp curettage Suction & sharp curettage

→ → Considerable intra-abdominal damage risk↑Considerable intra-abdominal damage risk↑

→ → Laparotomy to examine abdominal content (safest action)Laparotomy to examine abdominal content (safest action)

Other complications Other complications –– cervical incompetence or uterine cervical incompetence or uterine synechiaesynechiae


Menstrual aspirationMenstrual aspiration

Aspiration of endometrial cavity using a flexible cannula Aspiration of endometrial cavity using a flexible cannula and syringe within 1-3 weeks after failure to and syringe within 1-3 weeks after failure to menstruatemenstruate

Several points at early stage of gestationSeveral points at early stage of gestation

Woman not being pregnantWoman not being pregnant Implanted zygote may be missed by the curetteImplanted zygote may be missed by the curette Failure to recognize an ectopic pregnancy Failure to recognize an ectopic pregnancy Infrequently, a uterus can be perforated Infrequently, a uterus can be perforated


Laparotomy Laparotomy

Abdominal hysterotomy or hysterectomyAbdominal hysterotomy or hysterectomy

IndicationsIndications

Significant uterine diseaseSignificant uterine disease

Failure of medical induction during the 2Failure of medical induction during the 2ndnd trimester trimester

Medical induction of abortionMedical induction of abortion

Early abortionEarly abortion

Outpatient medical abortion is an acceptable Outpatient medical abortion is an acceptable alternative to surgical abortion in women with alternative to surgical abortion in women with pregnancies of less than 49 dayspregnancies of less than 49 days’’ gestation gestation

(ACOG, 2001b)(ACOG, 2001b)

Three medications for early medical abortionThree medications for early medical abortion Antiprogestin Antiprogestin mifeprostonemifeprostone AntimetaboliteAntimetabolite methotrexate methotrexate ProstaglandinProstaglandin misoprostol misoprostol

Medical induction of abortion _ Medical induction of abortion _ 22ndnd trimester trimester abortionabortion


OxytocinOxytocin

Successful induction of 2Successful induction of 2ndnd trimester abortion is trimester abortion is possible with high doses of oxytocin administered in possible with high doses of oxytocin administered in small volumes of IV fluidssmall volumes of IV fluids

Satisfactory alternatives to PG ESatisfactory alternatives to PG E22 for midtrimester for midtrimester abortionabortion

Laminaria tents inserted the night beforeLaminaria tents inserted the night before Chance of successful induction is greatly enhancedChance of successful induction is greatly enhanced


ProstaglandinsProstaglandins

Used extensively to terminate pregnancies, especially in the 2Used extensively to terminate pregnancies, especially in the 2ndnd T T PG EPG E11, E, E22, F2, F2αα

TechniqueTechnique

: Can act effectively on the cervix & uterus (86~95% : Can act effectively on the cervix & uterus (86~95% effectiveness)effectiveness)

Vaginal prostaglandin EVaginal prostaglandin E22 suppository & prostaglandin E suppository & prostaglandin E1 1 (misoprostol)(misoprostol) As a gel through a catheter into the cervical canal & lowermost uterusAs a gel through a catheter into the cervical canal & lowermost uterus Injection into the amnionic sac by amniocentesisInjection into the amnionic sac by amniocentesis Parenteral injectionParenteral injection Oral ingestionOral ingestion


Intra-amnionic hyperosmotic solutionsIntra-amnionic hyperosmotic solutions 20-25% saline or 30-40% urea injected into amnionic sac20-25% saline or 30-40% urea injected into amnionic sac → → stimulate uterine contraction & cervical dilatationstimulate uterine contraction & cervical dilatation Action mechanism : prostaglandin mediated ?Action mechanism : prostaglandin mediated ? Complications of hypertonic salineComplications of hypertonic saline

Death Death Hyperosmolar crisis (early into maternal circulation)Hyperosmolar crisis (early into maternal circulation) Cardiac failureCardiac failure Septic shockSeptic shock PeritonitisPeritonitis HemorrhageHemorrhage DICDIC Water intoxicationWater intoxication

Hyperosmotic urea : less likely to be toxicHyperosmotic urea : less likely to be toxic


Antiprogesterone RU 486Antiprogesterone RU 486 Oral agent used alone in combination with oral PG to Oral agent used alone in combination with oral PG to

effect abortions in early gestationeffect abortions in early gestation High receptor affinity for progesterone binding siteHigh receptor affinity for progesterone binding site → → Block progesterone actionBlock progesterone action Abortion rateAbortion rate

Single 600mg dose prior 6 weeks → 85%Single 600mg dose prior 6 weeks → 85% Addition of oral, vaginal or injected PG → over 95%Addition of oral, vaginal or injected PG → over 95%

If given within 72 hoursIf given within 72 hours Also highly effective as emergency postcoital contraceptionAlso highly effective as emergency postcoital contraception Progressively less effective after 72 hoursProgressively less effective after 72 hours

Side effects Side effects Nausea, vomiting, & gastrointestinal crampingNausea, vomiting, & gastrointestinal cramping Major risk → hemorrhage is a risk if abortion is incompleteMajor risk → hemorrhage is a risk if abortion is incomplete


Epostane Epostane

3ß-hydroxysteroid dehydrogenase inhibitor3ß-hydroxysteroid dehydrogenase inhibitor

→ → blocks the synthesis of endogenous progesteroneblocks the synthesis of endogenous progesterone

Frequent side effect – nauseaFrequent side effect – nausea

Hemorrhage is a risk if abortion is incompleteHemorrhage is a risk if abortion is incomplete

Consequences of elective abortionConsequences of elective abortion

Maternal mortalityMaternal mortality

Legally induced abortionLegally induced abortion

Relative safe during the first 2 months of pregnancyRelative safe during the first 2 months of pregnancy

( 0.6/100,000 procedures)( 0.6/100,000 procedures)

Doubled for each 2 weeks of delay after 8 weeksDoubled for each 2 weeks of delay after 8 weeks’’ gestation gestation


Impact on future pregnanciesImpact on future pregnancies

Fertility : not altered by an elective abortionFertility : not altered by an elective abortion

Vacuum aspiration for a first pregnancy Vacuum aspiration for a first pregnancy

: Do not increase the incidence of : Do not increase the incidence of 22ndnd trimester spontaneous abortions trimester spontaneous abortions Preterm deliveryPreterm delivery Ectopic pregnancyEctopic pregnancy LBW infantsLBW infants


Impact on future pregnanciesImpact on future pregnancies

Dilatations & curettage for a first pregnancy Dilatations & curettage for a first pregnancy

: Increased risks for: Increased risks for Ectopic pregnancy Ectopic pregnancy 22ndnd trimester spontaneous abortions trimester spontaneous abortions LBW infantsLBW infants

Multiple elective abortion :Multiple elective abortion : Not increased the incidence of preterm delivery & LBW Not increased the incidence of preterm delivery & LBW

infantsinfants Placenta previa Placenta previa

→ → increased following multiple sharp curettage abortion increased following multiple sharp curettage abortion proceduresprocedures


Septic abortionSeptic abortion

Most often associated with criminal abortionMost often associated with criminal abortion

Metritis is usual outcome, but parametritis, peritonitis, Metritis is usual outcome, but parametritis, peritonitis, endocarditis, and septicemia may all occurendocarditis, and septicemia may all occur

Management Management Prompt evacuation of products of conceptionPrompt evacuation of products of conception Broad-spectrum IV antimicrobialsBroad-spectrum IV antimicrobials

Resumption of ovulation after abortionResumption of ovulation after abortion

Ovulation may resume as early 2 weeks after an Ovulation may resume as early 2 weeks after an abortionabortion

Therefore, if pregnancy is to be prevented, Therefore, if pregnancy is to be prevented,

effective contraception should be initiated soon effective contraception should be initiated soon after abortionafter abortion

Date post:	27-Oct-2014
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Abortus William

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