Miscarriage - all you need to know

1. ABORTIONS
Dr Veena P
Associate Professor, OG

2. Categories of spontaneous abortion
• Threatened abortion
• Inevitable abortion
• Complete or incomplete abortion
• Missed abortion
• Septic abortion
• Recurrent abortion

3. Threatened abortion
• Definition
• Any bloody vaginal discharge or bleeding during 1st
half of pregnancy
• Bleeding is usually slight, but may persist for days or
weeks
• Frequency
• Extremely common (one out of four or five pregnant
women)

4. Threatened abortion
• Symptoms
• Usually bleeding begins first
• Cramping abdominal pain follows a few hours to
several days later
• Presence of bleeding & pain: Poor prognosis for
pregnancy continuation

5. Treatment
• Bed rest & acetaminophen-based analgesia
• Progesterone (IM) or synthetic progestational agent:
lack of evidence of effectiveness
• Often results in no more than a missed abortion
• D-negative women with threatened abortion
• Probably should receive anti-D immunoglobulin
Prognosis
• Approximately ½ will abort
• Risk of preterm delivery, low birth weight, perinatal
death↑
• Risk of malformed infant does not appear to be
increased

6. Inevitable abortion
• Gross rupture of membrane, evidenced by leaking
amnionic fluid, in the presence of cervical dilatation, but
no tissue passed during 1st half of pregnancy
• Placenta (in whole or in part) is retained in the uterus
→ Uterine contractions begin promptly or infection
develops
• The gush of fluid is accompanied by bleeding, pain, or
fever, abortion should be considered inevitable

7. Complete or incomplete abortion
• Complete abortion
• Following complete detachment & expulsion of the
conceptus
• The internal cervical os closes
• Incomplete abortion
• Expulsion of some but not all of the products of
conception during 1st half of pregnancy
• The internal cervical os remains open & allows
passage of blood and products of conception
→ Remove retained tissue without delay

8. Missed abortion
• Retention of dead products of conception in utero for
several weeks
• Many women have no symptoms except persistent
amenorrhea
• Uterus remain stationary in size, but mammary
changes usually regress
• Uterus become smaller
• Most terminate spontaneously
• Serious coagulation defect occasionally develop
after prolonged retention of fetus

9. Septic abortion
• Most often associated with criminal abortion
• Metritis is usual outcome, but parametritis,
peritonitis, endocarditis, and septicemia may
all occur
• Management
• Prompt evacuation of products of conception
• Broad-spectrum IV antimicrobials

10. Recurrent abortion
• Definition : Three or more consecutive spontaneous
abortions
• Clinical investigation of recurrent miscarriage
• Parental cytogenetic analysis
• Lupus anticoagulant & anti-cardiolipin antibodies
assays
• Cervical insufficiency
• Prognosis: Depends on potential underlying etiology &
number of prior losses

11. Induced abortion

12. Induced abortion
• The medical or surgical termination of pregnancy
before the time of fetal viability
• Therapeutic abortion
• Termination of pregnancy before of fetal viability for the
purpose of saving the life of the mother
• MTP law, rules and regulation
• PNDT act

13. Legal abortions
Abortions are termed legal only when all the following
conditions are met:
• Termination done by a medical practitioner approved by
the Act
• Termination done at a place approved under the Act
• Termination done for conditions and within the gestation
prescribed by the Act
• Other requirements of the rules & regulations are complied
with

14. Induced abortion - Indications
• Continuation of pregnancy may threaten the life of
women or seriously impair her health
• Persistent heart disease after cardiac
decompensation
• Advanced hypertensive vascular disease
• Invasive carcinoma of the cervix
• Pregnancy resulted from rape or incest
• Continuation of pregnancy is likely to result in the
birth of child with severe physical deformities or
mental retardation

15. Induced abortion
• Elective (voluntary) abortion
• Interruption of pregnancy before viability at the
request of the women, but not for reasons of impaired
maternal health of fetal disease
• Counseling before elective abortion
• Continued pregnancy with its risks & parental
responsibilities
• Continued pregnancy with its risks & its
responsibilities of arranged adoption
• The choice of abortion with its risks

16. Abortion Techniques
Surgical Techniques
• Cervical dilatation followed by
uterine evacuation
• Curettage
• Vacuum aspiration (suction
curettage)
• Dilatation and evacuation (D&E)
• Dilatation and extraction (D&X)
• Menstrual aspiration
• Laparotomy
• Hysterotomy
• Hysterectomy
Medical Techniques
• Intravenous oxytocin
• Intra-amnionic hyperosmotic fluid
• 20% saline/30% urea
• Prostaglandins E2, F2, E1, and
analogues
• Intra-amnionic injection
• Extraovular injection
• Vaginal insertion
• Parenteral injection
• Oral ingestion
• Antiprogesterones—RU 486
(mifepristone) and epostane
• Methotrexate: intramuscular & oral
• Various combinations of the above

17. Features of Medical and Surgical Abortion
Medical Abortion
• Usually avoids invasive
procedure
• Usually avoids anesthesia
• Requires two or more visits
• Days to weeks to complete
• Available during early
pregnancy
• High success rate (~95
percent)
• Bleeding moderate to heavy
for short time
• Requires follow-up to ensure
completion of abortion
Surgical Abortion
• Involves invasive procedure
• Allows use of sedation if
desired
• Usually requires one visit
• Complete in a predictable
period of time
• Available during early
pregnancy
• High success rate (99
percent)
• Bleeding commonly
perceived as light
• Does not require follow-up in
all cases

18. Surgical techniques for abortion
Dilatation and curettage
• Performed first by dilating the cervix & evacuating the
product of conception
• Mechanically scraping out of the contents (sharp curettage)
• Vacuum aspiration (suction curettage)
• Before 14 weeks, D&C or vacuum aspiration should be
performed
• After 16 weeks, dilatation & evacuation (D&E) is performed
 Wide cervical dilatation
 Mechanical destruction & evacuation of fetal parts

20. Surgical techniques for abortion
Complications : uterine perforation
• 2 important determinants
• Skill of the physician
• Position of the uterus (retroverted)
• Small defects by uterine sound or narrow dilator
→ often heal without complication
• Suction & sharp curettage
→ Considerable intra-abdominal damage risk↑
→ Laparotomy to examine abdominal content (safest
action)
• Other complications – cervical incompetence or uterine
synechiae

22. Surgical techniques for abortion
Menstrual aspiration
• Aspiration of endometrial cavity using a flexible
cannula and syringe within 1-3 weeks after failure to
menstruate
• Several points at early stage of gestation
• Woman not being pregnant
• Implanted zygote may be missed by the curette
• Failure to recognize an ectopic pregnancy
• Infrequently, a uterus can be perforated

23. Surgical techniques for abortion
Laparotomy
• Abdominal hysterotomy or hysterectomy
• Indications
• Significant uterine disease
• Failure of medical induction during the 2nd
trimester

24. Medical induction of abortion
Early abortion
• Outpatient medical abortion is an acceptable
alternative to surgical abortion in women with
pregnancies of less than 49 days’ gestation
• Three medications for early medical abortion
• Antiprogestin mifepristone
• Antimetabolite methotrexate
• Prostaglandin misoprostol

25. Regimens for Medical Termination of Early
Pregnancy
1. Mifepristone/Misoprostol
• Mifepristone, 100-600 mg orally followed by Misoprostol,
200-600 mcg orally or 800 mcg vaginally in multiple doses
over 6-72 hours
2. Methotrexate/Misoprostol
• Methotrexate, 50 mg/m2 intramuscularly or orally
followed by Misoprostol, 800 mcg vaginally in 3-7 days.
Repeat if needed 1 week after initial dose of methotrexate
3. Misoprostol alone
• 800 mcg vaginally, repeated for up to three doses

26. Medical induction of abortion
Oxytocin
• Successful induction of 2nd trimester abortion is
possible with high doses of oxytocin administered in
small volumes of IV fluids
• Satisfactory alternatives to PGE2 for mid-trimester
abortion
• Laminaria tents inserted the night before
• Chance of successful induction is greatly enhanced

27. Medical induction of abortion
Prostaglandins
• Used extensively to terminate pregnancies, especially in the
2nd trimester: PG E1, E2, F2α
• Technique: Can act effectively on the cervix & uterus
(86~95% effectiveness)
• Vaginal prostaglandin E2 suppository & prostaglandin E1
(misoprostol)
• As a gel through a catheter into the cervical canal &
lowermost uterus
• Injection into the amniotic sac by amniocentesis
• Parenteral injection
• Oral ingestion

28. Medical induction of abortion
• Intra-amnionic hyperosmotic solutions
• 20-25% saline or 30-40% urea injected into amnionic sac
→ stimulate uterine contraction & cervical dilatation
• Action mechanism : prostaglandin mediated ?
• Complications of hypertonic saline
• Death
• Hyperosmolar crisis (early into maternal circulation)
• Cardiac failure
• Septic shock
• Peritonitis
• Hemorrhage
• DIC
• Water intoxication
• Hyperosmotic urea : less likely to be toxic

29. Consequences of elective abortion
Maternal mortality
• Legally induced abortion
• Relatively safe during the first 2 months of
pregnancy
(0.6/100,000 procedures)
• Doubled for each 2 weeks of delay after 8 weeks’
gestation

30. Consequences of elective abortion
Impact on future pregnancies
• Fertility : not altered by an elective abortion
• Vacuum aspiration for a first pregnancy does not
increase the incidence of
• 2nd trimester spontaneous abortions
• Preterm delivery
• Ectopic pregnancy
• LBW infants
• Multiple elective abortion increases placenta previa
(multiple sharp curettage abortion procedures)

31. Consequences of elective abortion
• Septic abortion
• Most often associated with criminal abortion
• Metritis is usual outcome, but parametritis,
peritonitis, endocarditis, and septicemia may all
occur
• Management
• Prompt evacuation of products of conception
• Broad-spectrum IV antimicrobials

32. Resumption of ovulation after abortion
• Ovulation may resume as early 2 weeks after an
abortion
• Therefore, if pregnancy is to be prevented, effective
contraception should be initiated soon after abortion