2. Introduction
Abortion:: termination of pregnancy
before fetal viability (GA or weight)
The WHO defines it as
Expulsion or extraction of an embryo or
fetus weighing 500 g or less from its
mother. This typically corresponds to a GA
of 20 to 22 weeks or less
Ethiopian definition is
Termination of pregnancy before 28 wks
of gestation or weight < 1000g.
3. Spontaneous abortion: spontaneous loss of
a px at a period of gestation before the
stage of fetal viability
Includes threatened, inevitable, incomplete,
complete, and missed abortion.
Septic abortion is used to further classify any of these
that are complicated further by infection.
Recurrent abortion: ≥3 consecutive losses of
clinically recognized pregnancies prior to
viability
• Identify women with repetitive spontaneous
abortions so that an underlying factor(s) can be
treated to achieve a viable newborn.
Induced abortion: surgical or medical
termination of a live fetus that has not
reached viability.
4. 1st-TRIMESTER SPONTANEOUS
ABORTION
> 80 % of spontaneous abortions occur
within the 1st 12 weeks of gestation.
With 1st-trimester losses, death of the
embryo or fetus nearly always precedes
spontaneous expulsion.
Death is usually accompanied by hemorrhage
into the decidua basalis. This is followed by
adjacent tissue necrosis that stimulates
uterine contractions and expulsion.
5. An intact gestational sac is usually filled
with fluid and may or may not contain an
embryo or fetus.
Thus, the key to determining the cause of
early miscarriage is to ascertain the cause
of fetal death.
In contradistinction, in later pregnancy losses,
the fetus usually does not die before
expulsion, and thus other explanations are
sought.
6. Fetal Factors
• Approximately half of miscarriages are anembryonic, that is, with no
identifiable embryonic elements. Less accurately, the term blighted
ovum
• The other 50 % are embryonic miscarriages, which commonly display a
dev’tal abnormality of the zygote, embryo, fetus, or at times, the
placenta.
• Of embryonic miscarriage, half of these—25 % of all abortuses—have
chromosomal anomalies and thus are aneuploid abortions. The
remaining cases are euploid abortions, that is, carrying a normal
chromosomal complement
7. With 1st-trimester miscarriages, autosomal
trisomy is the most frequently identified
chromosomal anomaly. Although most
trisomies result from isolated nondisjunction,
balanced structural chromosomal rearrangements
are found in one partner in 2 to 4 % of couples
with recurrent miscarriages.
Trisomies have been identified in abortuses
for all except chromosome number 1, and those
with 13, 16, 18, 21, and 22 are most
common.
A previous miscarriage increases the baseline risk
for aneuploidy in a subsequent fetus from 1.4 to
1.7 % (Bianco, 2006). With two or three
previous miscarriages, the risk increases to
1.8 and 2.2 %, respectively.
8. Monosomy X (45,X) is the single most frequent
specific chromosomal abnormality. This is Turner
syndrome, which usually results in abortion, but
liveborn females are described.
Triploidy is often associated with hydropic or
molar placental degeneration. The fetus within
a partial hydatidiform mole frequently aborts
early, and the few carried longer are all grossly
deformed. Advanced maternal and paternal
age do not increase the incidence of
triploidy.
Tetraploid fetuses most often abort early in
gestation, and they are rarely liveborn.
Last, chromosomal structural abnormalities
infrequently cause abortion.
9. Maternal Factors
Infections
Some common viral, bacterial, and other infectious
agents that invade the normal human can cause
pregnancy loss.
Many are systemic and infect the fetoplacental
unit by bloodborne organisms.
Others may infect locally through genitourinary
infection or colonization.
However, despite the numerous infections acquired in
pregnancy, these uncommonly cause early abortion.
Brucella abortus, Campylobacter fetus, and
Toxoplasma gondii infections cause abortion in
livestock, but their role in human pregnancy is less clear
10. Medical Disorders
In general, early abortions are rarely due to
chronic wasting diseases such as
tuberculosis or carcinomatosis.
Diabetes mellitus and thyroid disease
Celiac disease, which has been reported to cause
recurrent abortions as well as both male and
female infertility.
Unrepaired cyanotic heart disease is likely a
risk for abortion, and in some, this may persist
after repair.
Eating disorders—anorexia nervosa and bulimia
nervosa—have been linked with subfertility,
preterm delivery, and fetal-growth restriction.
Inflammatory bowel disease and systemic
lupus erythematosus may increase the risk.
11. Medications.
Oral contraceptives or spermicidal agents
used in contraceptive creams and jellies are
not associated with an increased
miscarriage rate.
Similarly, nonsteroidal antiinflammatory
drugs or ondansetron are not linked.
A pregnancy with an intrauterine device
(IUD) in situ has an increased risk of
abortion and specifically of septic abortion.
Finally, studies have shown no increase in
pregnancy loss rates with meningococcal
conjugate or trivalent inactivated influenza
vaccines
12. Cancer.
Therapeutic doses of radiation are undeniably
abortifacient, but doses that cause abortion are not
precisely known. According to Brent (2009),
exposure to < 5 rads does not increase the risk.
The effects of chemotherapy in causing
abortion are not well defined. Particularly
worrisome are women with an early normal gestation
erroneously treated with methotrexate for an
ectopic pregnancy.
In a report of eight such cases, two viable-size
fetuses had multiple malformations.
In the remaining six cases, three each had a
spontaneous or induced abortion
13. Diabetes Mellitus
The abortifacient effects of uncontrolled
diabetes are wellknown.
Optimal glycemic control will mitigate
much of this loss.
Spontaneous abortion and major congenital
malformation rates are both increased in
women with insulin-dependent diabetes.
This is directly related to the degree of
periconceptional glycemic and metabolic
control.
14. Thyroid Disorders
Severe iodine deficiency, which is infrequent
in developed countries, has been associated
with increased miscarriage rates. Varying
degrees of thyroid hormone insufficiency are
common in women.
Although the worst—overt hypothyroidism—
is infrequent in pregnancy, subclinical
hypothyroidism has an incidence of 2 to 3 %.
Both are usually caused by autoimmune
Hashimoto thyroiditis, in which both
incidence and severity accrue with age.
15. Surgical Procedures
It is likely that uncomplicated surgical procedures
performed during early pregnancy do not
increase the risk for abortion.
Ovarian tumors can generally be resected without
causing miscarriage. An important exception
involves early removal of the corpus luteum or
the ovary in which it resides.
If performed before 10 weeks’ gestation,
supplemental progesterone should be given.
Between 8 and 10 weeks, a single 150-mg IM
injection of 17-hydroxyprogesterone caproate
is given at the time of surgery.
If between 6 to 8 weeks, then two additional
150-mg injections should be given 1 and 2
weeks after the first.
Major trauma—especially abdominal— can
cause fetal loss, but is more likely as
pregnancy advances
16. Nutrition
Extremes of nutrition—severe dietary
deficiency and morbid obesity—are associated
with increased miscarriage risks.
Dietary quality may also be important, as
this risk may be reduced in women who
consume fresh fruit and vegetables daily
(Maconochie, 2007).
Sole deficiency of one nutrient or moderate
deficiency of all does not appear to increase
risks for abortion.
Obesity is associated with a litany of
adverse pregnancy outcomes. These include
subfertility and an increased risk of
miscarriage and recurrent abortion.
17. Social and Behavioral Factors
Most commonly related to chronic and
especially heavy use of legal substances.
The most common used is alcohol, with its
potent teratogenic effects. That said, an
increased miscarriage risk is only seen with
regular or heavy use.
Excessive caffeine consumption—not well
defined—has been associated with an increased
abortion risk. There are reports that heavy
intake of approximately five cups of coffee
per day—about 500 mg of caffeine—
slightly increases the abortion risk.
18. Occupational and Environmental Factors
Earlier reports that implicated some chemicals as
increasing miscarriage risk include arsenic, lead,
formaldehyde, benzene, and ethylene oxide
(Barlow, 1982). More recently, there is evidence
that DDT—dichlorodiphenyltrichloroethane—
may cause excessive miscarriage rates (Eskenazi,
2009).
In fact, use of DDT-containing insecticides had
been suspended. But in 2006, it was again and is
still endorsed by the WHO (2011) for mosquito
control for malaria prevention.
Conclusions from a metaanalysis were that there is
a small incremental risk for spontaneous abortion
in women who worked with cytotoxic
antineoplastic chemotherapeutic agents
19. Immunological Factors
The most potent of these are
antiphospholipid antibodies directed
against binding proteins in plasma (Erkan,
2011).
Because associated pregnancy loss can be
repetitive, recurrent miscarriage due to
APS (is defined by these antibodies found
together with various forms of
reproductive losses along with
substantively increased risks for venous
thromboembolism)
20. Inherited Thrombophilias
Although thrombophilias were initially linked to
various pregnancy outcomes, most putative
associations have been refuted.
Currently, the American College of
Obstetricians and Gynecologists (2013a) is of
the opinion that there is not a definitive
causal link between these thrombophilias
and adverse pregnancy outcomes in general,
and abortion in particular.
21. Uterine Defects
• Various inherited and acquired uterine defects
are known to cause both early and late
recurrent miscarriages
22. Paternal Factors
Chromosomal abnormalities in sperm
reportedly had an increased abortion risk
(Carrell, 2003).
Increasing paternal age was significantly
associated with increased risk for
abortion in the Jerusalem Perinatal Study
(Kleinhaus, 2006). This risk was lowest before
age 25 years, after which it progressively
increased at 5-year intervals.
23. Symptoms and signs typically present Symptoms and signs
sometimes present
Probable
diagnosis
• Light bleeding
• Closed cervix
• The size of the uterus corresponds to
the gestational period
• Cramping/lower
abdominal pain
• Uterus softer than normal
Threatened
abortion
• Heavy bleeding
• Dilated cervix
• The size of the uterus corresponds
to the gestational period
• Cramping/lower
abdominal pain
• No expulsion of the
products of conception
• The uterus is tender
Inevitable
abortion
• Heavy bleeding
• Dilated cervix
• The size of the uterus is smaller than
that expected for the gestational
period
• Cramping/lower
abdominal pain
• History of partial expulsion
of the products of
conception
Incomplete
abortion
• Light bleeding
• Closed cervix
• The size of the uterus is smaller than
that expected for the gestational
period
• Uterus softer than normal
• Light cramping/ abdominal
pain
• History of expulsion of the
products of conception
Complete
abortion
24. • Light bleeding
• Abdominal pain, may be severe
• Closed cervix
• The size of the uterus is slightly
larger
• Uterus softer than normal
• Amenorrhoea/irregular
bleeding
• Fainting
• Presence of tender adnexal
mass
• Tenderness on moving the
cervix than normal
Ectopic
pregnancy
• Heavy bleeding
• Partial expulsion of the products of
conception which resemble grapes
• Dilated cervix
• The size of the uterus is larger than
that expected for the gestational
period
• Uterus softer than normal
• Nausea/vomiting
• Spontaneous abortion
• Cramping/lower abdominal
pain
• Presence of ovarian cysts
(easily ruptured)
• Early onset of pre-eclampsia
• No evidence of a foetus
Molar
pregnancy
• Bleeding usually spotting except
variceal bleeding and may precede
pregnancy
• Uterus corresponds to date
• Closed cervix
• Pregnancy sign and
symptoms
• Speculum and VE reveal the
specific cervical, vaginal or
vulvar lesion
Pregnancy with
cervical, vaginal
or vulvar lesion;
e.g., cervix/
vaginal Cancer
25. Clinical Classification of Spontaneous
Abortion
Threatened Abortion
The clinical diagnosis is presumed when bloody
vaginal discharge or bleeding appears through a
closed cervical os during the first 20 weeks.
Bleeding in early pregnancy must be
differentiated from implantation bleeding, which
some women have at the time of the expected
menses.
With miscarriage, bleeding usually begins 1st, and
cramping abdominal pain follows hours to days later.
There may be low-midline clearly rhythmic cramps;
persistent low backache with pelvic pressure; or dull
and midline suprapubic discomfort.
26. • Bleeding is by far the most predictive risk factor
for pregnancy loss. Overall, approximately half will
abort, but this risk is substantially less if there is fetal
cardiac activity.
• Even if miscarriage does not follow early
bleeding, the risk for later adverse pregnancy
outcomes is increased.
27. Threatened Abortion versus Ectopic
Pregnancy.
Every woman with an early pregnancy, vaginal
bleeding, and pain should be evaluated.
Serial quantitative serum B-hCG and
progesterone levels and transvaginal sonography
are used to ascertain if there is an intrauterine
live fetus.
With a robust uterine pregnancy,
Serum B- hCG levels should increase at least 53 to 66
% every 48 hours.
Serum progesteron concentrations < 5 ng/mL
suggest a dying pregnancy, whereas values > 20
ng/mL support the diagnosis of a healthy pregnancy.
Transvaginal sonography is used to locate the
pregnancy and determine if the fetus is alive. If this
cannot be done, then pregnancy of unknown
location is diagnosed.
28. The gestational sac may be seen by 4.5
weeks. At this same time, B-hCG levels are
generally considered to be 1500 to 2000
mIU/mL.
Another caveat is that a gestational sac may
appear similar to other intrauterine fluid
accumulations—the so-called
pseudogestational sac.
This pseudosac may be seen with ectopic
pregnancy and is easier to exclude once a yolk sac
is seen. Typically, the yolk sac is visible by 5.5
weeks and with a mean gestational-sac
diameter of 10 mm. Thus, the diagnosis of a
uterine pregnancy should be made cautiously if the
yolk sac is not yet seen.
29. At 5 to 6 weeks, a 1- to 2-mm embryo
adjacent to the yolk sac can be seen. Absence
of an embryo in a sac with a mean sac diameter of
16 to 20 mm suggests a dead fetus.
Finally, fetal cardiac activity can be detected
at 6 to 6.5 weeks with an embryonic length
of 1 to 5 mm and a mean sac diameter of 13
to 18 mm. A 5-mm embryo without cardiac
activity is likely dead.
Thus, an anembryonic gestation is diagnosed
when the mean gestational sac diameter
measures >/= 20 mm and no embryo is
seen.
Embryonic death is also diagnosed if an
embryo measuring >/= 10 mm has no
cardiac activity.
30. Management.
Acetaminophen-based analgesia will help relieve
discomfort from cramping.
If uterine evacuation is not indicated, bed rest is
often recommended but does not improve outcomes.
Avoid intercourse, Douching
Neither has treatment with a host of medications
that include chorionic gonadotropin.
With persistent or heavy bleeding, the hematocrit is
determined.
If there is significant anemia or hypovolemia,
then pregnancy evacuation is generally
indicated. In these cases in which there is a live
fetus, some choose transfusion and further
observation.
If any sign of pelvic infection– Evacuate the
uterus after antibiotic coverage
31. Anti-D Immunoglobulin
With spontaneous miscarriage, 2 % of Rh D-negative
women will become alloimmunized if not provided
passive isoimmunization.
With an induced abortion, this rate may reach 5 %.
The ACOG(2013c) recommends anti-Rh0 (D)
immunoglobulin given as 300 ug IM for all GAs, or
50 ug IM for pregnancies </= 12 weeks and 300
ug for >/= 13 weeks.
With threatened abortion, immunoglobulin
prophylaxis is controversial because of sparse
evidence-based data (ACOG, 2013c; Hannafin, 2006;
Weiss, 2002). That said, some choose to administer
anti-D immunoglobulin up to 12 weeks’•
gestation
for a threatened abortion and a live fetus.
At Parkland Hospital, we administer a 50-ug dose to
all Rh D-negative women with first-trimester
bleeding.
32. Inevitable Abortion
In the 1st trimester, gross rupture of the membranes
along with cervical dilatation is nearly always followed by
either uterine contractions or infection.
A gush of vaginal fluid during the 1st half of px usually
has serious consequences.
In some cases not associated with pain, fever, or
bleeding, fluid may have collected previously between the
amnion and chorion. If this is documented, then
diminished activity with observation is a reasonable
course.
After 48 hours, if no additional amnionic fluid
has escaped and if there is no bleeding,
cramping, or fever, then a woman may resume
ambulation and pelvic rest.
With bleeding, cramping, or fever, abortion is
considered inevitable, and the uterus is
evacuated.
33. Incomplete Abortion
Bleeding that follows partial or complete placental
separation and dilation of the cervical os is termed
incomplete abortion.
The fetus and the placenta may remain entirely
within the uterus or partially extrude through the
dilated os.
Before 10 weeks, they are frequently expelled
together, but later, they deliver separately.
Management options of incomplete abortion include
curettage, medical abortion, or expectant
management in clinically stable women. With
surgical therapy, additional cervical dilatation
may be necessary before suction curettage.
In others, retained placental tissue simply lies
loosely within the cervical canal and can be easily
extracted with ring forceps.
34. Complete Abortion
At times, expulsion of the entire pregnancy
may be completed before a woman presents
to the hospital.
A history of heavy bleeding, cramping, and
passage of tissue or a fetus is common.
Importantly, during examination, the cervical os
is closed.
Patients are encouraged to bring in passed
tissue, which may be a complete gestation,
blood clots, or a decidual cast. The last is a
layer of endometrium in the shape of the uterine
cavity that when sloughed can appear as a
collapsed sac
35. If an expelled complete gestational sac is not
identified, sonography is performed to differentiate a
complete abortion from threatened abortion or
ectopic pregnancy.
Xtic findings of a complete abortion include a minimally
thickened endometrium without a gestational sac.
However, this does not guarantee a recent uterine
pregnancy. Condous and associates (2005) described 152
women with heavy bleeding, an empty uterus with
endometrial thickness < 15 mm, and a diagnosis of
completed miscarriage. 6% were subsequently proven to
have an ectopic pregnancy. Thus, unless products of
conception are seen or unless sonography
confidently documents, at 1st an intrauterine
pregnancy, and then later an empty cavity, a complete
abortion cannot be surely diagnosed.
In unclear settings, serial serum hCG measurements aid
clarification. With complete abortion, these levels drop
quickly
36. Missed Abortion
Also termed early pregnancy failure or loss, missed
abortion.
Historically, the term was used to describe dead
products of conception that were retained for
days, weeks, or even months in the uterus with a
closed cervical os.
Early pregnancy appeared to be normal with
amenorrhea, nausea and vomiting, breast
changes, and uterine growth.
Because suspected fetal death could not be
confirmed, expectant management was the sole
option, and spontaneous miscarriage would
eventually ensue.
With rapid confirmation of fetal or embryonic death,
many women choose uterine evacuation. Although many
classify these as a missed abortion, the term is used
interchangeably with early pregnancy loss or wastage
37. Septic Abortion
Still, perhaps 1 to 2 % of women with threatened or
incomplete miscarriage develop a pelvic infection and sepsis
syndrome.
Elective abortion, either surgical or medical, is also
occasionally complicated by severe and even fatal infections.
Bacteria gain uterine entry and colonize dead conception
products. Organisms may invade myometrial tissues and
extend to cause parametritis, peritonitis, septicemia, and,
rarely, endocarditis.
Particularly worrisome are severe necrotizing infections and toxic
shock syndrome caused by group A streptococcus—S pyogenes.
Deaths have been reported from toxic shock syndrome due to
Clostridium perfringens. Similar infections are caused by
Clostridium sordellii and have clinical manifestations that begin
within a few days after an abortion.
Women may be afebrile when 1st seen with severe
endothelial injury, capillary leakage, hemoconcentration,
hypotension, and a profound leukocytosis.
38. Management of clinical infection includes prompt
administration of broad-spectrum antibiotics.
If there are retained products or fragments, then
suction curettage is also performed.
Most women respond to this treatment within 1 to 2
days, and they are discharged when afebrile.
Follow-up oral antibiotic treatment is likely unnecessary.
In a very few women, severe sepsis syndrome causes
ARDS, acute kidney injury, or DIC.
To prevent postabortal sepsis, prophylactic
antibiotics are given at the time of induced
abortion or spontaneous abortion that requires
medical or surgical intervention.
The ACOG (2011b) recommends doxycycline, 100 mg
orally 1 hr before and then 200 mg orally after a
surgical evacuation. At Planned Parenthood clinics,
for medical abortion, doxycycline 100 mg is taken
orally daily for 7 days and begins with
abortifacient administration
39. Management of Spontaneous Abortion
Unless there is serious bleeding or infection with an
incomplete abortion, any of three options are reasonable-
expectant, medical, or surgical management.
Each has its own risks and benefits—for example, the 1st two
are associated with unpredictable bleeding, and some
women will undergo unscheduled curettage.
Some of the risks and benefits are summarized as follows:
1. Expectant management of spontaneous incomplete
abortion has failure rates as high as 50 %.
2. Medical therapy with prostaglandin E1 (PGE1) has
varying failure rates of 5 to 40 %. In 1100 women
with suspected first-trimester abortion, 81 % had a
spontaneous resolution.
3. Curettage usually results in a quick resolution that
is 95-100% successful. It is invasive and not
necessary for all women.
40. MIDTRIMESTER ABORTION
The timespan that defines a midtrimester fetal loss
extends from the end of the 1st trimester until
the fetus weighs >/= 500 g or gestational
age reaches 20 weeks.
Abortion becomes much less common by the
end of the 1st trimester, and its incidence
decreases successively thereafter.
Overall, spontaneous loss in the 2nd trimester
is estimated at 1.5 to 3 % and after 16
weeks, it is only 1 % (Simpson, 2007; Wyatt,
2005).
1st-trimester bleeding doubles the incidence
of second-trimester loss
41.
42. Management
Midtrimester abortions are classified similarly to
first-trimester abortions.
An exception is that at these later gestational
ages, oxytocin in concentrated doses is
highly effective for labor induction or
augmentation.
Surgical midtrimester abortion for fetal
demise is technically more difficult.
That said, there can be significant morbidity with
either medical or surgical termination of these.
Overall, however, for elective delivery, available
data suggest that surgical termination by
dilatation and evacuation has fewer
complications than labor induction
43. INDUCED ABORTION
The term induced abortion is defined as the
medical or surgical termination of
pregnancy before the time of fetal
viability.
Definitions to describe its frequency include:
1. Abortion ratio—the number of abortions per
1000 live births, and
2. Abortion rate—the number of abortions per
1000 women aged 15 to 44 years.
44. Classification
Therapeutic Abortion
There are several diverse medical and surgical
disorders that are indications for termination of
pregnancy.
Examples include persistent cardiac
decompensation, especially with fixed pulmonary
hypertension; advanced hypertensive vascular
disease or diabetes; and malignancy.
In cases of rape or incest, most consider
termination reasonable.
The most common indication currently is to
prevent birth of a fetus with a significant
anatomical, metabolic, or mental deformity.
The seriousness of fetal deformities is wide ranging
and usually defies social, legal, or political classification.
45. Elective or Voluntary Abortion
The interruption of pregnancy before
viability at the request of the woman, but not
for medical reasons, is usually termed elective or
voluntary abortion.
Most abortions done today are elective, and
thus, it is one of the most commonly
performed medical procedures.
The pregnancy-associated mortality rate is
14-fold greater than the abortion-related
mortality rate—8 versus 0.6 deaths per
100,000 (Raymond, 2012).
The Executive Board of the ACOG(2013d) supports
the legal right of women to obtain an
abortion prior to fetal viability and considers
this a medical matter between a woman and her
physician.
46. Counseling before Elective Abortion
There are three basic choices available to a
woman considering an abortion:
1. Continued pregnancy with its risks and
parental responsibilities;
2. Continued pregnancy with arranged
adoption; or
3. Termination of pregnancy with its risks.
Knowledgeable and compassionate counselors
should objectively describe and provide
information regarding these choices so that a
woman or couple can make an informed
decision
49. Cervical Preparation
There are several methods that will soften and
slowly dilate the cervix to minimize trauma
from mechanical dilatation.
A Cochrane review confirmed that hygroscopic
dilators and cervical ripening medications
had similar efficacy in decreasing the length of
first-trimester procedure.
Of these, hygroscopic dilators are devices
that draw water from cervical tissues and
expand to gradually dilate the cervix.
One type is derived from various species of Laminaria
algae that are harvested from the ocean floor.
Another is Dilapan-S, which is composed of an acrylic-
based gel.
50. There are medications used for cervical
preparations.
The most common is misoprostol (Cytotec), which is
used off-label, and patients are counseled accordingly.
The dose is 400 to 600 ug administered orally,
sublingually, or placed into the posterior vaginal fornix.
Marginal benefits ascribed to misoprostol included
easier cervical dilatation and a lower composite
complication rate.
Another effective cervical-ripening agent is the
progesterone antagonist mifepristone (Mifeprex).
With this, 200 to 600 ug is given orally.
Other options include formulations of prostaglandins
E2 and F2a, which have unpleasant side effects and
are usually reserved as second-line drugs.
51. Surgical Abortion
Surgical pregnancy termination includes a transvaginal
approach through an appropriately dilated cervix or, rarely,
laparotomy with either hysterotomy or hysterectomy.
With transvaginal evacuation, preoperative cervical
ripening is favored and is typically associated with less pain,
a technically easier procedure, and shorter operating times.
Curettage usually requires intravenously or orally
administered sedatives or analgesics, and some also
use paracervical blockade with lidocaine.
No recommendations specifically address venous
thromboembolism (VTE) prophylaxis for curettage in
low-risk pregnant patients.
The American College of Chest Physicians (Bates, 2012)
recommends only early ambulation for cesarean
delivery in those without risk factors, and at our
hospital, we apply this also to less invasive curettage.
52. Dilatation and Curettage (D&C)
Transcervical approaches to surgical abortion require
first dilating the cervix and then evacuating the
pregnancy by mechanically scraping out the
contents-sharp curettage, by suctioning out the
contents— suction curettage, or both.
Vacuum aspiration, the most common form of suction
curettage, requires a rigid cannula attached to an electric-
powered vacuum source or to a handheld syringe for its
vacuum source.
Curettage:- either sharp or suction: is recommended
for gestations >/= 15 weeks.
Complication rates increase after the 1st trimester.
Perforation, cervical laceration, hemorrhage, incomplete
removal of the fetus or placenta, and postoperative
infections are among these.
The 5.6 % complication rate was made up equally of
hemorrhage, incomplete abortion, and infection. A second
curettage procedure was necessary in 2 %.
53. Technique.
After bimanual examination is performed to determine
uterine size and orientation, a speculum is inserted,
and the cervix is swabbed with povidone-iodine or
equivalent solution.
The anterior cervical lip is grasped with a toothed
tenaculum.
The cervix, vagina, and uterus are richly supplied by nerves
of Frankenhäuser plexus, which lies within connective
tissue lateral to the uterosacral and cardinal ligaments.
Thus, a paracervical block is effective to relieve pain. A local
anesthetic, such as 5 mL of 1 or 2% lidocaine, is most
effective if placed immediately lateral to the insertion of the
uterosacral ligaments into the uterus at 4 and 8 o’clock.
An intracervical block with 5-mL aliquots of 1% lidocaine
injected at 12, 3, 6, and 9 o’clock was reported to be equally
effective.
Dilute vasopressin may be added to the local
anesthetic to decrease blood loss
54. Uterine sounding measures the depth and inclination of
the cavity before other instrument insertion. If required,
the cervix is further dilated with Hegar, Hank, or Pratt
dilators until a suction cannula of the appropriate
diameter can be inserted.
Small cannulas carry the risk of leaving retained
intrauterine tissue postoperatively, whereas large
cannulas risk cervical injury and more discomfort.
The 4th and 5th fingers of the hand introducing the
dilator should rest on the perineum and buttocks as the
dilator is pushed through the internal os. This technique
minimizes forceful dilatation and provides a safeguard
against uterine perforation.
The suction cannula is moved toward the fundus
and then back toward the os and is turned
circumferentially to cover the entire surface of the
uterine cavity. When no more tissue is aspirated, a
gentle sharp curettage should follow to remove
any remaining placental or fetal fragments
55. Because uterine perforation usually occurs with
insertion of any of these instruments,
manipulations should be carried out with the
thumb and forefinger only.
For pregnancies beyond 16 weeks, the
fetus is extracted, usually in parts, using
Sopher forceps and other destructive
instruments.
Inherent risks include uterine perforation,
cervical laceration, and uterine bleeding
due to the larger fetus and placenta and to the
thinner uterine walls. Morbidity can be
minimized if careful attention is paid to
performing the steps outlined above.
56. Complications.
The incidence of uterine perforation with elective abortion
is variable, and determinants include clinician skill and
uterine position.
Perforation is more common with a retroverted
uterus and is usually recognized when the instrument
passes without resistance deep into the pelvis.
Observation is usually sufficient if the uterine perforation is small,
as when produced by a uterine sound or narrow dilator. Although
perforations through old cesarean incision or myomectomy scars
are potentially possible.
If some instruments—especially suction and sharp curettes—
pass through a uterine defect and into the peritoneal cavity,
considerable intraabdominal damage can ensue. In these women,
laparotomy or laparoscopy to examine the abdominal
contents is often the safest course of action.
Bowel injury can cause severe peritonitis and sepsis.
A rare complication of curettage with more advanced
pregnancies is sudden, severe consumptive coagulopathy.
57. If prophylactic antimicrobials are given, pelvic
sepsis is decreased by 40 to 90 % and depends
on whether the procedure is surgical or
medical.
Most infections that do develop respond readily
to appropriate antimicrobial treatment.
Rarely, infections such as bacterial endocarditis
will develop, but they can be fatal (Jeppson,
2008).
Uncommon long-term complications of
curettage include cervical insufficiency or
uterine synechiae.
58. Dilatation and Evacuation (D&E)
Beginning at 16 weeks, fetal size and
structure dictate use of this technique.
Wide mechanical cervical dilatation, achieved
with metal or hygroscopic dilators,
precedes mechanical destruction and
evacuation of fetal parts.
With complete removal of the fetus, a large-
bore vacuum curette is used to remove the
placenta and remaining tissue.
This is better accomplished using intraoperative
sonographic imaging.
59. Dilatation and Extraction (D&X)
This is similar to dilatation and evacuation
except that a suction cannula is used to
evacuate the intracranial contents after delivery
of the fetal body through the dilated cervix.
This aids extraction and minimizes uterine or
cervical injury from instruments or fetal bones.
In political parlance, this procedure has been
termed partial birth abortion.
60. Menstrual Aspiration
This is done within 1 to 3 wks after a missed menstrual period
and with a positive serum or urine pregnancy test result.
It is performed with a flexible 5- or 6-mm Karman cannula
that is attached to a syringe. This procedure has been referred to
as menstrual extraction, menstrual induction, instant period,
traumatic abortion, and mini-abortion.
A distinct drawback is that because the pregnancy is so
small, an implanted zygote can be missed by the curette, or
an ectopic pregnancy can be unrecognized. To identify placenta
in the aspirate, MacIsaac and Darney (2000) recommend that the
syringe contents be rinsed in a strainer to remove blood, then placed
in a clear plastic container with saline and examined with back
lighting.
Placental tissue macroscopically appears soft, fluffy, and
feathery. A magnifying lens, colposcope, or microscope also can
improve visualization.
61. Manual Vacuum Aspiration
This procedure is similar to menstrual aspiration but is used for early
pregnancy failures or elective termination up to 12 weeks.
Some recommend that pregnancy terminations done in the office
with this method be limited to <10 weeks because blood loss
rises sharply between 10 and 12 weeks.
For pregnancies < 8 weeks, preprocedure cervical
ripening is usually not necessary. After this time, some
recommend that osmotic dilators be placed the day prior
or misoprostol given 2 to 4 hours before the procedure.
Paracervical blockade with or without sedation is used. The
technique employs a hand-operated 60-mL syringe and cannula.
A vacuum is created in the syringe attached to the cannula, which is
inserted transcervically into the uterus.
The vacuum produces up to 60 mm Hg suction.
Complications are similar to other surgical methods
62. Hysterotomy or Hysterectomy
In some women with second-trimester
pregnancies who desire sterilization,
hysterotomy with tubal ligation is reasonable.
If there is significant uterine disease, then
hysterectomy may provide ideal treatment.
In some cases of a failed second-trimester
medical induction, either of these may be
considered.
63. Medical Abortion
According to the ACOG(2011c), outpatient medical
abortion is an acceptable alternative to surgical
pregnancy termination in appropriately selected
pregnant women less than 49 days’ menstrual age.
After this time, available data—albeit less robust—
support surgical abortion as preferable.
Throughout history, many natural substances have been
given for alleged abortifacient effects.
Currently, there are only three medications for early
medical abortion that have been widely studied. These
are used either alone or in combination and include:
1. The antiprogestin mifepristone,
2. The antimetabolite methotrexate, and
3. The prostaglandin misoprostol.
64. Mifepristone and methotrexate increase uterine
contractility by reversing progesterone induced
inhibition, whereas misoprostol directly stimulates
the myometrium.
Clark and associates (2006) have reported that
mifepristone causes cervical collagen
degradation, possibly from increased expression
of matrix metalloprotease-2 (MMP- 2).
Methotrexate and misoprostol are both
teratogens. Thus there must be a commitment to
completing the abortion once these drugs have been
given.
With these three agents, a number of dosing schemes
have been proven effective.
For all three, misoprostol is given initially. This is
either used alone or given with methotrexate or
mifepristone. In each instance, it is followed by further
but variable misoprostol doses.
65.
66. As shown in Table 18-3, any regimen used for •
early pregnancy
loss•
is likely to be successful for elective pregnancy
interruption. For elective termination at </= 63 days
’
gestation, randomized trials by von Hertzen (2009, 2010) and
Winikoff (2008) and their colleagues showed 92- to 96 %
efficacy when one of the mifepristone/misoprostol regimens
was used.
Similar results were reported from 10 large urban Planned
Parenthood clinics (Fjerstad, 2009a). In this latter study, buccal
misoprostoloral mifepristone regimens were 87-to 98 %
successful for abortion induction with pregnancies < 10 weeks•
f
gestation, and this rate diminished with advancing gestations.
In another study of 122 women at 9 to 12 weeks•
f gestation,
the success rate was approximately 80 percent .
67. Contraindications
In many cases, contraindications to medical abortion
evolved from exclusion criteria that were used in initial
clinical trials.
Thus, some are relative contraindications: in situ
intrauterine device; severe anemia,
coagulopathy, or anticoagulant use; and
significant medical conditions such as active liver
disease, cardiovascular disease, or uncontrolled
seizure disorders.
Because misoprostol diminishes glucocorticoid
activity, women with disorders requiring
glucocorticoid therapy are usually excluded
(American College of Obstetricians and Gynecologists,
2009b).
In women with renal insufficiency, the
methotrexate dose should be modified and given
with caution, or preferably, another regimen should be
chosen
68. Administration
With the mifepristone/misoprostol regimen,
mifepristone treatment is followed by misoprostol
given at that same time or up to 72 hours later. Some
prefer that misoprostol be administered on site, after which
the woman typically remains for 4 hours. Symptoms are
common within 3 hours and include lower abdominal pain,
vomiting, diarrhea, fever, and chills or shivering. In the first
few hours after misoprostol is given, if the pregnancy
appears to have been expelled, a pelvic examination is done
to confirm this. If not and if the pregnancy is still intact, the
woman is discharged and appointed to return in 1 to 2
weeks. Some choose to repeat a prostaglandin dose
(Dickinson, 2014). Conversely, if there is an incomplete
abortion on clinical or sonographic evaluation, then
suction curettage usually is recommended. Other
complications are hemorrhage and infection
69. With the methotrexate regimens, misoprostol is
given 3 to 7 days later, and women are seen again
at least 24 hours after misoprostol
administration. They are next seen approximately 7
days after methotrexate is given, and sonographic
examination is performed.
If an intact pregnancy is seen, then another dose of
misoprostol is given.
Afterward, the woman is seen again in 1 week if fetal
cardiac activity is present or in 4 weeks if there is no
heart motion.
If abortion has not occurred by the second visit, it is
usually completed by suction curettage.
70. Mifepristone
Mifepristone (RU-486), a derivative of norethindrone, binds
to the progesterone receptor with an affinity greater than
progesterone but does not activate the receptor, thereby
acting as an antiprogestin.
Mifepristone’s known actions on a pregnant uterus include
necrotizing the decidua, softening the cervix, and increasing
both uterine contractility and prostaglandin sensitivity
Administration of mifepristone followed by a prostaglandin
analogue, usually misoprostol, is the most commonly used
medical abortion regimen throughout the world.
As a progesterone receptor antagonist, mifepristone also has
several other potential medical applications, including
emergency contraception, cervical ripening for labor
induction, and treatment of conditions such as
symptomatic leiomyomata uteri, endometriosis,
Cushing’s syndrome, breast cancer, and glaucoma.
71. Misoprostol
Misoprostol is an inexpensive prostaglandin analogue in
a tablet form that is stable at room temperature.
Misoprostol is used clinically for prevention of gastric
ulcers in individuals taking antiinflammatory drugs on a
long-term basis, for abortion, and for labor induction.
Pharmacokinetic evaluation of oral and vaginal
administration of misoprostol demonstrates that oral
misoprostol is absorbed more rapidly, resulting in a
higher peak serum level, but vaginal administration
results in greater uterine contractility.
Recent evaluations of sublingual administration show
higher peak serum concentrations, which may result in
more unnecessary side effects.
Further study of buccal administration may be warranted
because its pharmacokinetic profile appears to be similar
to vaginal administration
72. Methotrexate is used less often today for medical
abortion because of the greater availability of
mifepristone.
Methotrexate blocks dihydrofolate reductase, an
enzyme involved in producing thymidine during DNA
synthesis.
Methotrexate exerts its action primarily on the
cytotrophoblast rather than the developing embryo.
Methotrexate has been used for more than 40 years to treat
neoplastic diseases, rheumatoid arthritis, and
psoriasis; other medical applications include treatment of
systemic lupus erythematosus, dermatomyositis,
severe asthma, Crohn’s disease, and extrauterine
pregnancy.
Tamoxifen has been used in combination with
misoprostol in some studies of early abortion. However,
randomized trials have demonstrated no benefit of using
a tamoxifen–misoprostol regimen compared with a
methotrexate–misoprostol regimen or misoprostol alone
73.
74.
75. Complications
In a 2-year review of more than 233,000 medical
abortions performed at Planned Parenthood
affiliates, there were 1530 (0.65 %) significant
adverse events.
Most of these were ongoing pregnancy (Cleland,
2013).
Bleeding and cramping with medical
termination can be significantly worse than
menstrual cramps. Thus adequate analgesia,
usually including a narcotic, is provided.
The ACOG (2011c) recommends that if there is
enough blood to soak two or more pads per hour
for at least 2 hours, the woman is instructed to
contact her provider to determine whether she
needs to be seen.
76. Unnecessary surgical intervention in women
undergoing medical abortion can be avoided if
properly indicated follow-up sonographic results
are interpreted appropriately. Specifically, if no
gestational sac is seen and there is no heavy
bleeding, then intervention is unnecessary. This
is true even when, as is common, the uterus
contains sonographically evident debris.
Another study reported that a multilayered
sonographic pattern indicated a successful
abortion (Tzeng, 2013). Clark and coworkers
(2010) provided data that routine postabortal
sonographic examination is unnecessary. They
instead recommend assessment of the clinical
course along with bimanual pelvic examination.
Follow-up serum â-hCG levels have shown promise
in preliminary investigations
77.
78. Oxytocin
Given alone in high doses, oxytocin will
result in secondtrimester abortion in 80 to
90 percent of cases.
Oxytocin is delivered in an isotonic
solution.
Thus, by avoiding excessive
administration of dilute intravenous
solutions, hyponatremia or water
intoxication is rare.
79.
80. CONTRACEPTION FOLLOWING
MISCARRIAGE OR ABORTION
Ovulation may resume as early as 2 weeks after an early pregnancy
termination. Plasma progesterone levels, which had plummeted
after the abortion, increased soon after LH surges. These hormonal
events agree with histological changes observed in endometrial.
Thus, it is important that unless another pregnancy is desired right
away, effective contraception should be initiated very soon after
abortion. There is no reason to delay this, and an intrauterine device can
be inserted after the procedure is completed.
Alternatively, any of the various forms of hormonal contraception
can be initiated at this time. For women who desire another pregnancy,
sooner may be preferable to later.
Specifically, Love and colleagues (2010) analyzed the next pregnancy
outcomes in nearly 31,000 women following miscarriage and found that
conceptions within 6 months after miscarriage had better
pregnancy outcomes compared with pregnancies conceived after 6
months.
