best note on abortion

1. AbortionAbortion
byby adugnaw,mDadugnaw,mD
studentstudent

2.  Current prevalce of mathernal deaht related to
abortion is 6% in ethiopia

4. Introduction
 Abortion whether induced or
spontaneous is a common health
problem. At least 15% of all pregnancies
end in spontaneous abortion.end in spontaneous abortion.
 Unsafe abortion is a major public
health problem and at least 20 million
women undergo unsafe abortion each
year.

5. Abortion complications are responsible
for around 14% of the approximately
500,000 maternal deaths that occur
each year and with millions of others
suffering chronic morbidities andsuffering chronic morbidities and
disabilities.
In Ethiopia maternal losses from
abortion and its complication account
for 25-50%.

6.  The term "fetus" will be used throughout this
discussion, although the term "embryo" is the correct
developmental term at ≤10 weeks of gestation
 Smoking cessation should be recommended for its
overall health benefitsoverall health benefits

7.  Nonsteroidal antiinflammatory drugs — The
use of nonsteroidal antiinflammatory drugs
(NSAIDs), but not acetaminophen , may be
associated with an increased risk of miscarriage if
used around the time of conception .used around the time of conception .
 The postulated mechanism is that prostaglandin
inhibitors interfere with the role prostaglandins play
in implantation, thus potentially leading to abnormal
implantation and pregnancy failure

8.  Prolonged ovulation to implantation
interval — Early losses have also been related to a
prolonged interval (ie, >10 days) between ovulation
and implantation
 There is no specific evidence that folate There is no specific evidence that folate
supplementation reduces the risk of miscarriage in
women with hyperhomocysteinemia, although this
has been suggested .
 However, folate supplements are routinely
recommended for all pregnant women anyway for
prevention of neural tube defects

9.  maternal weight — Prepregnancy body mass
index less than 18.5 or above 25 kg/m2has been
associated with an increased risk of infertility and
SAB
 Chromosomal abnormalities — Chromosomal Chromosomal abnormalities — Chromosomal
abnormalities account for approximately 50 percent
of all miscarriages.
 Most of these abnormalities are aneuploidies;
structural abnormalities and mosaicism are
responsible for relatively few abortions.

10.  Trisomy 16 is the most common autosomal trisomy
and is always lethal.
 Most chromosomal abnormalities in the embryo arise
de novo. Rarely, these defects are inherited as a
consequence of parental karyotypic abnormalities,consequence of parental karyotypic abnormalities,
such as balanced translocations

11. Congenital anomalies
— Congenital anomalies are caused by genetic or
chromosomal abnormalities, extrinsic factors (eg,
amniotic bands), and exposure to teratogens.
Potential teratogens include maternal disorders (eg,
diabetes mellitus with poor glycemic control), drugsdiabetes mellitus with poor glycemic control), drugs
(eg, isotretinoin ), physical stresses (eg, fever), and
environmental chemicals (eg, mercury)

12.  Trauma — Invasive
intrauterine procedures/trauma, such as chorionic
villus sampling and amniocentesis, increase the risk
of abortion
 Host factors — Pregnancy loss may also be related Host factors — Pregnancy loss may also be related
to the host environment.
 As an example, congenital or acquired uterine
abnormalities (eg, uterine septum, submucosal
leiomyoma, intrauterine adhesions) can interfere
with optimal implantation and growth

13.  Acute maternal infection with any of a large number
of organisms (eg, Listeria monocytogenes,
Toxoplasma gondii, parvovirus B19, rubella, herpes
simplex, cytomegalovirus, lymphocytic
choriomeningitis virus can lead to abortion fromchoriomeningitis virus can lead to abortion from
fetal or placental infection.
 Maternal endocrinopathies (eg, thyroid dysfunction,
Cushing's syndrome, polycystic ovary syndrome) can
also contribute to a suboptimal host environment

14.  PHARMACOKINETICS, METABOLISM, AND
PHYSIOLOGIC EFFECTS
 General population — Caffeine (methylated
xanthine 1,3,7-trimethylxantine) is a highly soluble
compound that readily crosses cell membranescompound that readily crosses cell membranes
throughout the body.
 It is rapidly absorbed in the stomach and small
intestine and can be detected in human tissues 30 to
45 minutes after ingestion, with peak blood
concentration reached within two hours.

15.  Clearance values are 1 to 3 mL/kg/min in both men
and women after low caffeine intake; however,
clearance is diminished with higher doses, largely
because of saturable metabolism of caffeine
metabolites that accumulate in plasma and reducemetabolites that accumulate in plasma and reduce
caffeine clearance .
 The volume of distribution of caffeine is 0.7 to
1.3 L/kg and elimination half life is 4.1 to 6.4 hours.

16.  Caffeine is metabolized in the liver by the
cytochrome P450 family. Cytochrome P450 1A2
(CYP 1A2) is the predominant isoform, accounting
for 95 percent of primary caffeine metabolism

17.  The primary metabolites of caffeine, paraxanthine
(1,7 dimethylxanthine), theophylline(1,3
dimethylxanthine) and theobromine (3,7
dimethylxanthine), share many of the biological
activities of caffeine and also occur independently inactivities of caffeine and also occur independently in
natural products .
 Paraxanthine is the main metabolite in humans and
is present in coffee beans; theophylline is a
significant xanthine in tea leaves; and theobromine,
the weakest of xanthines, is present in cacao beans.

18.  Metabolism of these metabolites leads to the
formation of monomethylxanthines and
methyluracils.
 Caffeine is excreted by the kidneys, mainly in the
form of different metabolites; only 5 to 10 percent isform of different metabolites; only 5 to 10 percent is
excreted unchanged

19.  Maternal and fetal kinetics — Caffeine and its
metabolites readily cross the placenta and can be
found in substantial quantities in the amniotic fluid
and fetal blood .
 Maternal caffeine metabolism declines significantly Maternal caffeine metabolism declines significantly
during pregnancy; the half life increases three-fold in
the third trimester, reaching a t 1/2 of 11.5 to 18 hours

20.  The fetus metabolizes caffeine very slowly, mainly due to
immaturity of caffeine-metabolizing hepatic microsome
enzymes and lack of CYP 1A2 activity in the placenta.
 Therefore, even low maternal caffeine consumption can
be expected to lead to prolonged fetal caffeine exposure,be expected to lead to prolonged fetal caffeine exposure,
particularly when the mother is a genetically slow
caffeine metabolizer.
 Infants of smokers have lower umbilical cord blood
caffeine concentrations and higher concentrations of
caffeine metabolites than infants of non-smokers,
reflecting faster caffeine metabolism

21.  The increased risk was observed with even small
amounts of caffeine consumption (above
10 mg/day) and did not appear to be dose-
dependent.
 The highest caffeine intake (above 300 mg/day) was The highest caffeine intake (above 300 mg/day) was
associated with anorectal atresia

22.  The March of Dimes recommends that women who are
pregnant or trying to become pregnant consume no more
than 200 mg of caffeine per day .
 Health Canada suggests daily caffeine intake of no more
than 300 mg/day in women who are planning to becomethan 300 mg/day in women who are planning to become
pregnant, pregnant women, and breastfeeding mothers
 Given the limitations and inconsistencies of available
data, we suggest women who are attempting to conceive
or who are pregnant or breastfeeding limit caffeine
consumption to less than 200 to 300 mg per day

23.  Intrauterine adhesions — Intrauterine
adhesions or synechiae lead to pregnancy loss
because there is insufficient endometrium to support
fetoplacental growth .
 The main cause of intrauterine adhesions is The main cause of intrauterine adhesions is
curettage for pregnancy complication
 Defective endometrial receptivity — Estrogen
and progesterone prepare the endometrium for
pregnancy

24. Immunologic factors
— Each step in the establishment of normal pregnancy
has been implicated as a possible site of immune-
mediated reproductive failure.
Both autoimmune and alloimmune mechanisms have
been proposedbeen proposed
 Antiphospholipid syndrome — Several
autoimmune diseases have been linked to poor
obstetric outcome, but antiphospholipid syndrome
(APS) is the only immune condition in which
pregnancy loss is a diagnostic criteria for the disease.

25.  Endocrine factors — Endocrine factors may
account for 15 to 60 percent of RPL.
 Luteal phase defect — Progesterone is essential
for successful implantation and maintenance of
pregnancy; therefore, disorders related to impairedpregnancy; therefore, disorders related to impaired
progesterone production or action are likely to affect
pregnancy success
 Diabetes mellitus — Although rare, poorly
controlled diabetes mellitus is associated with early
(and late) pregnancy loss

26.  The increased risk in poorly controlled diabetic
women is believed to be secondary to hyperglycemia,
maternal vascular disease, and possibly immunologic
factors.

27. Polycystic ovary syndrome
— The miscarriage rate in women with polycystic
ovary syndrome (PCOS) may be as high as 20 to 40
percent, which is higher than the baseline rate in the
general obstetric population (10 to 20 percent) .
The mechanism for excess pregnancy loss in theseThe mechanism for excess pregnancy loss in these
patients is unknown, but may be related to elevated
serum luteinizing hormone (LH) levels, high
testosterone and androstenedione concentrations
(which may adversely affect the endometrium), or
insulin resistance

28.  Genetic factors — Abnormalities of chromosome
number or structure are the most common cause of
sporadic early pregnancy loss, accounting for at least
50 percent of such losses in multiple studies

29.  Environmental chemicals and stress —
Although a frequent concern of patients, there is no
high-quality evidence showing a relationship
between RPL and occupational factors, stress, or low
level exposure to most environmental chemicals .level exposure to most environmental chemicals .
Chemicals that have been associated with sporadic
spontaneous pregnancy loss include anesthetic gases
(nitrous oxide ), arsenic, aniline dyes, benzene,
ethylene oxide, formaldehyde, pesticides, lead,
mercury, and cadmium

30.  Male factor — There is a trend toward repeated
miscarriages in women whose male partner has
abnormal sperm (eg, fewer than 4 percent normal
forms, sperm chromosome aneuploidy) .
 Paternal HLA sharing is not a risk factor for RPL, Paternal HLA sharing is not a risk factor for RPL,
both maternal HLA allele type may play a role .
Advanced paternal age may be a risk factor for
miscarriage

31.  Infection — Some infections, such as Listeria
monocytogenes, Toxoplasma gondii,
cytomegalovirus, and primary genital herpes, are
known to cause sporadic pregnancy loss, but no
infectious agent has been proven to cause RPLinfectious agent has been proven to cause RPL
 the relationship between untreated celiac disease
and pregnancy loss is not well defined.
 Although some controlled studies have observed a
significant association between poor reproductive
performance, including miscarriage, and celiac
disease

32.  Unexplained — The etiology of abortion of
chromosomally and structurally
normalembryos/fetuses in apparently healthy
women is unclear.

33. Risk factor
 Cocaine
 Gravidity
 Nonsteroidal antiinflammatory drugs
 Fever — Fevers of 100°F (37.8°C) or more may Fever — Fevers of 100°F (37.8°C) or more may
increase the risk of miscarriage
 Caffeine
 Prolonged ovulation to implantation interval
 Prolonged time to pregnancy
 Low-folate level

34.  maternal weight
 Celiac disease
 Chromosomal abnormalities
 Leiomyoma Leiomyoma
 Endometrial polyps
 Intrauterine adhesions
 Cervical insufficiency

35. DefinitionDefinitionDefinitionDefinition
The termination of pregnancy before the 28th
week, when the fetus weight is less than 1000
grams.
Early abortion: <12th week of pregnancy
Late abortion: 12th-28th week of pregnancy
Spontaneous abortion
Artificial abortion

36. EtiologyEtiologyEtiologyEtiology
Genetic factors:
chromosomal abnormal accounts 50～
60%
of the early abortionsof the early abortions
• Numeral abnormalities:
polyploidy, triploidy, monosomy
• Structural abnormalities:
break, translocation, deletion

37. EtiologyEtiologyEtiologyEtiology
Extrinsic factors
• Chemical: mercury, lead, cadmium,
smoking,smoking,
• Physical: video display terminals,
radioactive materials, noise,
hyperthermia

38. EtiologyEtiologyEtiologyEtiology
Maternal factors
• General diseases:
infection, heart diseases, hypertension,
anemia
• Reproductive organic diseases:
congenital uterine malformation, pelvic
tumor, cervical incompetence
• Endocrine disorders:
hypothyroidism
• Injuries

39. EtiologyEtiologyEtiologyEtiology
Defects in the developing placenta
Immunologic factors: paternal histo-Immunologic factors: paternal histo-
compatibility antigen , maternal
cellular immunity regular disorder,
deficiency of maternal blocking
antibody

40. PathologyPathologyPathologyPathology
The death of the embryo or rudimentary
analog
Hemorrhage into the decidua basalisHemorrhage into the decidua basalis
Uterine contraction, dilation of the cervix
Expulsion of the products conception

41.  DEFINITION — RPL classically refers to the
occurrence of three or more consecutive losses of
clinically recognized pregnancies prior to the 20th
week of gestation (ectopic, molar, and biochemical
pregnancies are not included).pregnancies are not included).
 However, many investigators use variations of this
definition

42.  RPL can be considered a primary or secondary
process: primary RPL refers to repeated miscarriages
in which a pregnancy has never been carried to
viability, while in secondary RPL, a live birth has
occurred at some time .occurred at some time .
 The prognosis for successful pregnancy is better with
secondary RPL
 There is no specific term for describing women who
have had multiple spontaneous miscarriages
interspersed with normal pregnancies (ie,
nonconsecutive pregnancy losses)

43.  eneral etiological categories of RPL include
anatomic, immunological, genetic, endocrine,
infectious, thrombophilic, and environmental factors
 Previous pregnancy loss — In a first pregnancy,
the risk of miscarriage is 11 to 13 percent .the risk of miscarriage is 11 to 13 percent .
 After one miscarriage, this rate rises slightly to 14 to
21 percent. After two or three miscarriages, the rate
is 24 to 29 percent and 31 to 33 percent, respectively.
However, several factors influence these rates

44. PathologyPathologyPathologyPathology
Before the 8th week of the pregnancy,
the abortus can be expelled completely
During the 8th-12th week of theDuring the 8th-12th week of the
pregnancy, retention of the tissue is
common
After the 12th week of the pregnancy, the
abortus may be expelled totally

45. Clinical subgroupsClinical subgroups
of abortionof abortion
Clinical subgroupsClinical subgroups
of abortionof abortion
Threatened abortion
Inevitable abortion
Incomplete abortion
Complete abortion
Septic abortion
Missed abortion

46. Threatened abortion
— Bleeding through a closed cervical os in the first half of pregnancy is quite
common and is termed threatened abortion. The bleeding is often painless, but
may be accompanied by minimal/mild suprapubic pain
On examination, the uterine size is appropriate for gestational age and the
cervix is long and closed. Fetal cardiac activity is detectable by ultrasound or
Doppler examination if the gestation is sufficiently advanced. The exact etiology
of bleeding often cannot be determined and is frequently attributed to marginalof bleeding often cannot be determined and is frequently attributed to marginal
separation of the placenta

47. Inevitable abortion — When abortion is imminent, bleeding increases, painful
uterinecramps/contractions reach peak intensity, and the cervix is dilated. The
gestational tissue can often be felt or visualized through the internal cervical os
Complete and incomplete abortion — When an abortion occurs before 12
weeks of gestation, it is common for the entire contents of the uterus to be
expelled, thereby resulting in a complete abortion. Over one third of all cases are
complete, rather than incomplete, abortions.
If a complete abortion has occurred, the uterus is small and well contracted with aIf a complete abortion has occurred, the uterus is small and well contracted with a
closed cervix, scant vaginal bleeding, and only mild cramping.
After 12 weeks, the membranes often rupture and the fetus is passed, but
significant amounts of placental tissue may be retained, leading to an incomplete
abortion, also called an abortion with retained products of conception

48.  On examination the cervical os is open, gestational
tissue may be observed in the vagina/cervix, and the
uterine size is smaller than expected for gestational
age, but not well contracted. The amount of bleeding
varies, but can be severe enough to causevaries, but can be severe enough to cause
hypovolemic shock. Painful cramps/contractions are
often present

49.  Missed abortion — A missed abortion refers to in-
utero death of the embryo or fetus prior to the 20th
week of gestation, with retention of the pregnancy
for a prolonged period of time. Women may notice
that symptoms associated with early pregnancy (eg,that symptoms associated with early pregnancy (eg,
nausea, breast tenderness) have abated and they
don't "feel pregnant" anymore; vaginal bleeding may
occur. The cervix is usually closed.

50.  Septic abortion — Common clinical features of
septic abortion include fever, chills, malaise,
abdominal pain, vaginal bleeding, and discharge,
which is often sanguinopurulent. Physical
examination may reveal tachycardia, tachypnea,examination may reveal tachycardia, tachypnea,
lower abdominal tenderness, and a boggy, tender
uterus with dilated cervix

51.  Infection is usually due to Staphylococcus aureus,
Gram negative bacilli, or some Gram positive cocci.
Mixed infections, anaerobic organisms, and fungi,
can also be encountered. The infection may spread,
leading to salpingitis, generalized peritonitis, andleading to salpingitis, generalized peritonitis, and
septicemia

52. DIFFERENTIAL DIAGNOSIS
 Physiologic (ie, believed to be related to
implantation)
 Ectopic pregnancy
 Impending or complete miscarriage
 Cervical, vaginal, or uterine pathology

53. Diagnosis
 Ultrasonography
 A definite diagnosis of nonviable intrauterine pregnancy
(missed abortion) can be made based upon either of the
following criteria:
 Absence of embryonic cardiac activity in an embryo with
crown-rump length greater than 5 mm .
 Absence of a yolk sac when the mean sac diameter is 13 Absence of a yolk sac when the mean sac diameter is 13
mm .
 Absence of an embryonic pole when the mean sac
diameter (average of diameters measured in each of three
orthogonal planes) is greater than 25 mm measured
transabdominally or greater than 18 mm by the
transvaginal technique

54.  When embryonic heart motion was detected at 5 to 6
weeks of gestation in women less than 36 years of
age, the risk of subsequent SAb was 4.5 percent;
however, the risk of miscarriage despite previous
detection of embryonic heart activity increased to 10detection of embryonic heart activity increased to 10
percent in women aged 36 to 39 years and 29
percent in women greater than or equal to 40 years
of age

55.  In women with recurrent pregnancy loss, the risk of
spontaneous pregnancy loss after observation of
embryonic heart activity remains high, about 22
percent

56. Findings potentially predictive of
pregnancy loss
1 Abnormal yolk sac - An abnormal yolk sac may be
large for gestational age, irregular, free floating in
the gestational sac rather than at the periphery, or
calcified.

57. 2 Slow fetal heart rate - Embryonic heart rate below
100 beats per minute (bpm) at 5 to 7 weeks of
gestation is slow
3 Small sac - Small mean sac size (MSS) is diagnosed
when the difference between the MSS and crown-when the difference between the MSS and crown-
rump length (CRL) is less than 5 mm (MSS - CRL < 5)
4 Subchorionic hematoma – A subchorionic
hematoma is a risk factor for SAb

58. management
 THREATENED ABORTION
 Bed rest
 Avod sexual

60. SEPTIC ABORTION
Stabilizing the patient
 Obtaining blood and endometrial cultures
 Promptly administering parenteral broad spectrum
antibiotics (eg, clindamycin 900 mg every eight hours
and gentamicin 5 mg/kg daily with or without ampicillin 2
g every four hours;g every four hours;
 or ampicillin and gentamicin and metronidazole 500 mg
every eight hours;
 or levofloxacin 500 mg daily and metronidazole;
 or single agents such as ticarcillin-clavulanate 3.1 g every
four hours, piperacillin-tazobactam 4.5 g every six hours,
 or imipenem 500 mg every six hours).

61.  Intravenous antibiotics are administered until the
patient has improved and been afebrile for 48 hours,
then are typically followed by oral antibiotics to
complete a 10- to 14-day course.
 The need to complete a full course with oral
antibiotics after clinical improvement has beenantibiotics after clinical improvement has been
questioned, based upon data from a randomized trial
that found no difference in women who received only
a short course of intravenous therapy .

62.  Evacuation of the uterus should begin promptly after
initiating antibiotics and stabilizing the patient in
cases of suspected septic abortion or retained products
of conception as delay in evacuation may be fatal.
 Suction curettage is less traumatic than sharp Suction curettage is less traumatic than sharp
curettage.

63. Indications for surgery and possible
hysterectomy
failure to respond to uterine evacuation and antibiotics,
pelvic abscess, and clostridial necrotizing myonecrosis
(gas gangrene).
A discolored, woody appearance of the uterus and
adnexa, suspected clostridial sepsis, crepitation of theadnexa, suspected clostridial sepsis, crepitation of the
pelvic tissue, and radiographic evidence of air within
the uterine wall are indications for total hysterectomy
and adnexectomy

64.  On the other hand, mild endometritis (low grade
fever, mild uterine tenderness, empty uterus on
ultrasound examination) after a complete
spontaneous abortion can be managed with oral
broad spectrum antibioticsbroad spectrum antibiotics

65. COMPLETE ABORTION
 Tissue that is passed should be examined to confirm that
it is (or is not) the product of conception
 Placental villi can be difficult to distinguish from
organized clot.
 One method is to rinse with water and then float the
tissue in a dish of water, preferably with a good lighttissue in a dish of water, preferably with a good light
source underneath.
 Villi have a frond-like appearance, which has been
described as similar to seaweed floating in the ocean .
 Ultrasound examination may be useful for confirming
the absence of significant amounts of retained
intrauterine tissue

66.  In our experience, if the ultrasound shows an empty
uterus and the bleeding is minimal, no further action
is needed.

67. INCOMPLETE, INEVITABLE, AND MISSED ABORTION
— Women with an incomplete, inevitable, or missed
abortion documented by ultrasound examination can
be managed surgically, medically, or expectantly.
 Surgical management
— The conventional treatment of first or early second— The conventional treatment of first or early second
trimester failed pregnancy is dilatation and curettage
(D&C) or dilatation and evacuation (D&E) to prevent
potential hemorrhagic and infectious complications
from the retained products of conception

68.  Surgical management is appropriate for women who
do not want to wait for spontaneous or medically
induced evacuation of the uterus and those with heavy
bleeding or intrauterine sepsis in whom delaying
therapy could be harmful
 We recommend doxycycline (100 mg orally for two
doses 12 hours apart on the day of the surgical
procedure) to reduce the risk of postabortal sepsis

69. Medical treatment
— The availability of effective medical therapies for
inducing abortion has created new options for women
who want to avoid surgery and in areas where surgical
intervention is notpractical.
Misoprostol (a prostaglandin E1 analog) is the mostMisoprostol (a prostaglandin E1 analog) is the most
commonly used such agent

70.  The expulsion rate was even higher with a dose of
600 to 800 mcg given vaginally (70 to 90 percent)
This may be due to the local effect of misoprostol on
the uterine cervix, the high drug concentration
achieved in uterine tissue, and the increased
bioavailability with vaginal administrationbioavailability with vaginal administration
 Buccal administration appears to be as effective as
vaginal administration, but is associated with more
side effects, probably related to differences in
pharmacokinetics for the two routes of
administration

71.  For missed abortion – 800 mcg per vaginam OR 600
mcg sublingually (each of these is a single dose)
 For incomplete abortion – 600 mcg orally (single
dose)
 Our preference is to use misoprostol 400 mcg per Our preference is to use misoprostol 400 mcg per
vaginam every four hours for four doses to take
advantage of the increased effectiveness of the vaginal
route while minimizing the risk of side effects, which
are dose and route dependent.
 The expulsion rate is 70 to 90 percent within 24
hours; thus, some women will still require surgical
evacuation.

72. Expectant management
— Expectant management (EM) is an alternative for
women with early pregnancy failure at less than 13
weeks of gestation who have stable vital signs and no
evidence of infection

73.  The majority of expulsions occur in the first two
weeks after diagnosis; however, some women may
require prolonged follow-up .
 Incomplete miscarriage is more likely to proceed to
expulsion within two weeks than a missed abortion.expulsion within two weeks than a missed abortion.
An interval of three to four weeks between diagnosis
of nonviable pregnancy and expulsion is not unusual.
Most women are willing to wait when appropriately
counseled and prepared for what to expect

74.  If spontaneous expulsion does not occur, medical or
surgical treatment can be administered.
 Following spontaneous or medically induced
expulsion,
 There are no universally defined criteria for an empty There are no universally defined criteria for an empty
uterus.
 One option is to proceed with surgical evacuation if
retained tissue with a diameter of more than 15 mm is
found .
 Others use a homogeneous intrauterine dimension less
than 11 cm2 in combined transverse and sagittal
planes to define an empty uterus

75. POSTABORTION CARE AND COUNSELING
— Women are advised to maintain pelvic rest (ie,
nothing per vagina) until two weeks after evacuation
or passage of the products of conception, at which
time coitus and use of tampons may be resumed.
It is customary to advise that pregnancy be deferredIt is customary to advise that pregnancy be deferred
for two to three months, although several studies
have shown no greater risk of adverse outcome with
a shorter interpregnancy interval .
Any type of contraception, including placement of
intrauterine contraception , may be started
immediately after the abortion has been completed

76. Alloimmunization prevention
— Women who are Rh(D)-negative and unsensitized
should receive Rh(D)-immune globulin following
surgical evacuation or upon diagnosis if medical
management or EM is planned. A dose of 50 mcg is
effective through the 12th week of gestation due toeffective through the 12th week of gestation due to
the small volume of red cells in the fetoplacental
circulation (mean red cell volume at 8 and 12 weeks
is 0.33 mL and 1.5 mL, respectively), although there
is no harm in giving the standard 300 microgram
dose, which is more readily available

77.  Resolution of positive hCG — Serum hCG values
typically return to normal within two to four weeks
after a completed abortion

78. Grief counseling
— Grief counseling is appropriate .
It is important to acknowledge the patient's (and
partner's) grief and provide empathy and support.
Risk factors for abnormal grief following a miscarriage
includeinclude
 A history of or current depression, anxiety, or other
psychiatric disorder
 Neurotic personality traits
 Lack of social support

79. FUTURE REPRODUCTIVE ISSUES
— The overall risk of miscarriage in future pregnancy
is approximately 20 percent after one miscarriage,
28 percent after two miscarriages, and 43 percent
after three or more miscarriages

80.  If the etiology of the loss is known or suspected, the
couple should be informed and counseled about
recurrence risks.
 If reversible risk factors for spontaneous abortion are
present, these can be addressed, as appropriate, in apresent, these can be addressed, as appropriate, in a
nonjudgmental way.
 When an etiology cannot be determined, it is important
to reassure the woman that there is no evidence that
something she might have done (eg, sexual intercourse,
heavy lifting, bumping her abdomen, stress) caused the
miscarriage.

81. The developing processesThe developing processes
of the abortionof the abortion
The developing processesThe developing processes
of the abortionof the abortion
Threatened abortion
Normal pregnancy Inevitable abortion
Complete abortion Incomplete abortion

82. Classifications andClassifications and
characteristicscharacteristics
Classifications andClassifications and
characteristicscharacteristics
conceptus Vaginal abdominal Cervix os Uterine
Subgroups expulsion bleeding pain dilation enlargement
Threatened no ＋ －＋ － compatible
abortion
Inevitable no ＋ ＋ ＋ ＋ ＋ － compatible
or abortion smalleror abortion smaller
Incomplete part ＋ ＋ ＋ ＋ ＋ － smaller
abortion
Complete all ＋ － － － normal
abortion

83. Classification of abortion
Normal pregnancy
Blighted
ovum
Missed
abortion
Threatened
abortion
Inevitable
abortion
Continuing
pregnancy
Incomplete
abortion
Complete
abortion

84. Special subgroups:Special subgroups:
MissedMissed abortion
Special subgroups:Special subgroups:
MissedMissed abortion
Expulsion of the conceptus does not
occur despite a prolonged period after
embryonic death.
Symptoms of pregnancy regress
Pregnancy test becomes negative
No fetal heart motion is detected
Uterine enlargement ceases

85. Special subgroups:
RecurrentRecurrent abortion
Special subgroups:
RecurrentRecurrent abortion
(Habitual abortion)
Three or more consecutive spontaneous
losses
of pregnancyof pregnancy
First-trimester: hypothyroidism,
chromosomal abnormalities,
immunologic factors
Second-trimester: uterine malformations,
cervical incompetence, myomas

86. Special subgroups:
SepticSeptic abortion
Special subgroups:
SepticSeptic abortion
Any type of spontaneous abortion is
complicated by infectioncomplicated by infection
Endometritis, parametritis, peritonitis
Fever, abdominal tenderness, uterine
pain
Septicemia, septic shock

87. DiagnosisDiagnosisDiagnosisDiagnosis
 History: amenorrhea, symptoms of
pregnancy, vaginal bleeding……
 Examination: general and pelvic
Ultrasounograph Ultrasounograph
 Pregnancy test, ß-HCG
 Others:

88. Differential diagnosisDifferential diagnosisDifferential diagnosisDifferential diagnosis
 Ectopic pregnancy
 Molar pregnancy
 Dysfunctional uterine bleeding (DUB) Dysfunctional uterine bleeding (DUB)
 Pelvic infective diseases (PID)
 Acute appendicitis

89. ManagementManagementManagementManagement
Threatened abortion :
rest, follow-up
Inevitable & incomplete abortion :Inevitable & incomplete abortion :
Evacuation of the uterus,vacuum or
suction curettage, oxytocin iv,
antibiotics
Complete abortion :
no further therapy is necessary.

90. Management
MissedMissed abortion
Management
MissedMissed abortion
First- trimester:
suction curettage
The second-trimester:The second-trimester:
D&E(dilation and evacuation)
D&C(dilation and curettage)
Induction of labor with
intravaginal prostaglandin E2 or
misoprostol

91. Management
RecurrentRecurrent abortion
Management
RecurrentRecurrent abortion
A workup for possible causes of recurrent
pregnancy loss (RPL): anatomic,
hormonal,genetic,and autoimmune factors
(underlying maternal factors)(underlying maternal factors)
Incompetent cervix: cerclage designed to
reinforce the cervix at the level of the internal
os at the end of the first trimester, the suture is
removed after 37 weeks’ gestation

92. Management
SepticSeptic abortion
Management
SepticSeptic abortion
 Evacuation of the uterus within a few hours after
antibiotics iv
 High-dose, broad-spectrum coverage antibiotics,
aggressive use before, during, and after removal of
necrotic tissue by curettage
 hysterectomy

93. The key element of post abortion
care are:
 Emergency treatment of incomplete abortion
and potentially life threatening complications
 Post-abortion family planning counseling and
services
 Links between post-abortion emergency Links between post-abortion emergency
services and the reproductive health care system
 HIV and STI
 Emotional support

94. Summary pointsSummary pointsSummary pointsSummary points
 The most frequent etiology of abortion is a
chromosomal abnormality of the conceptus and most
of the abortions occur in the first-trimester.
 The processes of the pathology decide the The processes of the pathology decide the
characteristics of the subgroups.
 Ultrasound is helpful in diagnosis.

95. Treatment
 PREOPERATIVE CONSIDERATIONS
 Laboratory tests — The patient's hematocrit (or
hemoglobin) and Rh(D) statu
 Imaging — Preoperative ultrasonography should
be considered if there is a discrepancy betweenbe considered if there is a discrepancy between
uterine size and gestational age, uncertain fetal
viability, or the diagnosis is in doubt (possible
ectopic pregnancy or hydatidiform mole)

96.  Antibiotic prophylaxis — Antibiotic prophylaxis
is recommended for surgical abortion as postabortal
endometritis occurs in 5 to 20 percent of women not
given antibiotics .
 Doxycycline (100 mg orally twice per day on the day Doxycycline (100 mg orally twice per day on the day
of the procedure), ofloxacin(400 mg orally twice per
day on the day of the procedure), or ceftriaxone (1 g
intravenously 30 minutes prior to the procedure) can
be used to help prevent these infections.

97.  Cervical preparation — Dilation of the cervix to
allow insertion of instruments and removal of the
products of conception is usually necessary prior to
surgical procedures for pregnancy termination. This
can be accomplished mechanically using osmoticcan be accomplished mechanically using osmotic
dilators (eg, laminaria) or rigid dilators, or by using
pharmacological agents (eg, misoprostol

98.  Osmotic dilators — Osmotic dilators (natural:
seaweed Laminaria japonica; synthetic: Dilapan-S,
Lamicel) absorb cervical moisture, gradually
enlarging the endocervical canal and softening the
cervix. Osmotic dilator-induced cervical change alsocervix. Osmotic dilator-induced cervical change also
results from the release of endogenous
prostaglandins, which further soften the cervix and
facilitate the dilation process.
 Use of osmotic dilators helps prevent cervical injury
and may also decrease the risk of uterine perforation

99.  In rare cases, a patient may have a hypersensitivity
or anaphylactic reaction to laminaria
 How to use laminaria — Proper use of laminaria
tents requires that they be inserted and left in place
for 12 to 18 hours to achieve optimal cervical dilationfor 12 to 18 hours to achieve optimal cervical dilation
(women can be sent home following insertion of the
laminaria tents), although they can be removed
earlier, after six hours, often with sufficient dilation

100.  Insertion of a large number of small diameter laminaria (2
or 3 mm) is preferable to using a few large ones (6 mm)
because placement is easier and there is better cervical
dilation.
 Some post-insertion cramping is common; a paracervical
block or other analgesic approach may be required .
 The laminaria are kept in place with two 4 by 4 gauze The laminaria are kept in place with two 4 by 4 gauze
sponges tucked into the fornices and the number of
laminaria inserted recorded in the woman's chart.
 She should avoid intercourse and return to the office when
instructed or if she develops bleeding, rupture of
membranes, or fever.
 Failure to remove the laminaria within 48 hours of
placement can result in severe infection.

101.  Prostaglandin E1 analogs — Misoprostol can
also be used
 When misoprostol was used in first trimester
procedures, 97 percent of patients had cervical
dilation of at least 8 mmdilation of at least 8 mm
 Mifepristone — The
antiprogesterone mifepristone promotes cervical
dilation for uterine evacuation, and may facilitate
manual and osmotic dilation

102.  Isosorbide dinitrate — Isosorbide dinitrate has
also been used for cervical ripening, with mixed results
compared to prostaglandins .
 The major side effect is headache
 preoperative cervical dilation with osmotic dilators preoperative cervical dilation with osmotic dilators
or misoprostol is safe and effective for second-
trimester uterine evacuation procedures

103. Local anesthesia
— Local anesthesia (eg, paracervical or uterosacral
block) with or without intravenous sedation is
sufficient for most first trimester procedures.
Most second trimester procedures require some
sedation.sedation.
 Options for conscious sedation include midazolam
(2 mg IV) or fentanyl (100 mcg IV).
Sedation administered orally medications is not as
effective as intravenously

104.  Analgesia — Administration of a nonsteroidal
antiinflammatory drug (eg, ibuprofen600 to 800
mg) one hour prior to the procedure appears to
diminish intraoperative and postoperative
discomfortdiscomfort

105. Paracervical block
— Paracervical block is placed by injecting a total dose of
approximately 10 to 20 mL of anesthetic agent (eg, 1
percent lidocaine or 0.25 percentbupivacaine ) deep into
the cervical stroma at the 12, 4, and 8 o'clock positions .
The dose of 10 mL of 1 percent lidocaine (100 mg)
[maximum dose 4.5 mg/kg body weight or 20 mL for a 50[maximum dose 4.5 mg/kg body weight or 20 mL for a 50
kg woman] achieves a peak plasma level well below the
toxic range and occurs 10 to 15 minutes following the
injection .
If laminaria or synthetic dilators were inserted, the
paracervical block can be deferred until after their
removal.

107.  Surgical — Dilation and evacuation (D&E)
procedures involve mechanically opening the uterine
cervix followed by evacuation of intrauterine
contents.
 They can be performed in a uterus of almost any size They can be performed in a uterus of almost any size
for removal of most types of intrauterine contents
(eg, placenta, molar tissue, fetal tissue).
 These procedures are the most common method of
pregnancy termination at ≤14 weeks of gestation

108.  Nonsurgical — Nonsurgical methods may be
employed in very early (<7 to 9 weeks) and late
pregnancy terminations (≥15 weeks); surgical
methods are recommended for pregnancies between
these gestational ages.these gestational ages.

109. POSTOPERATIVE CARE
 Women who are Rh(D)-negative and unsensitized
should receive 300 mcg Rh(D)-immune globulin
following the procedure (50 mcg is sufficient for
procedures in the first trimester)
 Methylergonovine maleate (0.2 mg orally every four Methylergonovine maleate (0.2 mg orally every four
hours for as many as five doses) is given by some
providers to decrease postabortal bleeding resulting
from uterine atony and to help prevent the
development of hematometra

110. COMPLICATIONS
1 Early complications
Hemorrhage
Uterine perforation
Hematometra — Immediate postoperative pain
without overt bleeding from the vagina may indicatewithout overt bleeding from the vagina may indicate
development of hematometra.
Hematometra (also known as uterine distension
syndrome or postabortal syndrome) usually presents
with complaints of dull, aching lower abdominal pain,
sometimes accompanied by tachycardia, diaphoresis,
or nausea

111. Delayed complications
— Late complications of suction curettage are those
occurring more than 72 hours after the procedure;
they develop in approximately 1 percent of cases.
Fever, infection, hemorrhage, and retained products
of conception are the most common delayedof conception are the most common delayed
complications

112. Ongoing pregnancy
— Ongoing pregnancy is more likely to be a complication of early rather
than late abortion.
 All women will continue to have an elevated level of hCG for a short
period following pregnancy termination.
 Return of the serum hCG concentration to undetectable following
pregnancy termination varies widely from 7 to 60 days .
 The period of time depends primarily upon the hCG concentration at
the time of termination.the time of termination.
 The hCG concentration peaks at 8 to 11 weeks at approximately
90,000 mIU.
 This is in contrast with term pregnancy, for which the hCG
concentration is lower.
 The decline in serum hCG is rapid for the first several days (half-life
9 to 31 hours) and then proceeds more slowly (half-life 55 to 64
hours)

113.  An ongoing intrauterine pregnancy may occur after
an attempted pregnancy termination if the products
of conception are not closely examined by an
experienced clinician at the time of the procedure
(and by a pathologist) to verify successful completion(and by a pathologist) to verify successful completion
 Alternatively, ongoing pregnancy may rarely result
from a multiple gestation in which only one of the
sacs was aborted.

114. WOMEN'S FEELINGS AFTER PREGNANCY
TERMINATION
— The most common emotional reactions after
pregnancy termination are relief, transient guilt,
sadness, and a sense of loss

115.  SUMMARY AND RECOMMENDATIONS
 Physicians performing any uterine evacuation procedure should
obtain a comprehensive patient history, perform a complete
physical examination with special attention to the uterine size
and position, and obtain confirmation of pregnancy.
 The gestational age should be determined by both menstrual
history and bimanual examination; ultrasound examination ishistory and bimanual examination; ultrasound examination is
useful if there is any uncertainty and at advanced gestational
ages.
 Antibiotic prophylaxis is recommended because it significantly
reduces the frequency of postabortal endometritis. Options
include doxycycline (100 mg orally twice per day on the day of
the procedure), ofloxacin (400 mg orally twice per day on the
day of the procedure), or ceftriaxone (1 g intravenously 30
minutes prior to the procedure).

116.  The patient's hematocrit (or hemoglobin) and Rh(D) status
should be determined. Rh(D)-negative patients should
receive anti-D immune globulin after the procedure.
 Mifepristone (RU-486), an antiprogestin, can be used for
the medical termination of early pregnancies (typically up
to 63 days of gestation).to 63 days of gestation).
 Cervical preparation may be performed with osmotic
dilators or prostaglandins, depending on clinician and
patient preference.
 Physicians who use nonsurgical methods for pregnancy
termination must be prepared themselves or in
conjunction with another physician to employ surgical
techniques for evaluation and treatment of complications
such as hemorrhage and retained products of conception

118. TheTheThe
End
The
End