This document discusses various types of spontaneous and induced abortions. It defines threatened, inevitable, complete, incomplete, missed, and septic abortions. It describes treatments for threatened abortion and discusses prognosis. It also outlines methods of both surgical (e.g. D&C, D&E) and medical (e.g. mifepristone, misoprostol) induction of early abortions, and complications of each. Long term consequences like impact on future pregnancies are addressed as well.

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