Abotion 1

Williams ObstetricsWilliams Obstetrics
Chapter 9 AbortionChapter 9 Abortion
OBGY R1 Lee Eun SukOBGY R1 Lee Eun Suk

AbortionAbortion
 Spontaneous abortionSpontaneous abortion
 PathologyPathology
 EtiologyEtiology
 Fetal FactorsFetal Factors
 Maternal FactorsMaternal Factors
 Paternal FactorsPaternal Factors
 Categories of Spontaneous AbortionCategories of Spontaneous Abortion
 Induced abortionInduced abortion
 History of abortionHistory of abortion
 IndicationsIndications
 Elective (Voluntary) AbortionElective (Voluntary) Abortion
 Presumption of ovulation after abortionPresumption of ovulation after abortion

AbortionAbortion
 Termination of pregnancy, either spontaneously orTermination of pregnancy, either spontaneously or
intentionallyintentionally
 Pregnancy termination prior to 20 weeksPregnancy termination prior to 20 weeks ’’ gestation orgestation or
less than 500-g birthweightless than 500-g birthweight
 Definition vary according to state laws for reportingDefinition vary according to state laws for reporting
abortions, fetal deaths, and neonatal deathsabortions, fetal deaths, and neonatal deaths

Spontaneous abortionSpontaneous abortion
 Abortion occurring without medical or mechanical meansAbortion occurring without medical or mechanical means
to empty the uterus is referred to asto empty the uterus is referred to as spontaneousspontaneous
 Another widely used term isAnother widely used term is miscarriagemiscarriage
 Hemorrhage into the decidua basinalis, followed by necrosis of tissuesHemorrhage into the decidua basinalis, followed by necrosis of tissues
adjacent to the bleedingadjacent to the bleeding
 If early, the ovum detaches, stimulating uterine contractionsIf early, the ovum detaches, stimulating uterine contractions
that result in its ovulationthat result in its ovulation
 Gestational sac is opened , fluid surrounding a small maceratedGestational sac is opened , fluid surrounding a small macerated
fetus or alternatively no fetus is visible →fetus or alternatively no fetus is visible → blighted ovumblighted ovum

 In later abortion, the retained fetus may undergoIn later abortion, the retained fetus may undergo macerationmaceration
 The skull bones collapse, the abdomen distends with bloodThe skull bones collapse, the abdomen distends with blood --
stained fluid, and the internal organs degeneratestained fluid, and the internal organs degenerate
 The skin softens and peels off in utero or at the slightest toughThe skin softens and peels off in utero or at the slightest tough
 When amnionic fluid is absorbed, the fetus may becomeWhen amnionic fluid is absorbed, the fetus may become
compressed and desiccated →compressed and desiccated → fetal compressusfetal compressus
 The fetus become so dry and compressed that it resemblesThe fetus become so dry and compressed that it resembles
parchment -parchment - a fetus papyraceousa fetus papyraceous

 More than 80 percent of abortions occur in the first 12More than 80 percent of abortions occur in the first 12
weeks of pregnancyweeks of pregnancy
 At least half result from chromosomal anomaliesAt least half result from chromosomal anomalies
 After the first trimester, both the abortion rate & theAfter the first trimester, both the abortion rate & the
incidence of chromosomal anomalies decreaseincidence of chromosomal anomalies decrease

 The risk of spontaneous abortion increases with parity asThe risk of spontaneous abortion increases with parity as
well as with maternal and paternal agewell as with maternal and paternal age
 The frequency of abortion increases from 12 percent inThe frequency of abortion increases from 12 percent in
women younger than 20 years to 26 percent in those olderwomen younger than 20 years to 26 percent in those older
than 40 yearsthan 40 years
 If a woman conceives within 3 months following a term birthIf a woman conceives within 3 months following a term birth
→→ incidence of abortion ↑incidence of abortion ↑

 The exact mechanism responsible for abortion are notThe exact mechanism responsible for abortion are not
apparentapparent
 In the first 3 months of pregnancyIn the first 3 months of pregnancy
 Death of the embryo or fetus nearly always precedesDeath of the embryo or fetus nearly always precedes
spontaneous expulsion of the ovumspontaneous expulsion of the ovum
 Finding of the cause of early abortion involves ascertainingFinding of the cause of early abortion involves ascertaining
the cause of fetal deaththe cause of fetal death
 In subsequent monthsIn subsequent months
 The fetus frequently does not die before expulsionThe fetus frequently does not die before expulsion
 Other explanations for its expulsion should be soughtOther explanations for its expulsion should be sought

Spontaneous abortion - Fetal factorsSpontaneous abortion - Fetal factors
 Abnormal zygotic developmentAbnormal zygotic development
 Early spontaneous abortion commonly display aEarly spontaneous abortion commonly display a
developmental abnormality of the zygote, embryo, earlydevelopmental abnormality of the zygote, embryo, early
fetus, or placentafetus, or placenta
 1000 spontaneous abortions analyzed by Hertig and1000 spontaneous abortions analyzed by Hertig and
SheldonSheldon
 Half demonstrated degenerated or absent embryos, that is,Half demonstrated degenerated or absent embryos, that is,
blighted ovablighted ova

 Aneuploid abortionAneuploid abortion
 Approximately 50 to 60 percent of embryos and earlyApproximately 50 to 60 percent of embryos and early
fetusesfetuses
that are spontaneously aborted contain chromosomal abnor-that are spontaneously aborted contain chromosomal abnor-
malities accounting for most of early pregnancy wastagemalities accounting for most of early pregnancy wastage
 Jacobs and HassoldJacobs and Hassold (1980)(1980)
 95 percent of chromosomal abnormalities95 percent of chromosomal abnormalities
 d/t maternal gametogenesis errord/t maternal gametogenesis error
 5 percent → d/t paternal error5 percent → d/t paternal error

 Aneuploid abortion -Aneuploid abortion - Autosomal trisomyAutosomal trisomy
 The most frequently identified chromosomal anomalyThe most frequently identified chromosomal anomaly
associated with first-trimester abortionsassociated with first-trimester abortions
 Most trisomies result fromMost trisomies result from isolated nondisjunction ,isolated nondisjunction ,
balanced structural chromosomal rearrangements arebalanced structural chromosomal rearrangements are
present in one partner in 2 to 4 percent of couples with apresent in one partner in 2 to 4 percent of couples with a
history of recurrent abortionshistory of recurrent abortions
 Autosomes 13, 16, 18, 21, and 22Autosomes 13, 16, 18, 21, and 22 –– most commommost commom

 Monosomy XMonosomy X
 The second frequent chromosomal abnormalityThe second frequent chromosomal abnormality
 Usually results in abortionUsually results in abortion
 Much less frequently in liveborn female infant (TurnerMuch less frequently in liveborn female infant (Turner
syndrome)syndrome)
 TriploidyTriploidy
 Associated with hydropic placental (molar) degenerationAssociated with hydropic placental (molar) degeneration
 Incomplete (partial) hydatidiform moles may contain triploidyIncomplete (partial) hydatidiform moles may contain triploidy
or trisomy for only chromosome 16or trisomy for only chromosome 16

 Tetraploid abortusesTetraploid abortuses
 Rarely are liveborn and most often are aborted early inRarely are liveborn and most often are aborted early in
gestationgestation
 Chromosomal structural abnormalitiesChromosomal structural abnormalities
 Identified only since the development of banding techniques,Identified only since the development of banding techniques,
infrequently cause abortioninfrequently cause abortion

 Euploid abortionEuploid abortion
 Abort later in gestational than aneuploidAbort later in gestational than aneuploid
 Three fourths of aneuploid abortions occurred before8 weeksThree fourths of aneuploid abortions occurred before8 weeks
 Euploid abortions peak at about 13 weeksEuploid abortions peak at about 13 weeks
 The incidence of euploid abortions increased dramatically after maternalThe incidence of euploid abortions increased dramatically after maternal
age exceeded 35 yearsage exceeded 35 years

Spontaneous abortionSpontaneous abortion –– Maternal factorsMaternal factors

InfectionsInfections
 Uncommon causes of abortion in humanUncommon causes of abortion in human
 Listeria monocytogenesListeria monocytogenes
 Clamydia trachomatisClamydia trachomatis
 Mycoplasma hominisMycoplasma hominis
 Ureaplasma urealyticumUreaplasma urealyticum
 Toxoplasma gondiiToxoplasma gondii

 Chronic debilitating diseasesChronic debilitating diseases
 In early pregnancy, fetuses seldom abort secondary toIn early pregnancy, fetuses seldom abort secondary to
chronic wasting disease such as tuberculosis orchronic wasting disease such as tuberculosis or
carcinomatosiscarcinomatosis
 Celiac sprueCeliac sprue
 Cause both male and female infertility and recurrent abortionsCause both male and female infertility and recurrent abortions

 Endocrine abnormalitiesEndocrine abnormalities
 HypothyroidismHypothyroidism
 Iodine deficiency associated with excessive miscarriagesIodine deficiency associated with excessive miscarriages
 Thyroid autoantibodies → incidence of abortion↑Thyroid autoantibodies → incidence of abortion↑
 Diabetes mellitusDiabetes mellitus
 The rates of spontaneous abortion & major congenitalThe rates of spontaneous abortion & major congenital
malformationsmalformations
 Poor glucose control → incidence of abortion↑Poor glucose control → incidence of abortion↑
 Progesterone deficiencyProgesterone deficiency
 Luteal phase defectLuteal phase defect
 Insufficient progesterone secretion by the corpus luteum orInsufficient progesterone secretion by the corpus luteum or
placentaplacenta
 Poor glucose control → incidence of abortion↑Poor glucose control → incidence of abortion↑

 NutritionNutrition
 Dietary deficiency of any one nutrients → not importantDietary deficiency of any one nutrients → not important
causecause
 Drug use and environmental factorDrug use and environmental factor
 TobaccoTobacco
 ↑↑ Risk for euploid abortionRisk for euploid abortion
 More than 14 cigarettes a day → the risk twofold greater ↑More than 14 cigarettes a day → the risk twofold greater ↑
 AlcoholAlcohol
 Spontaneous abortion & fetal anomalies → result from frequentSpontaneous abortion & fetal anomalies → result from frequent
alcohol use during the first 8 weeks of pregnancyalcohol use during the first 8 weeks of pregnancy
 Drinking twice a week → abortion rates doubled ↑Drinking twice a week → abortion rates doubled ↑
 Drinking daily → abortion rates tripled ↑Drinking daily → abortion rates tripled ↑
 CaffeineCaffeine
 At least 5 cups of coffee per day → slightly increased risk ofAt least 5 cups of coffee per day → slightly increased risk of
abortionabortion

 Drug use and environmental factorDrug use and environmental factor
 RadiationRadiation
 ContraceptivesContraceptives
 When intrauterine devices fail to prevent pregnancy → abortion↑When intrauterine devices fail to prevent pregnancy → abortion↑
 Environmental toxinsEnvironmental toxins
 Anesthetic gases : exact fetal risk of chronic maternal exposureAnesthetic gases : exact fetal risk of chronic maternal exposure
is unknownis unknown
 Arsenic, lead, formaldehyde, benzene, ethylene oxide →Arsenic, lead, formaldehyde, benzene, ethylene oxide →
abortifacientabortifacient
 Video display terminal & accompanying electromagnetic fieldsVideo display terminal & accompanying electromagnetic fields
short waves & ultrasound do not increase the risk of abortionshort waves & ultrasound do not increase the risk of abortion

 Immunological factorsImmunological factors –– autoimmune factorsautoimmune factors
 Recurrent pregnancy loss patients : 15%Recurrent pregnancy loss patients : 15%

AntiphospholipidAntiphospholipid antibodyantibody : most significant: most significant
 LCA (lupus anticoagulant), ACA (anticardiolipin Ab)LCA (lupus anticoagulant), ACA (anticardiolipin Ab)
 Reduce prostacyclin productionReduce prostacyclin production
→→ facilitating thromboxane dominant milieu → thrombosisfacilitating thromboxane dominant milieu → thrombosis
 Prostacyclin : produced by vascular endothelial cellProstacyclin : produced by vascular endothelial cell
→→ potent vasodilator & inhibit platelet aggregationpotent vasodilator & inhibit platelet aggregation
 Thromboxane A2 : produced by plateletsThromboxane A2 : produced by platelets
→→ vasoconstrictor & platelet aggregatorvasoconstrictor & platelet aggregator
 Strong association withStrong association with
 Decidual vasculopathy , placental infarction, fetal growth restrictionDecidual vasculopathy , placental infarction, fetal growth restriction
Early-onset preeclampsia, recurrent abortion, fetal deathEarly-onset preeclampsia, recurrent abortion, fetal death

 Immunological factorsImmunological factors –– autoimmune factorsautoimmune factors
 Therapy of antiphopholipid antibody syndromeTherapy of antiphopholipid antibody syndrome
: low dose aspirin, prednisone, heparin, intravenous Ig: low dose aspirin, prednisone, heparin, intravenous Ig
→→ affect both immune & coagulation systemaffect both immune & coagulation system
→→ counteract the adverse action of antibodiescounteract the adverse action of antibodies

 Immunological factorsImmunological factors –– alloimmune factorsalloimmune factors
 AllogeneityAllogeneity
 Genetic dissimilarities between animals of the same speciesGenetic dissimilarities between animals of the same species
 Human fetus is allogenic transplant tolerated by motherHuman fetus is allogenic transplant tolerated by mother
 Several test for diagnosis of alloimmune factorsSeveral test for diagnosis of alloimmune factors
 Maternal & paternal HLA comparisonMaternal & paternal HLA comparison
 Maternal serum test for blocking antibodiesMaternal serum test for blocking antibodies
: blocking antibodies to paternal antigens: blocking antibodies to paternal antigens
: ig G origin: ig G origin
 Maternal serum test for antipaternal antibodiesMaternal serum test for antipaternal antibodies
: cytotoxic antibodies to paternal leukocyte: cytotoxic antibodies to paternal leukocyte

 Inherited thrombophiliaInherited thrombophilia
 Many studies of aggregated thrombophiliasMany studies of aggregated thrombophilias
→→ excessive recurrent abortionsexcessive recurrent abortions
 LaparotomyLaparotomy
 Surgery performed during early pregnancySurgery performed during early pregnancy
→→ no evidence of tncreased abortionno evidence of tncreased abortion
 Peritonitis increases the likelihood of abortionPeritonitis increases the likelihood of abortion
 Physical traumaPhysical trauma
 Major abdominal trauma → abortion↑Major abdominal trauma → abortion↑

 Uterine defectsUterine defects –– acquired uterine defectsacquired uterine defects
 Uterine leiomyoma : usually do not cause abortionUterine leiomyoma : usually do not cause abortion
 Placental implantation over or in contact with myomaPlacental implantation over or in contact with myoma
→→ placental abruption, abortion, preterm labor ↑placental abruption, abortion, preterm labor ↑
→→ location is more important than sizelocation is more important than size
 Uterine synechiae (Asherman syndrome)Uterine synechiae (Asherman syndrome)
 Partial or complete obliteration of the uterine cavity byPartial or complete obliteration of the uterine cavity by
adherence of uterine walladherence of uterine wall
 Cause : destruction of large areas of endometrium by curettageCause : destruction of large areas of endometrium by curettage
→→ insufficient endometrium to support implantation &insufficient endometrium to support implantation &
menstruationmenstruation
→→ recurrent abortion, amenorrhea, hypomenorrhearecurrent abortion, amenorrhea, hypomenorrhea

 Uterine defectsUterine defects –– acquired uterine defectsacquired uterine defects
 Diagnosis of uterine synechiaeDiagnosis of uterine synechiae
 Hysterosalpingogram → characteristic multiple filling defectsHysterosalpingogram → characteristic multiple filling defects
 Hysteroscopy → most accurate & direct diagnosisHysteroscopy → most accurate & direct diagnosis
 Treatment of uterine synechiaeTreatment of uterine synechiae
 Lysis of adhesions via hysteroscopyLysis of adhesions via hysteroscopy
 Prevention of adherence : IUDPrevention of adherence : IUD
 Promotion of endometrial proliferationPromotion of endometrial proliferation
: Continuous high-dose estrogen (60-90 days): Continuous high-dose estrogen (60-90 days)

 Uterine defectsUterine defects –– developmental uterine defectsdevelopmental uterine defects
 Consequence of abnormal mullerian duct formation or fusionConsequence of abnormal mullerian duct formation or fusion
 SpontaneouslySpontaneously
 Induced by in utero exposure to DES (diethylstilbestrol)Induced by in utero exposure to DES (diethylstilbestrol)

 Incompetent cervixIncompetent cervix
 Painless dilatation of cervix in the 2Painless dilatation of cervix in the 2ndnd
or early in the 3or early in the 3rdrd
trimestertrimester
→→ prolapse & ballooning of membranes into vaginaprolapse & ballooning of membranes into vagina
→→ rupture of membrane & expulsion of immature fetusrupture of membrane & expulsion of immature fetus
 Unless effectively treated, tends to repeat in each pregnancyUnless effectively treated, tends to repeat in each pregnancy
 Diagnosis in nonpregnant womenDiagnosis in nonpregnant women
 HysterographyHysterography
 Pull-through techniques of inflated Foley catheter balloonsPull-through techniques of inflated Foley catheter balloons
 Acceptance without resistance at the internal os of specifically sized cervicalAcceptance without resistance at the internal os of specifically sized cervical
dilatorsdilators
 The use of transvaginal ultrasound in pregnant womenThe use of transvaginal ultrasound in pregnant women
 Cervical length - shorteningCervical length - shortening
 FunnelingFunneling

 Incompetent cervixIncompetent cervix –– EtiologyEtiology
 Previous trauma to the cervixPrevious trauma to the cervix
 Dilatation & curettageDilatation & curettage
 ConizationConization
 CauterizationCauterization
 Abnormal cervical developmentAbnormal cervical development
 Exposure to DES in uteroExposure to DES in utero

 Incompetent cervixIncompetent cervix –– TreatmentTreatment
 The operation is performed to surgicallyThe operation is performed to surgically
 Reinforcement of weak cervix by some type of purse string sutureReinforcement of weak cervix by some type of purse string suture
( Cerclage )( Cerclage )
 Prophylactic surgeryProphylactic surgery : generally performed between 12 &: generally performed between 12 &
16weeks16weeks
 Should be delayed until after 14 weeksShould be delayed until after 14 weeks’’ gestationgestation
→→ Early abortion due to other factors will be completedEarly abortion due to other factors will be completed
 The more advanced the pregnancy, the more likely the risk that surgicalThe more advanced the pregnancy, the more likely the risk that surgical
intervention stimulate preterm labor or membrane ruptureintervention stimulate preterm labor or membrane rupture
 Usually do not perform after about 23 weeksUsually do not perform after about 23 weeks

 Incompetent cervixIncompetent cervix –– Preoperative evaluationPreoperative evaluation
 SonographySonography
:: Confirm living fetus & exclude major fetal anomaliesConfirm living fetus & exclude major fetal anomalies
 Cervical cytologyCervical cytology
 Cultures for gonorrhea, chlamydia, group B streptococciCultures for gonorrhea, chlamydia, group B streptococci
 Obvious cervical infections → treatment is givenObvious cervical infections → treatment is given
 For at least a week before & after surgery → sexual intercourse should beFor at least a week before & after surgery → sexual intercourse should be
restrictedrestricted

 Incompetent cervixIncompetent cervix –– Cerclage proceduresCerclage procedures
 Types of operations commonly usedTypes of operations commonly used
 McDonaldMcDonald
 Modified ShirodkarModified Shirodkar
→→ 85~90% success rate85~90% success rate

 Incompetent cervixIncompetent cervix –– Transabdominal cerclageTransabdominal cerclage
 Requries laparotomy forRequries laparotomy for
 Placement of cerclage at uterine isthmus levelPlacement of cerclage at uterine isthmus level
 Cerclage removal, delivery, or bothCerclage removal, delivery, or both
 Anatomical defects of cervixAnatomical defects of cervix
 Failed transvaginal cerclageFailed transvaginal cerclage

 Incompetent cervixIncompetent cervix –– ComplicationsComplications
 High incidence when performed much after 20 weeksHigh incidence when performed much after 20 weeks
 Membranes rupturesMembranes ruptures
 ChorioamnionitisChorioamnionitis
 Intrauterine infectionIntrauterine infection
 Urgent removal of sutureUrgent removal of suture
 Operation failsOperation fails
 Signs of imminent abortion or deliverySigns of imminent abortion or delivery

Spontaneous abortionSpontaneous abortion –– Paternal factorsPaternal factors
 Little is known in the genesis of spontaneous abortionLittle is known in the genesis of spontaneous abortion
 Chromosomal translocations in sperm can lead toChromosomal translocations in sperm can lead to
abortionabortion

Categories of spontaneous abortionCategories of spontaneous abortion
 Threatened abortionThreatened abortion
 Inevitable abortionInevitable abortion
 Complete or incomplete abortionComplete or incomplete abortion
 Missed abortionMissed abortion
 Recurrent abortionRecurrent abortion

Threatened abortionThreatened abortion
 DefinitionDefinition
 Any bloody vaginal discharge or bleeding during 1Any bloody vaginal discharge or bleeding during 1stst
half of pregnancyhalf of pregnancy
 Bleeding is frequently slight, but may persist for days or weeksBleeding is frequently slight, but may persist for days or weeks
 FrequencyFrequency
 Extremely common (one out of four or five pregnant women)Extremely common (one out of four or five pregnant women)
 PrognosisPrognosis
 ApproximatelyApproximately ½½ will abortwill abort
 Risk of preterm delivery, low birthweight, perinatal death↑Risk of preterm delivery, low birthweight, perinatal death↑
 Risk of malformed infant does not appear to be increasedRisk of malformed infant does not appear to be increased

 SymptomsSymptoms
 Usually bleeding begins firstUsually bleeding begins first
 Cramping abdominal pain follows a few hours to several days laterCramping abdominal pain follows a few hours to several days later
 Presence of bleeding & painPresence of bleeding & pain
→→ Poor prognosis for pregnancy continuationPoor prognosis for pregnancy continuation
 TreatmentTreatment
 Bed rest & acetaminophen-based analgesiaBed rest & acetaminophen-based analgesia
 ProgesteroneProgesterone (IM)(IM) or synthetic progestational agentor synthetic progestational agent (PO or IM)(PO or IM)
 Lack of evidence of effectivenessLack of evidence of effectiveness
 Often results in no more than a missed abortionOften results in no more than a missed abortion
 D-negative women with threatened abortionD-negative women with threatened abortion
 Probably should receive anti-D immunoglobulinProbably should receive anti-D immunoglobulin

 TreatmentTreatment : slight bleeding persists for weeks: slight bleeding persists for weeks
 Vaginal sonographyVaginal sonography
 Serial serum quantitative hCGSerial serum quantitative hCG
 Serum progesteroneSerum progesterone
→→ can help ascertain if the fetus is alive & its locationcan help ascertain if the fetus is alive & its location
 Vaginal sonographyVaginal sonography
 Gestational sac(+) & hCG < 1000mIU/mlGestational sac(+) & hCG < 1000mIU/ml
→→ gestation is not likely to survivegestation is not likely to survive
→→ If any doubt(+), check the serum hCG level at intervals of 48hrsIf any doubt(+), check the serum hCG level at intervals of 48hrs
→→ if not increase more than 65%, almost always hopelessif not increase more than 65%, almost always hopeless
 Serum progesterone value < 5 ng/mlSerum progesterone value < 5 ng/ml
→→ dead conceptusdead conceptus

 Treatment : after death of conceptusTreatment : after death of conceptus
 Uterus should be emptiedUterus should be emptied
→→ examination of all passed tissue whether the abortion is completeexamination of all passed tissue whether the abortion is complete
 Ectopic pregnancy should be considered if gestational sacEctopic pregnancy should be considered if gestational sac
oror
fetus are not identifiedfetus are not identified

Inevitable abortionInevitable abortion
 Gross rupture of membrane,evidenced by leakingGross rupture of membrane,evidenced by leaking
amnionic fluid, in the presence of cervical dilatation, butamnionic fluid, in the presence of cervical dilatation, but
no tissue passed during 1no tissue passed during 1stst
half of pregnancyhalf of pregnancy
 Placenta (in whole or in part) is retained in the uterusPlacenta (in whole or in part) is retained in the uterus
→→ Uterine contractions begin promptly or infection developsUterine contractions begin promptly or infection develops
 The gush of fluid is accompanied by bleeding, pain, or fever,The gush of fluid is accompanied by bleeding, pain, or fever,
abortion should be considered inevitableabortion should be considered inevitable

 Complete abortionComplete abortion
 Following complete detachment & expulsion of the conceptusFollowing complete detachment & expulsion of the conceptus
 The internal cervical os closesThe internal cervical os closes
 Incomplete abortionIncomplete abortion
 Expulsion of some but not all of the products of conception during 1Expulsion of some but not all of the products of conception during 1stst
halfhalf
of pregnancyof pregnancy
 The internal cervical os remains open & allows passage of bloodThe internal cervical os remains open & allows passage of blood
 The fetus & placenta may remain entirely in utero or may partiallyThe fetus & placenta may remain entirely in utero or may partially
extrude through the dilated osextrude through the dilated os
→→ Remove retained tissue without delayRemove retained tissue without delay
Complete or incomplete abortionComplete or incomplete abortion

 Retention of dead products of conception in utero forRetention of dead products of conception in utero for
several weeksseveral weeks
 Many women have no symptoms except persistent amenorrheaMany women have no symptoms except persistent amenorrhea
 Uterus remain stationary in size, but mammary changes usuallyUterus remain stationary in size, but mammary changes usually
regress → uterus become smallerregress → uterus become smaller
 Most terminates spontaneouslyMost terminates spontaneously
 Serious coagulation defect occasionally develop after prolongedSerious coagulation defect occasionally develop after prolonged
retention of fetusretention of fetus
Missed abortionMissed abortion

 Definition : Three or more consecutive spontaneousDefinition : Three or more consecutive spontaneous
abortionsabortions
 Clinical investigation of recurrent miscarriageClinical investigation of recurrent miscarriage
 Parental cytogenetic analysisParental cytogenetic analysis
 Lupus anticoagulant & anticardiolipin antibodies assaysLupus anticoagulant & anticardiolipin antibodies assays
 Postconceptional evaluationPostconceptional evaluation
 Serial monitoring ofSerial monitoring of ß–ß–hCGhCG from missed mens periodfrom missed mens period
 ß–ß–hCG>1500mIU/ml → USGhCG>1500mIU/ml → USG
 Maternal serumMaternal serum αα-fetoprotein assessment-fetoprotein assessment (GA16-18wks)(GA16-18wks)
 Amniocentesis → fetal karyotypeAmniocentesis → fetal karyotype
 PrognosisPrognosis
 Depends on potential underlying etiology & number of prior lossesDepends on potential underlying etiology & number of prior losses
Recurrent abortionRecurrent abortion

INDUCED ABORTIONINDUCED ABORTION

 The medical or surgical termination of pregnancy beforeThe medical or surgical termination of pregnancy before
the time of fetal viabilitythe time of fetal viability
 Therapeutic abortionTherapeutic abortion
 Termination of pregnancy before of fetal viability for theTermination of pregnancy before of fetal viability for the
purposepurpose
of saving the life of the motherof saving the life of the mother
Induced abortionInduced abortion

 IndicationIndication
 Continuation of pregnancy may threaten the life of women orContinuation of pregnancy may threaten the life of women or
seriously impair her healthseriously impair her health
 Persistent heart disease after cardiac decompensationPersistent heart disease after cardiac decompensation
 Advanced hypertensive vascular diseaseAdvanced hypertensive vascular disease
 Invasive carcinoma of the cervixInvasive carcinoma of the cervix
 Pregnancy resulted from rape or incestPregnancy resulted from rape or incest
 Continuation of pregnancy is likely to result in the birth ofContinuation of pregnancy is likely to result in the birth of
child with severe physical deformities or mental retardationchild with severe physical deformities or mental retardation

 Elective (voluntary) abortionElective (voluntary) abortion
 Interruption of pregnancy before viability at the request ofInterruption of pregnancy before viability at the request of
the women, but not for reasons of impaired maternal healththe women, but not for reasons of impaired maternal health
oror
fetal diseasefetal disease
 Counseling before elective abortionCounseling before elective abortion
 Continued pregnancy with its risks & parental responsibilitiesContinued pregnancy with its risks & parental responsibilities
 Continued pregnancy with its risks & its responsibilities of arrangedContinued pregnancy with its risks & its responsibilities of arranged
adoptionadoption
 The choice of abortion with its risksThe choice of abortion with its risks

Surgical techniques for abortionSurgical techniques for abortion
 Dilatation and curettageDilatation and curettage
 Performed first by dilating the cervix & evacuating thePerformed first by dilating the cervix & evacuating the
product of conceptionproduct of conception
 Mechanically scraping out of the contents (sharp curettage)Mechanically scraping out of the contents (sharp curettage)
 Vacuum aspiration (suction curettage)Vacuum aspiration (suction curettage)
 BothBoth
 Before 14 weeks, D&C or vacuum aspiration should beBefore 14 weeks, D&C or vacuum aspiration should be
performedperformed
 After 16 weeks, dilatation & evacuation (D&E) is performedAfter 16 weeks, dilatation & evacuation (D&E) is performed
 Wide cervical dilatationWide cervical dilatation
 Mechanical destruction & evacuation of fetal partsMechanical destruction & evacuation of fetal parts

 Dilatation and curettageDilatation and curettage
 Hygroscopic dilatorsHygroscopic dilators
: swell slowly & dilate cervix → cervical trauma can be: swell slowly & dilate cervix → cervical trauma can be
minimizedminimized
 Laminaria tentsLaminaria tents
:: stem of brown seaweed ( Laminaria digitata or japonica)stem of brown seaweed ( Laminaria digitata or japonica)
→→ drawing water from proteoglycan complexes of cervixdrawing water from proteoglycan complexes of cervix
→→ dissociation allow the cervix to soften & dilatedissociation allow the cervix to soften & dilate
 Insertion technique : tip rests just at the level of internal osInsertion technique : tip rests just at the level of internal os
 Usually after 4-6hours, laminaria dilate the cervix sufficiently toUsually after 4-6hours, laminaria dilate the cervix sufficiently to
allow easier mechanical dilation & curettageallow easier mechanical dilation & curettage
 May cause cramping painMay cause cramping pain
→→ easily managed with 60 mg codeine every 3-4 hourseasily managed with 60 mg codeine every 3-4 hours

 Technique for dilatation & curettageTechnique for dilatation & curettage
 Remove laminaria → Uterus is sounded carefully toRemove laminaria → Uterus is sounded carefully to
 Identify the status of the internal osIdentify the status of the internal os
 Confirm uterus size & positionConfirm uterus size & position
 Further dilation of cervix with Hegar dilatorFurther dilation of cervix with Hegar dilator

 Complications : uterine perforationComplications : uterine perforation
 2 important determinants2 important determinants
 Skill of the physicianSkill of the physician
 Position of the uterus (retroverted)Position of the uterus (retroverted)
 Small defects by uterine sound or narrow dilatorSmall defects by uterine sound or narrow dilator
→→ often heal without complicationoften heal without complication
 Suction & sharp curettageSuction & sharp curettage
→→ Considerable intra-abdominal damage risk↑Considerable intra-abdominal damage risk↑
→→ Laparotomy to examine abdominal content (safest action)Laparotomy to examine abdominal content (safest action)
 Other complicationsOther complications –– cervical incompetence or uterine synechiaecervical incompetence or uterine synechiae

 Menstrual aspirationMenstrual aspiration
 Aspiration of endometrial cavity using a flexible cannula andAspiration of endometrial cavity using a flexible cannula and
syringe within 1-3 weeks after failure to menstruatesyringe within 1-3 weeks after failure to menstruate
 Several points at early stage of gestationSeveral points at early stage of gestation
 Woman not being pregnantWoman not being pregnant
 Implanted zygote may be missed by the curetteImplanted zygote may be missed by the curette
 Failure to recognize an ectopic pregnancyFailure to recognize an ectopic pregnancy
 Infrequently, a uterus can be perforatedInfrequently, a uterus can be perforated

 LaparotomyLaparotomy
 Abdominal hysterotomy or hysterectomyAbdominal hysterotomy or hysterectomy
 Significant uterine diseaseSignificant uterine disease
 Failure of medical induction during the 2Failure of medical induction during the 2ndnd
trimestertrimester

Medical induction of abortionMedical induction of abortion
 Early abortionEarly abortion
 Outpatient medical abortion is an acceptable alternative toOutpatient medical abortion is an acceptable alternative to
surgical abortion in women with pregnancies of less than 49surgical abortion in women with pregnancies of less than 49
daysdays’’ gestationgestation
(ACOG, 2001b)(ACOG, 2001b)
 Three medications for early medical abortionThree medications for early medical abortion
 AntiprogestinAntiprogestin mifeprostonemifeprostone
 AntimetaboliteAntimetabolite methotrexatemethotrexate
 ProstaglandinProstaglandin misoprostolmisoprostol

Medical induction of abortion _Medical induction of abortion _ 22ndnd
trimestertrimester
abortionabortion

 OxytocinOxytocin
 Successful induction of 2Successful induction of 2ndnd
trimester abortion is possible withtrimester abortion is possible with
high doses of oxytocin administered in small volumes of IVhigh doses of oxytocin administered in small volumes of IV
fluidsfluids
 Satisfactory alternatives to PG ESatisfactory alternatives to PG E22 for midtrimester abortionfor midtrimester abortion
 Laminaria tents inserted the night beforeLaminaria tents inserted the night before
 Chance of successful induction is greatly enhancedChance of successful induction is greatly enhanced

 ProstaglandinsProstaglandins
 Used extensively to terminate pregnancies, especially in theUsed extensively to terminate pregnancies, especially in the
22ndnd
TT
 PG EPG E11 , E, E22 , F2, F2αα
 TechniqueTechnique
: Can act effectively on the cervix & uterus (86~95%: Can act effectively on the cervix & uterus (86~95%
effectiveness)effectiveness)
 Vaginal prostaglandin EVaginal prostaglandin E22 suppository & prostaglandin Esuppository & prostaglandin E11
(misoprostol)(misoprostol)
 As a gel through a catheter into the cervical canal & lowermostAs a gel through a catheter into the cervical canal & lowermost
uterusuterus
 Injection into the amnionic sac by amniocentesisInjection into the amnionic sac by amniocentesis
 Parenteral injectionParenteral injection
 Oral ingestionOral ingestion

 Intra-amnionic hyperosmotic solutionsIntra-amnionic hyperosmotic solutions
 20-25% saline or 30-40% urea injected into amnionic sac20-25% saline or 30-40% urea injected into amnionic sac
→→ stimulate uterine contraction & cervical dilatationstimulate uterine contraction & cervical dilatation
 Action mechanism : prostaglandin mediated ?Action mechanism : prostaglandin mediated ?
 Complications of hypertonic salineComplications of hypertonic saline
 DeathDeath
 Hyperosmolar crisis (early into maternal circulation)Hyperosmolar crisis (early into maternal circulation)
 Cardiac failureCardiac failure
 Septic shockSeptic shock
 PeritonitisPeritonitis
 HemorrhageHemorrhage
 DICDIC
 Water intoxicationWater intoxication
 Hyperosmotic urea : less likely to be toxicHyperosmotic urea : less likely to be toxic

 Antiprogesterone RU 486Antiprogesterone RU 486
 Oral agent used alone in combination with oral PG to effectOral agent used alone in combination with oral PG to effect
abortions in early gestationabortions in early gestation
 High receptor affinity for progesterone binding siteHigh receptor affinity for progesterone binding site
→→ Block progesterone actionBlock progesterone action
 Abortion rateAbortion rate
 Single 600mg dose prior 6 weeks → 85%Single 600mg dose prior 6 weeks → 85%
 Addition of oral, vaginal or injected PG → over 95%Addition of oral, vaginal or injected PG → over 95%
 If given within 72 hoursIf given within 72 hours
 Also highly effective as emergency postcoital contraceptionAlso highly effective as emergency postcoital contraception
 Progressively less effective after 72 hoursProgressively less effective after 72 hours
 Side effectsSide effects
 Nausea, vomiting, & gastrointestinal crampingNausea, vomiting, & gastrointestinal cramping
 Major risk → hemorrhage is a risk if abortion is incompleteMajor risk → hemorrhage is a risk if abortion is incomplete

 EpostaneEpostane
 3ß-hydroxysteroid dehydrogenase inhibitor3ß-hydroxysteroid dehydrogenase inhibitor
→→ blocks the synthesis of endogenous progesteroneblocks the synthesis of endogenous progesterone
 Frequent side effect – nauseaFrequent side effect – nausea
 Hemorrhage is a risk if abortion is incompleteHemorrhage is a risk if abortion is incomplete

Consequences of elective abortionConsequences of elective abortion
 Maternal mortalityMaternal mortality
 Legally induced abortionLegally induced abortion
 Relative safe during the first 2 months of pregnancyRelative safe during the first 2 months of pregnancy
( 0.6/100,000 procedures)( 0.6/100,000 procedures)
 Doubled for each 2 weeks of delay after 8 weeksDoubled for each 2 weeks of delay after 8 weeks ’’ gestationgestation

 Impact on future pregnanciesImpact on future pregnancies
 Fertility : not altered by an elective abortionFertility : not altered by an elective abortion
 Vacuum aspiration for a first pregnancyVacuum aspiration for a first pregnancy
: Do not increase the incidence of: Do not increase the incidence of
 22ndnd
trimester spontaneous abortionstrimester spontaneous abortions
 Preterm deliveryPreterm delivery
 Ectopic pregnancyEctopic pregnancy
 LBW infantsLBW infants

 Impact on future pregnanciesImpact on future pregnancies
 Dilatations & curettage for a first pregnancyDilatations & curettage for a first pregnancy
: Increased risks for: Increased risks for
 Ectopic pregnancyEctopic pregnancy
 22ndnd
trimester spontaneous abortionstrimester spontaneous abortions
 LBW infantsLBW infants
 Multiple elective abortion :Multiple elective abortion :
 Not increased the incidence of preterm delivery & LBW infantsNot increased the incidence of preterm delivery & LBW infants
 Placenta previaPlacenta previa
→→ increased following multiple sharp curettage abortionincreased following multiple sharp curettage abortion
proceduresprocedures

 Septic abortionSeptic abortion
 Most often associated with criminal abortionMost often associated with criminal abortion
 Metritis is usual outcome, but parametritis, peritonitis,Metritis is usual outcome, but parametritis, peritonitis,
endocarditis, and septicemia may all occurendocarditis, and septicemia may all occur
 ManagementManagement
 Prompt evacuation of products of conceptionPrompt evacuation of products of conception
 Broad-spectrum IV antimicrobialsBroad-spectrum IV antimicrobials

Resumption of ovulation after abortionResumption of ovulation after abortion
 Ovulation may resume as early 2 weeks after an abortionOvulation may resume as early 2 weeks after an abortion
 Therefore, if pregnancy is to be prevented,Therefore, if pregnancy is to be prevented,
effective contraception should be initiated soon aftereffective contraception should be initiated soon after
abortionabortion

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