Gyn

1. Type
Definitions
Early Abortion before 12 wk gestation
Late Abortion between 12 and 20 wk gestation
Spontaneous Noninduced abortion
Induced Termination of pregnancy for medical or elective reasons
Therapeutic Termination of pregnancy because the woman’s life or health is endangered or because the
fetus is dead or has malformations incompatible with life
Threatened Vaginal bleeding occurring before 20 wk gestation without cervical dilation and indicating
that spontaneous abortion may occur
Inevitable Vaginal bleeding or rupture of the membranes accompanied by dilation of the cervix
Incomplete Expulsion of some products of conception
Complete Expulsion of all products of conception
Recurrent or
habitual
≥ 3 consecutive spontaneous abortions
Missed Undetected death of an embryo or a fetus that is not expelled and that causes no bleeding
(also called blighted ovum, anembryonic pregnancy, or intrauterine embryonic demise)
Septic Serious infection of the uterine contents during or shortly before or after an abortion

3.  Spontaneous abortion is noninduced embryonic or
fetal death or passage of products of conception
before 20 wk gestation or weight <500 g .
 Prevalence
 About 20 to 30% of women with confirmed
pregnancies bleed during the first 20 wk of
pregnancy;
 half of these women spontaneously abort.
 Thus, incidence of spontaneous abortion is about
10 to 15% in confirmed pregnancies.
 Incidence in all pregnancies is probably higher
because some very early abortions are mistaken for
a late menstrual period.

4.  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.
 Acute maternal infection -eg, Listeria monocytogenes, Toxoplasma gondii,
parvovirus B19, rubella, herpes simplex, cytomegalovirus, lymphocytic
choriomeningitis virus can lead to abortion from fetal or placental
infection.
 Chromosomal abnormalities,
 Maternal endocrinopathies (eg, thyroid dysfunction, Cushing's syndrome,
polycystic ovary syndrome) can also contribute to a suboptimal host
environment. Since corpus luteum progesterone production is an integral
component of successful pregnancy, it is plausible that early pregnancy
loss could be due to corpus luteum dysfunction; The effect of thyroid
disease and thyroid peroxidase antibodies on abortion risk is also.
 A hypercoagulable state due to inherited or acquired thrombophilia and
abnormalities of the immune system (eg, systemic lupus erythematosus,
antiphospholipid syndrome) that lead to immunological rejection or
placental damage are active areas of investigation.
 Other causes include immunologic abnormalities, major trauma-Invasive
intrauterine procedures/trauma, such as chorionic villus sampling and
amniocentesis, increase the risk of abortion, and uterine abnormalities (eg,
fibroids, adhesions).
 Most often, the cause is unknown Unexplained 50%

5.  Age > 35
 History of spontaneous abortion
 Cigarette smoking
 Use of certain drugs (eg, cocaine, alcohol, high doses of
caffeine)
 Fevers of 100°F (37.8°C) or more may increase the risk of
miscarriage, but the only two large studies have been
contradictory and inconclusive.
 Low-folate level — were associated with an increased risk of
SAb at 6 to 12 weeks of gestation, but only when the fetal
karyotype was abnormal.
 A poorly controlled chronic disorder (eg, diabetes,
hypertension, overt thyroid disorders) in the mother
Subclinical thyroid disorders, a retroverted uterus, and minor
trauma have not been shown to cause spontaneous abortions.
Maternal weight — Prepregnancy body mass index less than
18.5 or above 25 kg/m2 has been associated with an
increased risk of infertility and SAB

6.  Crampy pelvic pain,
 bleeding, and eventually expulsion of tissue.
Late spontaneous abortion may begin with a
gush of fluid when the membranes rupture.
Hemorrhage is rarely massive. A dilated cervix
indicates that abortion is inevitable.
 If products of conception remain in the uterus
after spontaneous abortion, vaginal bleeding
may occur, sometimes after a delay of hours to
days.
 Infection may also develop, causing fever, pain,
and sometimes sepsis.

7.  Clinical criteria-Women who are actively in the process
of having a spontaneous abortion usually present with a
history of amenorrhea, vaginal bleeding, and pelvic
pain.
 Usually ultrasonography and quantitative β subunit of
human chorionic gonadotropin (β-hCG)
 Diagnosis of threatened, inevitable, incomplete, or
complete abortion is often possible based on clinical
criteria (see Table: Characteristic Symptoms and Signs in
Spontaneous Abortions) and a positive urine pregnancy
test. However, ultrasonography and quantitative
measurement of serum β-hCG are usually done to
exclude ectopic pregnancy and to determine whether
products of conception remain in the uterus (suggesting
that abortion is incomplete rather than complete).
However, results may be inconclusive, particularly
during early pregnancy.


8.  Definition. Uterine bleeding before 20 weeks with a closed
cervical os and a confirmed viable intrauterine gestation.
 Vaginal spotting or heavier bleeding occurs in 20–25% of
pregnant women and may persist for days or weeks.
However, some bleeding near the time of expected
menses may be physiologic.
 Half of these pregnancies will eventually miscarry, but the
risk is substantially lower if fetal cardiac activity is
demonstrated. Fetuses that do not miscarry remain at
increased risk for preterm delivery, low birthweight, and
perinatal death.
 Treatment. There are no effective therapies and patients
are monitored expectantly unless the pregnancy is
undesired or non-viable. Bed rest is often recommended,
but does not alter the course.

9.  Definition. Imminent, partial, or complete expulsion of products
of conception before 20 weeks’ gestation through a dilated
cervix.
 When the placenta, in whole or in part, detaches from the uterus,
bleeding ensues. Typically bleeding is profuse and associated
with uterine cramping. During incomplete miscarriage, the
internal os remains open and allows passage of blood. Following
complete detachment and expulsion of the gestational products,
the internal cervical os closes.
 Incomplete miscarriages usually occur between 6 and 14 weeks’
gestation; complete miscarriages are most common <6 or >14
weeks.
 Treatment. Suction curettage is typically required for inevitable
or incomplete miscarriage; complete miscarriages may be
managed expectantly without evacuation.


10.  Definition. Any threatened, inevitable, or incomplete
miscarriage associated with a fever before 20 weeks’
gestation.
 Retained products of conception after spontaneous
miscarriage, legal termination of pregnancy, or illegal
termination of pregnancy acts as a nidus for the
development of a local infection that is poten- tially fatal if
generalized sepsis ensues.
 Patients usually present with fever, chills, leukocytosis,
uterine ten- derness, and a foul-smelling cervicovaginal
discharge.
 Treatment. Broad-spectrum intravenous antibiotics,
prompt uterine evacuation, and supportive therapy in
severe cases. However, a large, grossly infected uterus is
at risk for perforation and may be allowed to evacuate
with pitocin or prostaglandin stimulation.

11.  Missed abortion is suspected if the uterus does
not progressively enlarge or if quantitative β-
hCG is low for gestational age or does not double
within 48 to 72 h. Missed abortion is confirmed if
ultrasonography shows any of the following:
 Disappearance of previously detected embryonic
cardiac activity
 Absence of such activity when the fetal crown-
rump length is > 5 mm (determined by
transvaginal ultrasonography)
 Absence of a fetal pole (determined by
transvaginal ultrasonography) when the mean sac
diameter (average of diameters measured in 3
orthogonal planes) is > 18 mm

12.  Definition. Fetal demise before 20 weeks’ gestation
without detach- ment of the placenta – resulting in
retention of products of conception for days or weeks
behind a closed cervical os.
 Typically, after the demise there is an episode of
bleeding that sub- sides and is followed by a
continuous brown vaginal discharge. Many women
have no other symptoms. Very rarely, prolonged
retention of a dead fetus after midpregnancy can
result in coagulopathy.
 Treatment. Management is individualized, depending
on the cir- cumstances. Expectant management is
often difficult for the patient to endure after being
informed of the demise. Medical management is
often the safest option.

13.  Ultrasonography is the most useful test in the diagnostic evaluation of
women with suspected Sab.
 There is no role for monitoring hCG levels once the presence of an
intrauterine pregnancy has been established sonographically.
 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 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.
 These measurements correspond to a gestational age of approximately
6 weeks. Serial examinations four to seven days apart are helpful to
assess viability of the pregnancy when findings are equivocal or
development appears to be lagging behind that expected by dating
criteria. The normal sequential development during very early
pregnancy, as noted sonographically, is shown in the table
A gestational sac size of 2 to 3 mm may be visualized at four weeks and one to three days
The yolk sac can be noted initially at the beginning of the fifth week of gestation
An embryonic pole with cardiac activity can be first detected at 5.5 to 6 weeks

14.  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.
 Slow fetal heart rate - Embryonic heart rate below 100 beats per minute (bpm) at 5 to 7 weeks of gestation is slow.
If slow cardiac activity is observed, it is prudent to perform a follow-up sonogram (in five to seven days) to
document loss of the cardiac activity before proceeding to dilatation and curettage.
 Small sac - Small mean sac size (MSS) is diagnosed when the difference between the MSS and crown-rump length
(CRL) is less than 5 mm (MSS - CRL < 5).
Poor pregnancy outcome - a sac with an irregular contour, mean sac diameter growth rate less than 1 mm/day,
minimal decidual thickness/hypoechogenicity of the choriodecidual area/absent double decidual sac, and low sac
position in the uterus.
 Subchorionic hematoma – A subchorionic hematoma is a risk factor for SAb. A large subchorionic hematoma (ie,
comprising at least 25 percent of the volume of the gestational sac) is concerning. There was also an increased risk
of placental abruption and preterm premature rupture of membranes. Increased risks of preterm labor and stillbirth
appeared to be dependent upon the presence of vaginal bleeding.
 Pregnancy outcome associated with subchorionic hematoma appears to depend upon location, with worse
outcomes for retroplacental than marginal hematomas. Women with retroplacental hematomas are more likely to
have an adverse outcome than those that are marginal (only the margin of the placenta is separated). Data are
mixed regarding whether increasing size of the hematoma increases the risk of adverse outcomes.

15. Transabdominal sagittal sonogram of uterus reveals
subchorionic hematoma (H) extending posteriorly around
chorion (arrows) and lifting edge of anterior placenta (P).
Appearance should not be confused with that of unfused
amnion. Amnion is the thin membrane continuous along
anterior placental edge, but limited by umbilical cord
insertion; subchorionic bleeding leads to edge of placenta.

16.  Termination of pregnancy

17.  Definition. Elective or voluntary “abortion” is
the interruption of pregnancy before viability
at the request of the woman.
 About 1.2 million terminations are performed
annually in the USA. Half the women are
younger than 25 years. About 88% are
conducted up to 12 weeks, 10% from 13
weeks to 20 weeks, and 1–2% beyond 20
weeks.
 Half the abortions worldwide are considered
unsafe. Unsafe abor- tion accounts for an
estimated 13% of all maternal deaths.

18.  The Abortion Pill:
Medical Abortion with Mifepristone and
Misoprostol

19.  Medical Abortion is a form of early abortion caused
by the combination of two medications,
mifepristone and misoprostol that is an option for
women who are 8-9 weeks pregnant or less. Also
known as RU486 or medication abortion.
 During the first appointment at the clinic patient
receive the mifepristone pill - RU486 orally. A
progesterone receptor antagonist that blocks the
hormone needed to maintain the pregnancy.
 Then 24 to 72 hours later patient at home takes the
second medication,
 Misoprostol (Cytotec, USA) IS prostaglandin E1
analogs. Misoprostol causes contractions resulting
in a miscarriage.
 Mifepristone and misoprostol are FDA approved.

20.  Mifepristone blocks the hormone progesterone
needed to maintain the pregnancy. Because this
hormone is blocked, the uterine lining begins to
shed, the cervix begins to soften and bleeding
may occur. With the later addition of the
misoprostol, the uterus contracts and the
pregnancy is usually expelled within 6 to 8 hours.
 Because the woman chooses when she takes the
second medication within the time frame of 24 to
72 hours after the first medication, she has some
control over the timing of when she expels the
pregnancy and experiences the side effects of
bleeding and cramping.

21.  A follow-up exam is scheduled for two weeks
later to make sure the process is complete.
 If women have not yet miscarried, doctor
perform a aspiration abortion.
 A very small percentage (5%) of women do
not pass the pregnancy tissue and need a
suction procedure to complete the process.

22. Side Effects
Most of the side effects when using this early abortion option are
caused by the second medication, misoprostol. Side-effects may
include:
heavy bleeding,
headache,
nausea,
vomiting,
diarrhea, and
heavy cramping.
Risks
Vaginal bleeding with medical abortion could be extremely heavy. In
rare situations it could require a aspiration abortion and very rarely,
a blood transfusion.
If pregnancy is continued after taking these medications, there is a
high risk of fetal deformities.

23.  These are 99% effective.
 About 90% of all terminations in the USA and the UK.
 The cervix is first dilated, then the uterine cavity is
mechanically evacuated.
 Surgical termination is a simple procedure and is safer
than childbirth when performed before week 16.
 Manual vacuum aspiration (MVA) can be performed up to
6–7 weeks’ gestation without regional anesthesia. A soft,
flexible, plastic cannula is attached to a handheld self-
locking syringe. Evacuation is accomplished by repetitive
in-and-out, rotating movements.
 Electric vacuum aspiration (EVA) uses an electric pump,
requires a paracervical block and cervical dilation, and is
used for terminations between 6 and 15 weeks’ gestation.

24.  The frequency of complications depends on operator experience
and gestational age (increased if <6 weeks or >16 weeks).
 Immediate complications. Hemorrhage, cervical injury,
anesthesia complications. The use of osmotic dilators (laminaria)
significantly reduces the risk of uterine perforation.
 Late complications. Retained products of conception, infection
(endometritis), and Rh sensitization.
 Mortality rate. Fewer than 1/100,000 surgical procedures when a
patient is under the care of an experienced clinician.


25.  Dilation and evacuation (D&E) is performed
between 15 and 20 weeks’ gestation.
 Due to the larger fetal size, the procedure is
often done in the operating room under general
anesthesia.
 Cervical preparation and dilation precedes
mechanical destruction and evacuation of fetal
parts using specialized (Sopher) forceps. The
placenta and remaining tissue are then removed
by suction curettage.
 Regardless of technique, identification of
products of conception is mandatory before the
procedure is considered complete.