Abortion

Abortion
• Termination of pregnancy, either spontaneously or
intentionally

• Pregnancy termination prior to 22 weeks’ gestation or

less than 500-g birthweight

• Definition vary according to state laws for reporting

abortions, fetal deaths, and neonatal deaths
 Spontaneous abortion

► Abortion occurring without medical or mechanical means

to empty the uterus is referred to as spontaneous
► Another widely used term is miscarriage

► Pathology
► Hemorrhage into the decidua basinalis, followed by necrosis of
tissues adjacent to the bleeding
► If early, the ovum detaches, stimulating uterine contractions
that result in its ovulation
► Gestational sac is opened , fluid surrounding a small macerated
fetus or alternatively no fetus is visible → blighted ovum
 Spontaneous abortion
► Pathology

► In later abortion, the retained fetus may undergo maceration

► The skull bones collapse, the abdomen distends with blood-
stained fluid, and the internal organs degenerate
► The skin softens and peels off in utero or at the slightest
tough

► When amnionic fluid is absorbed, the fetus may become

compressed and desiccated → fetal compressus

► The fetus become so dry and compressed that it resembles

parchment - a fetus papyraceous
 Spontaneous abortion

• Etiology

• More than 80 percent of abortions occur in the first 12

weeks of pregnancy

• At least half result from chromosomal anomalies

• After the first trimester, both the abortion rate & the
incidence of chromosomal anomalies decrease
 Spontaneous abortion

► Etiology

► The risk of spontaneous abortion increases with parity

as well as with maternal and paternal age

► The frequency of abortion increases from 12 percent in

women younger than 20 years to 26 percent in those
older than 40 years

► If a woman conceives within 3 months following a term

birth
→ incidence of abortion ↑
F9-3
 Spontaneous abortion – Maternal factors

• Infections

• Uncommon causes of abortion in human

• Listeria monocytogenes
• Clamydia trachomatis
• Mycoplasma hominis
• Ureaplasma urealyticum
• Toxoplasma gondii
 Spontaneous abortion – Maternal factors

• Chronic debilitating diseases

• In early pregnancy, fetuses seldom abort secondary to

chronic wasting disease such as tuberculosis or
carcinomatosis

• Celiac sprue

• Cause both male and female infertility and recurrent abortions

Spontaneous abortion – Maternal factors

►Endocrine abnormalities

►Hypothyroidism
►Iodine deficiency associated with excessive miscarriages
►Thyroid autoantibodies → incidence of abortion↑

►Diabetes mellitus
►The rates of spontaneous abortion & major congenital malformations
►Poor glucose control → incidence of abortion↑

►Progesterone deficiency
►Luteal phase defect
►Insufficient progesterone secretion by the corpus luteum or placenta
 Spontaneous abortion – Maternal factors

►Nutrition
►Dietary deficiency of any one nutrients → not important cause

►Drug use and environmental factor

►Tobacco
►↑ Risk for euploid abortion
► More than 14 cigarettes a day → the risk twofold greater ↑
►Alcohol
► Spontaneous abortion & fetal anomalies → result from frequent alcohol use
during the first 8 weeks of pregnancy
► Drinking twice a week → abortion rates doubled ↑
► Drinking daily → abortion rates tripled ↑
►Caffeine
► At least 5 cups of coffee per day → slightly increased risk of abortion
 Spontaneous abortion – Maternal factors

► Inherited thrombophilia
► Many studies of aggregated thrombophilias
→ excessive recurrent abortions

► Laparotomy
► Surgery performed during early pregnancy
→ no evidence of tncreased abortion
► Peritonitis increases the likelihood of abortion

► Physical trauma
► Major abdominal trauma → abortion↑
 Spontaneous abortion – Maternal factors

► Incompetent cervix
► Painless dilatation of cervix in the 2nd or early in the 3rd
trimester
→ prolapse & ballooning of membranes into vagina
→ rupture of membrane & expulsion of immature fetus
► Unless effectively treated, tends to repeat in each pregnancy
► Diagnosis in nonpregnant women
► Hysterography
► Pull-through techniques of inflated Foley catheter balloons
► Acceptance without resistance at the internal os of specifically sized
cervical dilators
► The use of transvaginal ultrasound in pregnant women
► Cervical length - shortening
► Funneling
Spontaneous abortion – Maternal factors

• Incompetent cervix – Etiology

• Previous trauma to the cervix

• Dilatation & curettage
• Conization
• Cauterization

Abnormal cervical developmento

 Spontaneous abortion – Maternal factors

►Incompetent cervix – Treatment

►The operation is performed to surgically

► Reinforcement of weak cervix by some type of purse string suture
( Cerclage )

►Prophylactic surgery : generally performed between 12 & 16weeks

► Should be delayed until after 14 weeks’ gestation
→ Early abortion due to other factors will be completed

►The more advanced the pregnancy, the more likely the risk that surgical
intervention stimulate preterm labor or membrane rupture
► Usually do not perform after about 23 weeks
 Spontaneous abortion – Maternal factors

► Incompetent cervix – Preoperative evaluation

► Sonography
: Confirm living fetus & exclude major fetal anomalies

► Cervical cytology

► Cultures for gonorrhea, chlamydia, group B streptococci

► Obvious cervical infections → treatment is given
► For at least a week before & after surgery → sexual intercourse should
be restricted
 Spontaneous abortion – Maternal factors

• Incompetent cervix – Cerclage procedures

• Types of operations commonly used

• McDonald

• Modified Shirodkar

→ 85~90% success rate

 Categories of spontaneous abortion
• Threatened abortion

Threatening
• Inevitable abortion abortion
Inevitable abortion
Incomplete abortion
• Complete or incomplete Complete abortion
abortion Missed abortion
Septic abortion
Recurrent abortion
• Missed abortion

• Recurrent abortion
Categories of spontaneous abortion

Threatened abortion

► Definition
► Any bloody vaginal discharge or bleeding during 1st half of
pregnancy
► Bleeding is frequently slight, but may persist for days or weeks

► Frequency
► Extremely common (one out of four or five pregnant women)

► Prognosis
► Approximately ½ will abort
► Risk of preterm delivery, low birthweight, perinatal death↑
► Risk of malformed infant does not appear to be increased
Categories of spontaneous abortion

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

►Treatment
►Bed rest & acetaminophen-based analgesia
►Progesterone (IM) or synthetic progestational agent (PO or IM)
►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
Categories of spontaneous abortion

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
Categories of spontaneous abortion

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
► The fetus & placenta may remain entirely in utero or may
partially extrude through the dilated os
→ Remove retained tissue without delay
Categories of spontaneous abortion

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 terminates spontaneously

► Serious coagulation defect occasionally develop after prolonged

retention of fetus
Categories of spontaneous abortion

Recurrent abortion

►Definition : Three or more consecutive spontaneous abortions

►Clinical investigation of recurrent miscarriage

►Parental cytogenetic analysis
►Lupus anticoagulant & anticardiolipin antibodies assays
►Postconceptional evaluation
►Serial monitoring of ß–hCG from missed mens period
► ß–hCG>1500mIU/ml → USG
►Maternal serum α-fetoprotein assessment (GA16-18wks)
►Amniocentesis → fetal karyotype
►Prognosis
►Depends on potential underlying etiology & number of prior losses
INDUCED ABORTION
 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
 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)
► Both

►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
 Surgical techniques for abortion

►Dilatation and curettage

►Hygroscopic dilators
: swell slowly & dilate cervix → cervical trauma can be minimized

►Laminaria tents
: stem of brown seaweed ( Laminaria digitata or japonica)
→ drawing water from proteoglycan complexes of cervix
→ dissociation allow the cervix to soften & dilate
► Insertion technique : tip rests just at the level of internal os
► Usually after 4-6hours, laminaria dilate the cervix sufficiently to allow easier
mechanical dilation & curettage
► May cause cramping pain
→ easily managed with 60 mg codeine every 3-4 hours
 Surgical techniques for abortion

• Technique for dilatation & curettage

• Remove laminaria → Uterus is sounded carefully to

• Identify the status of the internal os

• Confirm uterus size & position

• Further dilation of cervix with Hegar dilator

 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
 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
 Surgical techniques for abortion

• Laparotomy

• Abdominal hysterotomy or hysterectomy

• Indications

• Significant uterine disease

Failure of medical induction during the 2 nd trimester

 Medical induction of abortion

►Early abortion

► Outpatient medical abortion is an acceptable

alternative to surgical abortion in women with
pregnancies of less than 42 days’ gestation
(ACOG, 2001b)

► Three medications for early medical abortion

► Antiprogestin mifeprostone
► Prostaglandin misoprostol
 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 PG E2 for midtrimester abortion

• Laminaria tents inserted the night before

• Chance of successful induction is greatly enhanced
 Medical induction of abortion

► Prostaglandins

► Used extensively to terminate pregnancies, especially in the 2 nd

T
► 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 amnionic sac by amniocentesis
► Parenteral injection
► Oral ingestion
 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
 Medical induction of abortion
►Antiprogesterone RU 486
►Oral agent used alone in combination with oral PG to effect
abortions in early gestation
►High receptor affinity for progesterone binding site
→ Block progesterone action
►Abortion rate
►Single 600mg dose prior 6 weeks → 85%
►Addition of oral, vaginal or injected PG → over 95%
►If given within 72 hours
►Also highly effective as emergency postcoital contraception
►Progressively less effective after 72 hours
►Side effects
►Nausea, vomiting, & gastrointestinal cramping
►Major risk → hemorrhage is a risk if abortion is incomplete