abortion
DESCRIPTION
wala lngTRANSCRIPT
Types of AbortionTypes of Abortion
Irene Ann L. PerochoIrene Ann L. Perocho
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 or Termination of pregnancy, either spontaneously or intentionallyintentionally
Pregnancy termination prior to 20 weeksPregnancy termination prior to 20 weeks’’ gestation gestation or less than 500-g birthweight or less than 500-g birthweight
Definition vary according to state laws for reporting Definition 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 Abortion occurring without medical or mechanical means to empty the uterus is referred to as means to empty the uterus is referred to as spontaneousspontaneous
Another widely used term is Another widely used term is miscarriagemiscarriage
Pathology Pathology Hemorrhage into the decidua basinalis, followed by necrosis of Hemorrhage into the decidua basinalis, followed by necrosis of
tissues adjacent to the bleedingtissues adjacent 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
Spontaneous abortionSpontaneous abortion
Pathology Pathology
In later abortion, the retained fetus may undergo In 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 The skin softens and peels off in utero or at the slightest
toughtough
When amnionic fluid is absorbed, the fetus may become When 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 The fetus become so dry and compressed that it resembles parchment - resembles parchment - a fetus papyraceousa fetus papyraceous
Spontaneous abortionSpontaneous abortion
Etiology Etiology
More than 80 percent of abortions occur in the first 12 More 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 & the After the first trimester, both the abortion rate & the incidence of chromosomal anomalies decreaseincidence of chromosomal anomalies decrease
F9-1F9-1
Spontaneous abortionSpontaneous abortion
EtiologyEtiology
The risk of spontaneous abortion increases with parity The risk of spontaneous abortion increases with parity as well as with maternal and paternal ageas well as with maternal and paternal age
The frequency of abortion increases from 12 percent in The frequency of abortion increases from 12 percent in women younger than 20 years to 26 percent in those women younger than 20 years to 26 percent in those older than 40 yearsolder than 40 years
If a woman conceives within 3 months following a term If a woman conceives within 3 months following a term birthbirth
→ → incidence of abortion ↑incidence of abortion ↑
F9-2F9-2
Spontaneous abortionSpontaneous abortion
EtiologyEtiology
The exact mechanism responsible for abortion are not The 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 precedes Death 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 ascertaining Finding of the cause of early abortion involves ascertaining
the cause of fetal deaththe cause of fetal death
In subsequent months In 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 a Early spontaneous abortion commonly display a developmental abnormality of the zygote, embryo, early developmental abnormality of the zygote, embryo, early fetus, or placentafetus, or placenta
1000 spontaneous abortions analyzed by Hertig and 1000 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
F9-3F9-3
Spontaneous abortion - Fetal factorsSpontaneous abortion - Fetal factors
Aneuploid abortionAneuploid abortion
Approximately 50 to 60 percent of embryos and early Approximately 50 to 60 percent of embryos and early fetuses fetuses
that are spontaneously aborted contain chromosomal that are spontaneously aborted contain chromosomal abnor-malities accounting for most of early pregnancy abnor-malities accounting for most of early pregnancy wastagewastage
Jacobs and Hassold Jacobs and Hassold (1980)(1980)
95 percent of chromosomal abnormalities 95 percent of chromosomal abnormalities d/t maternal gametogenesis error d/t maternal gametogenesis error
5 percent → d/t paternal error5 percent → d/t paternal error
T9-1T9-1
Spontaneous abortion - Fetal factorsSpontaneous abortion - Fetal factors
Aneuploid abortion - Aneuploid abortion - Autosomal trisomyAutosomal trisomy
The most frequently identified chromosomal anomaly The most frequently identified chromosomal anomaly associated with first-trimester abortionsassociated with first-trimester abortions
Most trisomies result from Most trisomies result from isolated nondisjunction , isolated nondisjunction , balanced structural chromosomal rearrangements are balanced structural chromosomal rearrangements are present in one partner in 2 to 4 percent of couples with present in one partner in 2 to 4 percent of couples with a history of recurrent abortionsa history of recurrent abortions
Autosomes 13, 16, 18, 21, and 22 Autosomes 13, 16, 18, 21, and 22 –– most commom most commom
Spontaneous abortion - Fetal factorsSpontaneous abortion - Fetal factors
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 (Turner Much 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 Incomplete (partial) hydatidiform moles may contain
triploidy or trisomy for only chromosome 16triploidy or trisomy for only chromosome 16
Spontaneous abortion - Fetal factorsSpontaneous abortion - Fetal factors
Tetraploid abortusesTetraploid abortuses
Rarely are liveborn and most often are aborted early in Rarely are liveborn and most often are aborted early in gestationgestation
Chromosomal structural abnormalitiesChromosomal structural abnormalities
Identified only since the development of banding Identified only since the development of banding techniques, infrequently cause abortiontechniques, infrequently cause abortion
Spontaneous abortion - Fetal factorsSpontaneous abortion - Fetal factors
Euploid abortionEuploid abortion
Abort later in gestational than aneuploid Abort 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 The incidence of euploid abortions increased dramatically after maternal age exceeded 35 yearsmaternal age exceeded 35 years
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
InfectionsInfections
Uncommon causes of abortion in humanUncommon causes of abortion in human
Listeria monocytogenes Listeria monocytogenes Clamydia trachomatisClamydia trachomatis Mycoplasma hominis Mycoplasma hominis Ureaplasma urealyticumUreaplasma urealyticum Toxoplasma gondiiToxoplasma gondii
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Chronic debilitating diseasesChronic debilitating diseases
In early pregnancy, fetuses seldom abort secondary to In early pregnancy, fetuses seldom abort secondary to chronic wasting disease such as tuberculosis or chronic wasting disease such as tuberculosis or carcinomatosiscarcinomatosis
Celiac sprue Celiac sprue
Cause both male and female infertility and recurrent Cause both male and female infertility and recurrent abortionsabortions
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Endocrine abnormalitiesEndocrine abnormalities
Hypothyroidism Hypothyroidism 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 congenital The 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 or Insufficient progesterone secretion by the corpus luteum or
placentaplacenta Poor glucose control → incidence of abortion↑Poor glucose control → incidence of abortion↑
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
NutritionNutrition Dietary deficiency of any one nutrients → not important Dietary 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 frequent Spontaneous 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 of At least 5 cups of coffee per day → slightly increased risk of
abortion abortion
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Drug use and environmental factorDrug use and environmental factor
RadiationRadiation In sufficient doses → abortifacientIn sufficient doses → abortifacient
ContraceptivesContraceptives When intrauterine devices fail to prevent pregnancy → When intrauterine devices fail to prevent pregnancy →
abortion↑abortion↑ Environmental toxinsEnvironmental toxins
Anesthetic gases : exact fetal risk of chronic maternal Anesthetic gases : exact fetal risk of chronic maternal exposure is unknownexposure is 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
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Immunological factors Immunological factors –– autoimmune factors autoimmune factors Recurrent pregnancy loss patients : 15%Recurrent pregnancy loss patients : 15% Antiphospholipid antibody : most significantAntiphospholipid antibody : 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 Decidual vasculopathy , placental infarction, fetal growth restrictionrestriction
Early-onset preeclampsia, recurrent abortion, fetal deathEarly-onset preeclampsia, recurrent abortion, fetal death
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Immunological factors Immunological factors –– autoimmune factors autoimmune factors
Therapy of antiphopholipid antibody syndrome Therapy 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
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Immunological factors Immunological factors –– alloimmune factors alloimmune factors
Allogeneity Allogeneity Genetic dissimilarities between animals of the same Genetic dissimilarities between animals of the same
speciesspecies 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 antibodies Maternal 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
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
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↑
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Uterine defects Uterine defects –– acquired uterine defects acquired 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 by Partial or complete obliteration of the uterine cavity by
adherence of uterine walladherence of uterine wall Cause : destruction of large areas of endometrium by Cause : destruction of large areas of endometrium by
curettagecurettage
→ → insufficient endometrium to support implantation & insufficient endometrium to support implantation & menstruationmenstruation
→ → recurrent abortion, amenorrhea, hypomenorrhearecurrent abortion, amenorrhea, hypomenorrhea
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Uterine defects Uterine defects –– acquired uterine defects acquired uterine defects
Diagnosis of uterine synechiaeDiagnosis of uterine synechiae Hysterosalpingogram → characteristic multiple filling Hysterosalpingogram → characteristic multiple filling
defectsdefects 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)
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Uterine defects Uterine defects –– developmental uterine defects developmental uterine defects
Consequence of abnormal mullerian duct formation or Consequence of abnormal mullerian duct formation or fusionfusion
SpontaneouslySpontaneously Induced by in utero exposure to DES (diethylstilbestrol)Induced by in utero exposure to DES (diethylstilbestrol)
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Incompetent cervixIncompetent cervix Painless dilatation of cervix in the 2Painless dilatation of cervix in the 2ndnd or early in the 3 or 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 Acceptance without resistance at the internal os of specifically sized
cervical dilatorscervical dilators The use of transvaginal ultrasound in pregnant womenThe use of transvaginal ultrasound in pregnant women
Cervical length - shorteningCervical length - shortening Funneling Funneling
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Incompetent cervix Incompetent cervix –– Etiology Etiology
Previous trauma to the cervixPrevious trauma to the cervix Dilatation & curettage Dilatation & curettage ConizationConization CauterizationCauterization
Abnormal cervical developmentAbnormal cervical development Exposure to DES in uteroExposure to DES in utero
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Incompetent cervix Incompetent cervix –– Treatment Treatment
The operation is performed to surgicallyThe operation is performed to surgically Reinforcement of weak cervix by some type of purse string suture Reinforcement 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 ’’ gestation gestation → → 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 The more advanced the pregnancy, the more likely the risk that surgical intervention stimulate preterm labor or membrane surgical intervention stimulate preterm labor or membrane rupturerupture
Usually do not perform after about 23 weeksUsually do not perform after about 23 weeks
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Incompetent cervix Incompetent cervix –– Preoperative evaluation Preoperative evaluation
SonographySonography
: : Confirm living fetus & exclude major fetal anomaliesConfirm living fetus & exclude major fetal anomalies
Cervical cytology Cervical 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 For at least a week before & after surgery → sexual intercourse
should be restrictedshould be restricted
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Incompetent cervix Incompetent cervix –– Cerclage procedures Cerclage procedures
Types of operations commonly usedTypes of operations commonly used
McDonald McDonald
Modified Shirodkar Modified Shirodkar
→ → 85~90% success rate85~90% success rate
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Incompetent cervix Incompetent cervix –– Transabdominal cerclage Transabdominal 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
Indications Indications Anatomical defects of cervix Anatomical defects of cervix Failed transvaginal cerclageFailed transvaginal cerclage
Spontaneous abortion Spontaneous abortion –– Maternal Maternal factorsfactors
Incompetent cervix Incompetent cervix –– Complications Complications
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 abortion Spontaneous abortion –– Paternal Paternal factorsfactors
Little is known in the genesis of spontaneous Little is known in the genesis of spontaneous abortionabortion
Chromosomal translocations in sperm can lead to Chromosomal 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
Definition Definition Any bloody vaginal discharge or bleeding during 1Any bloody vaginal discharge or bleeding during 1stst half of half of
pregnancypregnancy 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 Approximately Approximately ½½ will abort will 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 increased Risk of malformed infant does not appear to be increased
Categories of spontaneous Categories of spontaneous abortionabortion
Symptoms Symptoms Usually bleeding begins firstUsually bleeding begins first Cramping abdominal pain follows a few hours to several days Cramping abdominal pain follows a few hours to several days
laterlater Presence of bleeding & painPresence of bleeding & pain
→ → Poor prognosis for pregnancy continuationPoor prognosis for pregnancy continuation
Treatment Treatment Bed rest & acetaminophen-based analgesia Bed rest & acetaminophen-based analgesia Progesterone Progesterone (IM)(IM) or synthetic progestational agent or 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
Threatened abortionThreatened abortion
Categories of spontaneous Categories of spontaneous abortionabortion
Threatened abortionThreatened abortion
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 sonography Vaginal 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
Categories of spontaneous Categories of spontaneous abortionabortion
Threatened abortionThreatened abortion
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 Ectopic pregnancy should be considered if gestational sac or sac or
fetus are not identified fetus are not identified
Categories of spontaneous Categories of spontaneous abortionabortion
Inevitable abortionInevitable abortion
Gross rupture of membrane,evidenced by leaking Gross rupture of membrane,evidenced by leaking amnionic fluid, in the presence of cervical dilatation, amnionic fluid, in the presence of cervical dilatation, but no tissue passed during 1but no tissue passed during 1stst half of pregnancy half 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 Uterine contractions begin promptly or infection developsdevelops
The gush of fluid is accompanied by bleeding, pain, or The gush of fluid is accompanied by bleeding, pain, or fever, abortion should be considered inevitablefever, abortion should be considered inevitable
Categories of spontaneous Categories of spontaneous abortionabortion
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 Expulsion of some but not all of the products of conception
during 1during 1stst half of pregnancy half of pregnancy The internal cervical os remains open & allows passage of The internal cervical os remains open & allows passage of
bloodblood The fetus & placenta may remain entirely in utero or may The fetus & placenta may remain entirely in utero or may
partially extrude through the dilated os partially extrude through the dilated os
→ → Remove retained tissue without delay Remove retained tissue without delay
Complete or incomplete abortionComplete or incomplete abortion
Categories of spontaneous Categories of spontaneous abortionabortion
Retention of dead products of conception in utero for Retention 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 prolonged Serious coagulation defect occasionally develop after prolonged retention of fetus retention of fetus
Missed abortionMissed abortion
Categories of spontaneous Categories of spontaneous abortionabortion
Definition : Three or more consecutive spontaneous Definition : 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 of Serial monitoring of ß–ß–hCGhCG from missed mens period from missed mens period
ß–ß–hCG>1500mIU/ml → USGhCG>1500mIU/ml → USG Maternal serum Maternal serum αα-fetoprotein assessment -fetoprotein assessment (GA16-18wks)(GA16-18wks) Amniocentesis → fetal karyotype Amniocentesis → fetal karyotype
PrognosisPrognosis Depends on potential underlying etiology & number of prior lossesDepends on potential underlying etiology & number of prior losses
Recurrent abortionRecurrent abortion
Categories of spontaneous Categories of spontaneous abortionabortion
INDUCED ABORTIONINDUCED ABORTION
The medical or surgical termination of pregnancy The medical or surgical termination of pregnancy before the time of fetal viabilitybefore the time of fetal viability
Therapeutic abortionTherapeutic abortion
Termination of pregnancy before of fetal viability for Termination of pregnancy before of fetal viability for the purpose the purpose
of saving the life of the motherof saving the life of the mother
Induced abortionInduced abortion
Induced abortionInduced abortion
IndicationIndication
Continuation of pregnancy may threaten the life of Continuation of pregnancy may threaten the life of women or seriously impair her healthwomen or seriously 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 Continuation of pregnancy is likely to result in the birth of child with severe physical deformities or mental of child with severe physical deformities or mental retardationretardation
Induced abortionInduced abortion
Elective (voluntary) abortionElective (voluntary) abortion
Interruption of pregnancy before viability at the Interruption of pregnancy before viability at the request of the women, but not for reasons of impaired request of the women, but not for reasons of impaired maternal health ormaternal health or
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 Continued pregnancy with its risks & its responsibilities of
arranged adoptionarranged adoption 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 the Performed 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 be Before 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
Surgical techniques for abortionSurgical techniques for abortion
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 to Usually after 4-6hours, laminaria dilate the cervix sufficiently to
allow easier mechanical dilation & curettageallow easier mechanical dilation & curettage May cause cramping pain May cause cramping pain
→ → easily managed with 60 mg codeine every 3-4 hourseasily managed with 60 mg codeine every 3-4 hours
Surgical techniques for abortionSurgical techniques for abortion
Technique for dilatation & curettage Technique 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
Surgical techniques for abortionSurgical techniques for abortion
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 curettage Suction & 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 complications Other complications –– cervical incompetence or uterine cervical incompetence or uterine synechiaesynechiae
Surgical techniques for abortionSurgical techniques for abortion
Menstrual aspirationMenstrual aspiration
Aspiration of endometrial cavity using a flexible cannula Aspiration of endometrial cavity using a flexible cannula and syringe within 1-3 weeks after failure to and syringe within 1-3 weeks after failure to menstruatemenstruate
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 pregnancy Failure to recognize an ectopic pregnancy Infrequently, a uterus can be perforated Infrequently, a uterus can be perforated
Surgical techniques for abortionSurgical techniques for abortion
Laparotomy Laparotomy
Abdominal hysterotomy or hysterectomyAbdominal hysterotomy or hysterectomy
IndicationsIndications
Significant uterine diseaseSignificant uterine disease
Failure of medical induction during the 2Failure of medical induction during the 2ndnd trimester trimester
Medical induction of abortionMedical induction of abortion
Early abortionEarly abortion
Outpatient medical abortion is an acceptable Outpatient medical abortion is an acceptable alternative to surgical abortion in women with alternative to surgical abortion in women with pregnancies of less than 49 dayspregnancies of less than 49 days’’ gestation gestation
(ACOG, 2001b)(ACOG, 2001b)
Three medications for early medical abortionThree medications for early medical abortion Antiprogestin Antiprogestin mifeprostonemifeprostone AntimetaboliteAntimetabolite methotrexate methotrexate ProstaglandinProstaglandin misoprostol misoprostol
Medical induction of abortion _ Medical induction of abortion _ 22ndnd trimester trimester abortionabortion
Medical induction of abortionMedical induction of abortion
OxytocinOxytocin
Successful induction of 2Successful induction of 2ndnd trimester abortion is trimester abortion is possible with high doses of oxytocin administered in possible with high doses of oxytocin administered in small volumes of IV fluidssmall volumes of IV fluids
Satisfactory alternatives to PG ESatisfactory alternatives to PG E22 for midtrimester for midtrimester abortionabortion
Laminaria tents inserted the night beforeLaminaria tents inserted the night before Chance of successful induction is greatly enhancedChance of successful induction is greatly enhanced
Medical induction of abortionMedical induction of abortion
ProstaglandinsProstaglandins
Used extensively to terminate pregnancies, especially in the 2Used extensively to terminate pregnancies, especially in the 2ndnd T T 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 E suppository & prostaglandin E1 1 (misoprostol)(misoprostol) As a gel through a catheter into the cervical canal & lowermost uterusAs a gel through a catheter into the cervical canal & lowermost uterus Injection into the amnionic sac by amniocentesisInjection into the amnionic sac by amniocentesis Parenteral injectionParenteral injection Oral ingestionOral ingestion
Medical induction of abortionMedical induction of abortion
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
Death Death 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
Medical induction of abortionMedical induction of abortion
Antiprogesterone RU 486Antiprogesterone RU 486 Oral agent used alone in combination with oral PG to Oral agent used alone in combination with oral PG to
effect abortions in early gestationeffect abortions 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 effects Side 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
Medical induction of abortionMedical induction of abortion
Epostane Epostane
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’’ gestation gestation
Consequences of elective abortionConsequences of elective abortion
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 pregnancy Vacuum aspiration for a first pregnancy
: Do not increase the incidence of : Do not increase the incidence of 22ndnd trimester spontaneous abortions trimester spontaneous abortions Preterm deliveryPreterm delivery Ectopic pregnancyEctopic pregnancy LBW infantsLBW infants
Consequences of elective abortionConsequences of elective abortion
Impact on future pregnanciesImpact on future pregnancies
Dilatations & curettage for a first pregnancy Dilatations & curettage for a first pregnancy
: Increased risks for: Increased risks for Ectopic pregnancy Ectopic pregnancy 22ndnd trimester spontaneous abortions trimester spontaneous abortions LBW infantsLBW infants
Multiple elective abortion :Multiple elective abortion : Not increased the incidence of preterm delivery & LBW Not increased the incidence of preterm delivery & LBW
infantsinfants Placenta previa Placenta previa
→ → increased following multiple sharp curettage abortion increased following multiple sharp curettage abortion proceduresprocedures
Consequences of elective abortionConsequences of elective abortion
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
Management Management 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 Ovulation may resume as early 2 weeks after an abortionabortion
Therefore, if pregnancy is to be prevented, Therefore, if pregnancy is to be prevented,
effective contraception should be initiated soon effective contraception should be initiated soon after abortionafter abortion