Abortion

Zelele
MD,Obstetrician and Gynecologist
 Introduction
• Definitions:
– Abortion is spontaneous or induced termination of
pregnancy before fetal viability
– For statistical and legal purposes, viability is usually
defined by pregnancy duration and fetal birthweight.
– CDC and WHO define abortion as pregnancy
termination before 20 weeks' gestation or with a fetus
born weighing < 500 g
 Incidence
• Early pregnancy loss is common,
occurring in 10% of all clinically
recognized pregnancies.
• Approximately 80% of all cases of
pregnancy loss occur within the first
trimester
 Etiology and Risk factors
• Chromosomal abnormalities • Radiotherapy
– Numerical abnormalities • Chemotherapy and other
• Aneuploid abortion-more than 80% Medications
 Autosomal trisomy
– Progesterone antagonists,
– Structural abnormalities prostaglandin E1
• Maternal factors (misoprostol), and
– DM,Thyroid disorder ,IBD,SLE- methotrexate
APAS • Obesity and low BMI raise risk
– Advanced maternal age of abortion
• Infection • Alcohol use
– Chlamydia trachomatis • Cigarette smoking
– Ebola virus
– Mycoplasma genitalium
• Bisphenol A,polychlorinated
biphenyls and DDT
 Spontaneous abortion
• More than 80 % occur during the first 12
weeks of gestation and approximately
50% of cases are attributed to
chromosomal abnormalities
 Clinical Classification
• Commonly used categories include
threatened, inevitable, incomplete,
complete, and missed abortion
Threatened Abortion
 It is presumed when bloody vaginal
discharge or blood exits through a closed
internal cervical os
 Approximately one fourth of pregnant
women experiences first-trimester spotting
or bleeding
• Of these, 43 percent will subsequently miscarry
Diagnosis
 DDx
• Spontaneous abortion
• Ectopic pregnancy
• Molar pregnancy
Investigations
 Hematocrit
 Blood type
 Serum β-hCG
• It should increase at least 33-49% every 48
hours in IUP
• At serum β-hCG ≥ 3500mIU/ml, IUP is detected
in 99% of cases
 TVU
• Pregnancy location
 Intrauterine gestational sac
 Double-decidual sign
 It can usually be seen by 4.5 weeks
 Yolk sac is seen at 5.5 weeks
 Embryo is seen at 6weeks
 Cardiac motion can be detected at 6-6.5 weeks
• Fetal viability
 Serum progesterone level
• It has poor sensitivity
• less than 5mg/dl....?
• Greater than 20 ng/dl....?
Management
 Bed rest
• It does not improve outcome
 Acetaminophen
• relieve cramping
 Pregnancy evacuation
• Significant anemia or hypovolemia
Inevitable Abortion
 Amnionic fluid leaking through a dilated
cervix portends almost certain abortion
• Either uterine contractions begin promptly or
infection develops
Evacuate the uterus
• In the rare case ,there may not be associated
pain, fever, or bleeding
Diminished activity
Resume ambulation after 48 hrs
Incomplete Abortion
 Partial or complete placental separation and dilation of the
cervical os is termed incomplete abortion.
 The fetus and the placenta may remain entirely within the
uterus or partially extrude through the dilated os
 Rx options:
• Curettage
• Medical abortion
• Expectant management
 The removed products of conception are sent to pathology
for standard histologic analysis
• Products of conception
• GTD
Complete Abortion
 In some cases, expulsion of the entire pregnancy is
completed before a patient presents for care
• A history of heavy bleeding, cramping, and tissue passage
• On pelvic examination, the cervical os is closed
 Adiagnosis of complete abortion should not be made
unless an intrauterine pregnancy was previously
diagnosed sonographically or passage of a gestational
sac has been confirmed.
• TVS is performed to differentiate a complete abortion from
threatened abortion or ectopic pregnancy
• In unclear settings, serial serum β-hCG measurements aid
clarification
 Missed abortion
 Dead products of conception that were retained for
weeks or months in a uterus with a closed cervical os.
• the term is used interchangeably with early pregnancy loss
 Criteria for diagnosis of early pregnancy loss
• CRL≥7mm and no heartbeat
• MSD≥25mm and no embryo
• Absence of embryo with heart beat≥2weeks after a scan
showed a gestational sac without a yolk sac
• Absence of embryo with heartbeat≥11days after a scan showed
a gestational sac with a yolk sac
Ultrasonographic criteria
suggestive of missed abortion..
Septic Abortion
 With current abortion practices, rates are < 1 percent
 Infections are usually polymicrobial
 To prevent postabortal sepsis, prophylactic antibiotics
are given at the time of surgical evacuation of incomplete
or induced abortion
• doxycycline 200-mg oral preoperative dose
 Rx
• Broad-spectrum antibiotics
 Metronidazole,Ampicillin and Gentamycin is one option
• Uterine evacuation
 For women with septic incomplete abortion or for those with retained
fragments, intravenous antimicrobial therapy is promptly followed by
uterine evacuation
Management sumarry
 Unless there is serious bleeding or infection, management of
spontaneous abortion can be individualized
 Any of three management options is reasonable
• Expectant
 unpredictable bleeding
 unscheduled curettage
• Medical
 mifepristone 200mg po followed by misoprostol 800mcg vaginally
 The dose may be repeated in 1 to 2 days
• Surgical
 definitive and predictable
 Preferred for pts with anemia or hypovolemia
 D negative women
• Anti D 300mcg Im stat for all gestational age (ACOG)
 Recurrent miscarriage
 The definition of RPL varies across professional
societies
• It was previously defined as three or more consecutive losses
• ASRM and ESHRE
 Recurrent pregnancy loss (RPL) is defined as the loss of two or more
pregnancies
 Prevalence of abnormal test findings is similar to that of women with three or more
losses
 Losses need not be consecutive

• Evaluation and treatment are considered earlier in

couples with concordant subfertility
• Remarkably, the chances for a successful pregnancy are
> 50 percent even after five losses in women aged <45
years
Etiology
 Three are widely accepted:
• Parental chromosomal abnormalities
• Antiphospholipid antibody syndrome, and
• Acquired or congenital uterine abnormalities

 Genetic factors most frequently result in

early embryonic losses, whereas
autoimmune or anatomic abnormalities
more likely lead to second-trimester losses
• For a given individual with RPL, each miscarriage tends to occur near the
same gestational age
Parental Chromosomal
Abnormalities
 Parental Karyotype
• An abnormal parental karyotype is estimated to account for 2
to 5 percent of RPL cases.
• Karyotype evaluation of both parents is recommended (ASRM 2012)
 Balanced reciprocal translocations-50%
 Balanced translocations are the most common structural chromosomal
abnormality
 Robertsonian translocations-24%
 X chromosome mosaicism-12%
 example-47,XXY-Klinefelter syndrome
 Inversions and various other anomalies made up the remainder
Parental chromosomal
abnormalities...
 Sperm DNA Testing
• Semen analysis and assays for DNA integrity or other
genetic abnormalities are not recommended as part of
RPL evaluation
 Screening Products of Conception
• It is not recommended as a routine part of the RPL
evaluation at present
 Whole Genome Sequencing
• Under investigation
Treatment
 Individualized treatment is indicated in couples
with a structural genetic abnormality
 The prognosis is generally good without
intervention for couples with a balanced
translocation
• 85 percent of couples had a healthy child
 Approaches are:
• IVF with PGT
• Use of donor gametes
• CVS or amniocentesis
Anatomic factors
 15% of women with RPL have an acquired or congenital uterine
anomaly
 Acquired Uterine Defects
• Intrauterine synechiae
 also known as Asherman syndrome
 adhesiolysis lowered the miscarriage rate
• Uterine leiomyomas
 It can cause abortion when located near the placental implantation site
 Most agree that consideration be given to excision of submucosal and
intracavitary leiomyomas
• Endometrial polyps
• Cervical insufficiency
 Cerclage placement.
Anatomic factors...

 Developmental Anomalies
• Unicornuate, bicornuate, and septate uteri are all associated with
increased early miscarriage and second trimester loss, fetal
malpresentation, and preterm labor rates
• Uterine anomaly correction
 Most experts recommend hysteroscopic resection of a uterine septum
 Uterine metroplasty is generally not recommended except for women who
have had a very high number of pregnancy losses
 Cesarean delivery
 high rate of postoperative pelvic adhesion formation and subsequent infertility
Immunologic factors
 15% of women with RPL
 Antiphospholipid antibodies in conjunction with specific
clinical findings are termed the antiphospholipid antibody
syndrome-APS
• This is the only autoimmune disorder that is clearly linked to
pregnancy loss
 The mechanism is unclear but can be divided in to 3 categories-
thrombosis,inflammation and abnormal placentation
 Miscarriage due to APS most often occurs after 10 weeks
APS treatment
 Concomitant use of glucocorticoids and heparin
generally is not recommended
 Guidelines from ACOG suggest that women with RPL
and APS who have not had a thrombotic event receive
prophylactic low-dose aspirin-81 mg orally per day-and
heparin when pregnancy is diagnosed.
• This is continued until delivery and 6 weeks postpartum
• Some experts suggest initiating low-dose aspirin prior to
conception
Endocrinologic factors
 8 to 12 percent of recurrent miscarriages
are the result of endocrine factors
• Luteal Phase Defect
• Thyroid Disease
• Hyperprolactinemia
• Diabetes Mellitus
• Polycystic Ovarian Syndrome
• Thrombophilias
Luteal Phase Defect

• It is postulated to be associated with

inadequate endometrial development at
implantation
• At this time, progesterone treatment is not
recommended
Thyroid Disease

 Both hypothyroidism and hyperthyroidism are associated

with increased risk of miscarriage
 Current recommendations suggest that all women with
RPL undergo thyroid function testing
• This includes antibody testing for anti-thyroid peroxidase
antibodies
 Overt hypo- or hyperthyroidism should be treated to
prevent pregnancy complications
Hyperprolactinemia
• Many experts still suggest measuring
prolactin levels in patients with RPL
Diabetes Mellitus

 Type 1 diabetes substantively raises risks for spontaneous

abortion and major congenital malformations
– Poor glycemic control
– Ovarian insulin resistance
Polycystic Ovarian Syndrome

 Hyperinsulinemia
• Insulin modulates insulin-like growth factor
actions in the ovary, thereby affecting
folliculogenesis and steroid production
 At this time, routine metformin treatment
for women with PCOS solely to treat
pregnancy loss is not recommended
Thrombophilias

• Testing for these abnormalities for RPL is

no longer recommended
Evaluation and Treatment
 Timing and extent of evaluation is based on maternal age,
coexistent infertility, symptoms, and level of patient anxiety
 General testing may include parental karyotyping, uterine
cavity evaluation, and testing for APS
 Unfortunately, a putative cause will be identified in only
about half of couples with RPL
• Empiric treatment for unexplained pregnancy loss is
discouraged
• Couples may be anxious to try any treatment
 Evaluation also assesses the potential need for
psychologic support
Induced abortion
 The term induced abortion defines medical or
surgical termination of pregnancy before the
time of fetal viability
 Worldwide, an estimated 56 million induced
abortions occur each year
 An estimated 25 million abortions annually are
considered unsafe
• In 2012, unsafe abortion was linked to complications in an
estimated 6.9 million women worldwide and to 8 percent
of maternal deaths
Indications
• Induced abortions are performed for
social, economic, or maternal health
indications.
• Medical and surgical conditions include
persistent cardiac decompensation,
pulmonary arterial hypertension, advanced
hypertensive vascular disease, diabetes
with end-stage organ failure, and
malignancy
 Abortion techniques
• First-trimester abortion can be performed
with either medication or surgery
Surgical Abortion
 Cervical preparation softens and slowly dilates the cervix
 Options
 Medical
 400-µg buccal misoprostol 2-4hrs prior to procedure
 mifepristone
 Mechanical
 hygroscopic dilators
 Laminaria
 Dilapan-S

• For pregnancies ≤8 weeks, preprocedural cervical ripening is

usually unnecessary
• Adolescents, nulliparas, or women with gestations ≥12 weeks may
especially benefit from preoperative cervical preparation
• Cervical preparation lower trauma,lessen pain,ease the procedure
and shorten operating time
Vacuum Aspiration

EVA MVA
•Suction is recommended •MVA is portable, is
for gestational ages ≤15 quieter than EVA,
weeks and does not
•Suction aspiration is require electricity
highly effective
Dilation and Evacuation
 D & E is the most frequently used method for
second trimester uterine evacuation
 Preoperative cervical preparation is essential
 Bierer or Sopher forceps
 D & E completion is confirmed with identification
of all fetal parts (four extremities, spine, and
calvarium)
 Many clinicians routinely perform D & E with
sonographic guidance
Medication Abortion
 Mifepristone
 It primes the myometrium and cervix for prostaglandin
activity
 cervical collagen degradation
 enhanced MMP expression
 Misoprostol is a PGE1 analogue that directly
stimulates the myometrium
 Methotrexate is an antimetabolite that stops cell
division
 It halts fetal growth and placental implantation
Contraindications to medication
abortion
• A patient's unwillingness to have a procedure in the
event of heavy bleeding or ongoing pregnancy
• An in situ intrauterine device
• A confirmed or suspected ectopic pregnancy; and
• severe anemia, coagulopathy, or anticoagulant use
• Unable for follow up visit
 Counseling
• Thorough counseling should include a description of cramping and
bleeding during conceptus passage.
• Bleeding that soaks two or more pads per hour for more than 2
consecutive hours warrants a provider discussion or evaluation.
• Women without bleeding within 24 hours of taking misoprostol
should contact their clinician because they may be at risk of ectopic
pregnancy or abortion failure.
• A woman is reassessed after 7 to 14 days with TVS or serum β-
hCG level to confirm no ongoing pregnancy and medication abortion
completion
 Abortion consequences
• Morbidity and mortality associated with abortion is very low.
• Early abortions are even safer, and the relative mortality risk of
abortion approximately doubles for each 2 weeks after 8 weeks'
gestation
• Pregnancy-associated mortality is 14-fold greater than abortion-
related mortality (8 versus 0.6 deaths per 100,000)
• Induced abortion does not negatively affect a woman's mental
health
• Effects of being denied an abortion may be more detrimental to
psychologic well-being than obtaining a wanted procedure
 Essential elements of
postabortion care
1. Community and service provider
partnerships
 Prevent unwanted pregnancies and unsafe
abortion
 Mobilize resources to help women receive
appropriately and timely care for complications
of abortion
 Ensure that health services reflect and meet
community expectations and needs
2. Counseling
 Identify and respond womens emotional and
physical health needs and other concerns
 Essential elements of
postabortion care…
3. Treatment
 Treat incomplete and unsafe abortion and potentially life
threatening complications
4. Family planning and contraceptive services
 Help women practice birthspacing or prevent an unwanted
pregnancy
 Ovulation may resume as early as 2 weeks after an early
pregnancy loss
 Options
 IUCD
 Hormonal conraceptives

5. Reproductive and other health services

 Preferably provide on site or via referrals to other accessible
facilities in providers network
Thank you