Abortion
Williams Obstetrics and Gynecology 25th ed
Nomenclature
Abortion
Pregnancy termination or loss before 20weeks or with fetus delivered weighing <500g
spontaneous abortion
Includes threatened, inevitable, complete , incomplete or missed
Septic abortion
Complicated by infection
Recurrent pregnancy Loss
2 or more failed pregnancies <20weeks AOG or fetal weight <500g
Pregnancy off unknown location
Pregnancy identified by bHCG without a confirmed sonographic location
Pathogenesis
80% of spontaneous abortions occur within 12 weeks AOG
Death usually accompanied by hemorrhage into the decidua basalis, followed by adjacent
tissue necrosis that stimulates uterine contractions and expulsion
Incidence
Pregnancies aged 5 to 20weeks incidence ranges from 11 to 22%
Etiology
Etiology
Fetal factors • Chromosomal anomalies
Maternal factors • Age >35yrs old
• Infections
• Medical disorders
• Anatomical factors
• Exposure to chemotherapy/radiation
• Social and behavioral factors
• Occupational and environmental
factors
Paternal factors Age
Spermatozoa anomalies
Fetal Factors
chromosomal abnormality
Most common in first trimester, 50%
75% occurred by 8wks gestation
95% are caused by maternal gametogenesis errors
Most common abnormalities are trisomies
Chromosome 13, 16, 18, 21, 22 are most common
Monosomy X (45,X) single most frequent specific chromosomal abnormality
Maternal factors
Anatomical
Congenital genital tract anomalies
Asherman syndrome
Uterine leiomyoma
Incompetent cervix
Cervical Insufficiency/incompetent cervix
Painless cervical dilatation in 2nd trimester
Can be followed by prolapsed and ballooning of membrane into vagina then expulsion of
immature fetus
Indications
unequivocal history of second-trimester painless delivery, prophylactic cerclage placement is an option
and reinforces a weak cervix by an encircling suture.
physical finding of early dilation of the internal cervical os
presence of funneling in transvaginal sonography; membranes into a dilated internal os, but with a
closed external os
cervical length measurement
16 and 24weeks- every 2 weeks
CL 25-29mm weekly interval
CL <25mm cerclage is offered
Contraindications
Bleeding, contractions, ruptured membrane
Spontaneous Abortion Clinical Classification
Threatened abortion
Incomplete abortion
Complete abortion
Missed abortion
Inevitable abortion
Septic abortion
Threatened abortion
Bleeding appears through a close cervical os
Must be differentiated from that implantation bleeding
Maybe accompanied the suprapubic discomfort, mild cramps, pelvic pressure or persistent
low backache
Management
Bed rest Early pregnancy + vaginal bleeding + pain =
primary goal is prompt diagnosis of ectopic
HCT, HGB and BT requested
pregnancy, serial BhCG and TVS
Incomplete Abortion
Bleeding follows partial or complete placental separation and dilatation of the cervical os
Before 10weeks AOG- placenta are frequently expelled together
Management
Curettage- quick resolution, 95-100% successful
Misoprostol- 800ug vaginal, 400ug oral/SL
Expectant
Complete Abortion
Complete expulsion of entire pregnancy and cervical os subsequently closes
History of heavy bleeding, cramping and passage of tissue
TVS
Minimally thickened endometrium without GS
Empty uterus with endometrial thickness <15mm
Complete abortion cannot be surely diagnosed unless
True products of conception are seen
Sonography confidently documents 1st an intrauterine pregnancy then later an empty cavity
serial serum BHCG level measurements aid clarification
Missed abortion
Dead products of conception that have been retained for days or weeks in the uterus with
closed cervical os
TVS
At 5 to 6 weeks- 1-2mm embryo adjacent to the yolk sac can be seen
6-6.5weeks
fetal cardiac activity typically detected
CRL 1-5mm
MSD 13-18mm
Guidelines for Early pregnancy Loss
Yolk sac diameter ≥6mm in pregnancies <10 wks AOG
Slower heart rate <85bpm
<5mm difference between MSD and CRL
Subchrionic hematoma
Inevitable Abortion
Preterm premature rupture of membrane(PPROM) at a previable gestational age
Nearly always followed by either uterine contractions, infection and termination
Risk factors
Prior PPROM
Prior 2nd trimester delivery
Tobacco use
2nd trimester spontaneous PPROM at previable age, 70-80% will deliver within 2-5weeks
Evacuation
If with bleeding, cramping and fever
Expectant
Antibiotics are considered and given for 7days to extend latency
Types Cervix Uterus BOW FHT Plan
Threatened closed Compatible + + Bed rest
abortion Tocolysis
Missed closed Compatible + - Cervical
abortion ripening
±curettage
Complete closed Incompatible - - Observe
abortion TVS
Measure HCG
Incomplete Open Incompatible - - Expectantly
abortion Curettage
Medical(misop
rostol)
Inevitable Open Compatible - +/- Expectant
abortion Oxytocin
Curettage
Septic abortion
With spontaneous or induced abortion organism may invade myometrial tissues and
extend to cause parametritis, peritonitis and septicemia
Most bacteria are part of the normal vaginal flora
Severe necrotizing infections and toxic shock syndrome – group A streptococcus- S.
pyogenes
Management
Broad spectrum antibiotic
Suction curettage
Most patient respond 1-2days treatment, discharged once afebrile
Induced Abortion
Therapeutic abortion
Termination of pregnancy for medical indications
Fetus with significant anatomical, metabolic or mental deformity
In cases of incest or rape
Elective/voluntary abortion
Interruption of pregnancy before viability at the request of the woman
Postabortal contraception
Ovulation may resume as early as 8days but average time is 3 weeks
Effective contraception is initiated
For those who desire another pregnancy, conception should be delayed with interval of
6months
Thank you.
