Joshua H.

Gaboy

Definition
- Termination of pregnancy before the fetus develops sufficiently to survive

- Terminatio prior to 20 weeks gestation or less than 500g birthweight

Classification
1. Spontaneous

2. Induced

Spontaneous Abortion
- Occur without medical or mechanical means to empty the uterus

- Miscarriage

Spontaneous Abortion
Etiology: - 80% occur in first 12 weeks (50% from chromosomal abnormalities) - Increases with
- Parity - Maternal and paternal age - Conception within 3 months after a term birth

Fetal Factors
1. Abnormal zygotic development
- Of 1000 spontaneous abortions, half demonstrated degenerated or absent embryos, that is, blighted ova
Hertig and Sheldon (1943)

- Morphological disorganization of growth in 40% of abortuses that were expelled spontaneously before 20 weeks
- Poland and Co-workers (1981)

Fetal Factors
2. Aneuploid Abortion
- Autosomal trisomy MC
- Monosomy X (45,X)

- Triploidy molar pregnancy

3. Euploid Abortion
- abort later in gestation

Maternal Factors
1. Infections
Mycoplasma hominis Ureaplasma urealyticum Treponema pallidum HIV-1

2. Endocrine Abnormalities - Hypothyroidism - DM - Progesterone deficiency

Maternal Factors
3.

Nutrition

- Dietary deficiency of one or more nutrients may cause abortion

3. Drug use and Environmental Factors
Tobacco Alcohol Caffeine Radiation Contraceptives

Maternal Factors
4. Immunologic Factors
- Antiphospholipid Antibodies: Lupus anticoagulant and Anti cardiolipin antibodies - Placental thrombosis and infarction - Prostacyclin and Protein C inhibition

5. Inherited Thrombophilia 6. Laparotomy

7. Physical Trauma
- contributes minimally to incidence of abortion

Maternal Factors
8. Uterine Defects
Acquired Uterine Defects
- Leiomyomas does not usually cause abortion - Ashermans syndrome uterine synechiae, usually results from destruction of large areas of endometrium by curettage Developmental Defects

- Abnormal mullerian duct formation

Maternal Factors
9. Incompetent Cervix

- painless cervical dilatation with prolapse and ballooning of membranes into the vagina followed by expulsion of an immature fetus - previous trauma, abnormal development
- Cerclage

Paternal Factors
Chromosomal abnormalities in sperm have been associated with abortion

Categories of Spontaneous abortion

1. Threatened Abortion

Bloody vaginal discharge or bleeding through a closed cervical os during the first half of pregnancy
With lower abdominal pain and persistently low back pain Bleeding anterior rhythmic crampy pain DDx: Ectopic pregnancy, Inevitable abortion, endocervical polyp, cervical lesions Bed rest, Acetaminophen-based analgesics

Categories of Spontaneous abortion

2. Inevitable Abortion

- Gross rupture of membranes in the presence of cervical dilatation

- Pain, fever, or bleeding

- Tx: Prompt evacuation by curettage

Categories of Spontaneous abortion

3. Complete and Incomplete Abortion

- Placenta detaches from uterus causes bleeding

- Complete: complete detachment and expulsion of the conceptus with cervix closed

- Incomplete: retained products of conception with cervix remained open

- Tx: Evacuation extraction using forceps or suction curettage

Categories of Spontaneous abortion

3. Missed Abortion

- Uterus retains dead products of conception behind a closed cervix for days or even weeks
- Uterine and breast changes of pregnancy regress - May terminate spontaneously expulsion of the abortus

Categories of Spontaneous abortion

5. Recurrent or Habitual Abortion

- 3 or more consecutive spontaneous abortions

- Occur in 0.3 0.4% of women - Autoimmune disorders and parental cytogenetics - Prognosis: Majority of women who attempt pregnancy after being diagnosed with recurrent abortion will have successful outcomes, with or with out treatment

Induced Abortion
Definition

- The medical or surgical termination of pregnancy before the time of fetal viability
Indications:

- Persistent heart disease, advanced hypertensive vascular disease, invasive carcinoma of the cervix

Induced Abortion
Surgical Techniques

1. Dilatation and Curettage

- Dilating the cervix - Evacuating pregnancy by mechanically scraping out the contents (sharp curettage), by suctioning out the contents (suction curettage), or both. - Vaccum aspiration MC form of suction curettage - < 16 weeks

Induced Abortion
Surgical Techniques

1. Dilatation and Curettage

- > 16 weeks: Dilatation and Evacuation wide
mechanical dilatation by metal or hygroscopic dilators. Dilatation and Extraction : suction evacuation of extracranial contents after delivery of fetal body, minimizes uterine or cervical injury (partial birth abortion)

Induced Abortion
Surgical Techniques

Hygroscopic Dilators
- Devices that slowly dilates the cervix minimizing trauma from mechanical dilatation
-

Draw water from cervical tissues and expand gradually dilating the cervix
Laminaria digitata, Laminaria japonica,

Induced Abortion
Medical Induction of Labor

1. Early Abortion
Mifepristone (antiprogestin), Methotrexate (antimetabolite): increase uterine contractility by reversing the progesterone-induced inhibition of contractions Misoprostol (prostaglandin): direct myometrium stimulation

Induced Abortion
Medical Induction of Labor

2. Second-Trimester Abortion
Oxytocin: Given as single agent in high dose, mixed with isotonic solution

Prostaglandin E2: 20mg suppositories placed in the posterior vaginal fornix, nausea and vomiting, fever and diarrhea Prostaglandin E1: Misoprostol

Induced Abortion
Consequences of Elective Abortion

Septic Abortions
- Usually caused by pathogenic organisms of vaginal flora and bowel: Anaerobic bacteria and coliforms
Diagnostic Criteria
Fever (38 C or higher) for 24 hrs History of Mechanical interference Discharge from the cervix Tenderness of the Uterus, parametrium or adnexae

Induced Abortion
Consequences of Elective Abortion

Septic Abortions
- Treatment:
Prompt intravenous evacuation of broad spectrum antimicrobial followed by evacuation of products of conception

Resumption of Ovulation after Abortion

Ovulation may resume as early as 2 weeks after an abortion LH surge 16 to 28 days in 15/18 women studied
- Lahteenma ki and Luukkainen

increase in plasma progesterone levels agree with histological changes observed in endometrial biopsies
- Boyd and Holmstrom, 1972

Induced Abortion
Consequences of Elective Abortion

Septic Abortions
- Treatment:
Prompt intravenous evacuation of broad spectrum antimicrobial followed by evacuation of products of conception