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ABORTION

NOMENCLATURE
FIRST-TRIMESTER SPONTANEOUS ABORTION
CLINICAL CLASSIFICATION OF SPONTANEOUS ABORTION
MANAGEMENT OF SPONTANEOUS ABORTION
RECURRENT MISCARRIAGE
MIDTRIMESTER ABORTION
CERVICAL INSUFFICIENCY
INDUCED ABORTION
TECHNIQUES FOR ABORTION
SURGICAL ABORTION
MEDICAL ABORTION
CONSEQUENCES OF ELECTIVE ABORTION

The word abortion derives from the Latin aboririto miscarry. Abortion is
defined as the spontaneous or induced termina- tion of pregnancy before
fetal viability.
Newer terms made possible by widespread use of sonography and human
chorionic gonadotropin measurements that identify extremely early
pregnancies include early pregnancy loss, wasted age, or failure

Nomenclature
Viability lies between the lines that separate abortion from preterm birth. It is
usually defined by pregnancy duration and fetal birthweight for statistical and
legal purposes
The National Center for Health Statistics, the Centers for Disease Control and
Prevention, and the World Health Organization all define abortion as
pregnancy termina- tion before 20 weeks gestation or with a fetus born
weighing 500 g.
As indicated above, technological developments have revolutionized current
abortion
terminology. Transvaginal sonography (TVS) and precise
measurement of serum human chorionic gonadotropin (hCG) concentrations
are used to identify extremely early pregnancies as well as those with an
intrauterine versus ectopic location.

Nomenclature
Terms that have been in clinical use for many decades are generally used to
describe later pregnancy losses. These include:

1.Spontaneous abortionthis category includes threatened, inevitable,


incomplete, complete, and missed abortion. Septic abortion is used to
further classify any of these that are complicated further by infection.
2.Recurrent abortionthis term is variably defined, but it is meant to identify
women with repetitive spontaneous abortions so that an underlying factor(s)
can be treated to achieve a viable newborn.
3.Induced abortionthis term is used to describe surgical or medical
termination of a live fetus that has not reached viability

First Trimester Spontaneous


Abortion
Pathogenesis
More than 80 percent of spontaneous abortions occur within the first 12
weeks of gestation. With first-trimester losses, death of the embryo or fetus
nearly always precedes spontaneous expulsion.
Death is usually accompanied by hemorrhage into the decidua basalis. This
is followed by adjacent tissue necrosis that stimulates uterine contractions
and expulsion. An intact gestational sac is usually filled with fluid and may or
may not contain an embryo or fetus.
In contradistinction, in later pregnancy losses, the fetus usually does not die
before expulsion, and thus other explanations are sought.

First Trimester Spontaneous


Abortion
Incidence
Statistics regarding the incidence of spontaneous abortion vary according to
the diligence used for its recognition. Wilcox and colleagues (1988) studied
221 healthy women through 707 menstrual cycles and found that 31 percent
of pregnancies were lost after implantation. They used highly specific assays
for minute concentrations of maternal serum -hCG and reported that two
thirds of these early losses were clinically silent.

First Trimester Spontaneous


Abortion
Fetal Factors
As shown in Table 18-1, approximately half of miscarriages anembryonic,
that is, with no identifiable embryonic ele ments. Less accurately, the term
blighted ovum may be used (Silver, 2011). The other 50 percent are
embryonic miscarriages, which commonly display a developmental
abnormality of the zygote, embryo, fetus, or at times, the placenta. Of
embryonic miscarriage, half of these25 percent of all abortuseshave
chromosomal anomalies and thus are aneuploid abortions. The remaining
cases are euploid abortions, that is, carrying a normal chromosomal
complement.

First Trimester Spontaneous


Abortion
Aneuploid Abortion
Both abortion rates and
gestational age, 50 per
chromosomal abnormalities
losses and in only 5 percent
at earlier gestational ages.

chromosomal anomalies decrease with advancing


cent of embryonic abortions are aneuploid, but
are found in just a third of second-trimester fetal
of third-trimester stillbirths. Aneuploid abortion occurs

Kajii and associates (1980) noted that 75 percent of aneuploid abortions occurred
by 8 weeks. Of these, 95 percent of chromosomal abnormalities are caused by
maternal gametogenesis errors, and5 percent by paternal errors (Jacobs, 1980).
With first-trimester miscarriages, autosomal trisomy is the most frequently
identified chromosomal anomaly. Although most trisomies result from isolated
nondisjunction, balanced structural chromosomal rearrangements are found in
one partner in 2 to 4 percent of couples with recurrent miscarriages.

First Trimester Spontaneous


Abortion
Aneuploid Abortion
Monosomy X (45,X) is the single most frequent specific chromosomal
abnormality. This is Turner syndrome, which usually results in abortion, but
liveborn females are described (Chap. 13, p. 264). Conversely, autosomal
monosomy is rare and incompatible with life.
Triploidy is often associated with hydropic or molar placen- tal degeneration
(Chap. 20, p. 398). The fetus within a partial hydatidiform mole frequently
aborts early, and the few carried longer are all grossly deformed. Advanced
maternal and pater- nal age do not increase the incidence of triploidy.
Tetraploid fetuses most often abort early in gestation, and they are rarely
liveborn.
Last, chromosomal structural abnormalities infrequently cause
abortion.

First Trimester Spontaneous


Abortion
Euploid Abortion
Chromosomally normal fetuses abort later than those that are aneuploid.
Specifically, the rate of euploid abortions peaks at approximately 13 weeks
(Kajii, 1980). In addition, the inci- dence of euploid abortions increases
dramatically after maternal age exceeds 35 years (Stein, 1980).

Maternal Factors
Infections
Brucella abortus, Campylobacter fetus, and Toxoplasma gondii infections
cause abortion in
livestock, but their role in human pregnancy is less clear (Feldman, 2010;
Hide, 2009; Mohammad, 2011; Vilchez, 2014).
There appear to be no abortifacient effects of infec- tions caused by Listeria
monocytogenes, parvovirus, cytomega lovirus, or herpes simplex virus
(Brown, 1997; Feldman, 2010).
Data concerning a link between some other infections and increased abortion
are conflicting. Examples are Mycoplasma and Ureaplasma (Quinn,
1983a,b; Temmerman, 1992).

Maternal Factors
Medical Disorders
In general, early abortions are rarely due to chronic wast- ing diseases such
as tuberculosis or carcinomatosis. There are a few specific disorders possibly
linked with increased early pregnancy loss.
Those associated with diabetes mellitus and thyroid disease are discussed
subsequently. Another example is celiac disease, which has been reported to
cause recurrent abor- tions as well as both male and female infertility.

Maternal Factors
Medical Disorders
Medications. Only a few medications have been evaluated concerning a role
with early pregnancy loss. Oral contraceptives or spermicidal agents used in
contraceptive creams and jellies are not associated with an increased
miscarriage rate. Similarly, non- steroidal antiinflammatory
drugs or
ondansetron are not linked (Edwards, 2012; Pasternak, 2013). A pregnancy with
an intra uterine device (IUD) in situ has an increased risk of abortion and
specifically of septic abortion (Chap. 38, p. 700).
Cancer. Therapeutic doses of radiation are undeniably aborti facient, but
doses that cause abortion are not precisely known (Chap. 46, p. 930). According
to Brent (2009), exposure to < 5 rads does not increase the risk. Cancer
survivors who were previously treated with abdomi nopelvic radiotherapy may
later be at increased risk for miscarriage.

Maternal Factors
Medical Disorders
Wo and Viswanathan (2009) reported an associated two- to eightfold
increased risk for miscarriages, low-birthweight and growth-restricted infants,
preterm delivery, and perinatal mortality in women previously treated with
radiotherapy. Hudson (2010) found an associated increased risk for miscarriage in those given radiotherapy and chemotherapy in the past for a
childhood cancer.

Maternal Factors
Medical Disorders
Diabetes Mellitus
The abortifacient effects of uncontrolled diabetes are well- known. Optimal
glycemic control will mitigate much of this loss and is discussed in Chapters 8 (p.
157) and 57 (p. 1128). Spontaneous abortion and major congenital malformation
rates are both increased in women with insulin-dependent diabetes. This is directly
related to the degree of periconceptional glycemic and metabolic control.

Thyroid Disorders
These have long been suspected to cause early pregnancy loss and other adverse
pregnancy outcomes. Severe iodine deficiency, which is infrequent in developed
countries, has been associated with increased miscarriage rates (Castaeda, 2002).
Varying degrees of thyroid hormone insufficiency are common in women.

Maternal Factors
Medical Disorders
Surgical Procedures
The risk of miscarriage caused by surgery is not well studied. There is extensive
interest in pregnancy outcomes following bariatric surgery, because as
discussed on page 353, obesity is an uncontested risk factor for miscarriage.
However, currently, it is not known if this risk is mitigated by weight-reduction
surgery (Guelinckx, 2009).
Nutrition
Extremes of nutritionsevere dietary deficiency and mor bid obesityare
associated with increased miscarriage risks. Dietary quality may also be
important, as this risk may be reduced in women who consume fresh fruit and
vegetables daily (Maconochie, 2007).

Maternal Factors
Medical Disorders
Sole deficiency of one nutrient or moderate deficiency of all does not appear
to increase risks for abortion. Even in extreme casesfor example,
hyperemesis gravidarumabortion is rare (Maconochie, 2007). Other
examples discussed on page 352 ar anorexia and bulimia nervosa.
Importantly, Bulik and col leagues (2010) reported that half of pregnancies in
women with anorexia nervosa were unplanned.
Obesity is associated with a litany of adverse pregnancy outcomes. These
include subfertility and an increased risk of miscarriage and recurrent abortion
(Jarvie, 2010; Lashen, 2004; Satpathy, 2008).

Maternal Factors
Medical Disorders
Social and Behavioral Factors
Lifestyle choices reputed to be associated with an increased mis- carriage risk are
most commonly related to chronic and especially heavy use of legal substances.
The most common used is alco- hol, with its potent teratogenic effects.
At least 15 percent of pregnant women admit to cigarette smoking (Centers for
Disease Control and Prevention, 2013). It seems intuitive, but unproven, that
cigarettes could cause early pregnancy loss by a number of mechanisms that
cause adverse late-pregnancy outcomes (Catov, 2008).
Excessive caffeine consumptionnot well definedhas been associated with an
increased abortion risk. There are reports that heavy intake of approximately five
cups of coffee per dayabout 500 mg of caffeineslightly increases the abortion
risk

Maternal Factors
Occupational and Environmental Factors
It is intuitive to limit exposure of pregnant women to any toxin. That said,
although some environmental toxins such as benzene are implicated in fetal
malformations, data with miscarriage risk is less clear (Lupo, 2011). The
major reason is that it is not possible to accurately assess environmental
exposures. Earlier reports that implicated some chemicals as increasing
miscarriage risk include arsenic, lead, formal- dehyde, benzene, and ethylene
oxide (Barlow, 1982).
Increased miscarriage risk was found for dental assistants exposed to more
than 3 hours of nitrous oxide daily if there was no gas-scavenging equipment

Maternal Factors
Immunological Factors
There is, however, an increased risk for early pregnancy loss with some
immune-mediated disorders. The most potent of these are antiphospholipid
antibodies directed against binding proteins in plasma. These along with
clinical and laboratory findings provide criteria for the antiphospholipid
antibody syndromeAPS.

Paternal Factors
These factors in the genesis of miscarriage are not well studied.
Chromosomal abnormalities in sperm reportedly had an increased abortion
risk (Carrell, 2003). Increasing paternal age was significantly associated with
increased risk for abortion in the Jerusalem Perinatal Study (Kleinhaus, 2006).
This risk was lowest before age 25 years, after which it progressively
increased at 5-year intervals.

Clinical Classification of
Spontaneous Abortion
Threatened Abortion
The clinical diagnosis of threatened abortion is presumed when bloody
vaginal discharge or bleeding appears through a closed cervical os during the
first 20 weeks .
Almost a fourth of women develop clinically significant bleeding during early
gestation that may persist for days or weeks. With miscarriage, bleeding
usually begins first, and cramping abdominal pain follows hours to days later.

Clinical Classification of
Spontaneous Abortion
Threatened Abortion versus Ectopic Pregnancy.
Every woman with an early pregnancy, vaginal bleeding, and pain should be
evaluated. The primary goal is prompt diagnosis of an ectopic pregnancy.
Serum progesterone concentrations < 5 ng/mL suggest a dying pregnancy,
whereas values 20 ng/mL support the diagnosis of a healthy pregnancy.
Transvaginal sonography is used to locate the pregnancy and determine if
the fetus is alive.
Another caveat is that a gestational sac may appear similar to other
intrauterine fluid accumulationsthe so-called pseudogestational sac. This
pseudosac may be seen with ectopic pregnancy and is easier to exclude once
a yolk sac is seen.

Clinical Classification of
Spontaneous Abortion
Threatened Abortion versus Ectopic Pregnancy.
At 5 to 6 weeks, a 1- to 2-mm embryo adjacent to the yolk sac can be seen
(Daya, 1993). Absence of an embryo in a sac with a mean sac diameter of 16
to 20 mm suggests a dead fetus (Levi, 1988; Nyberg, 1987).
Finally, fetal cardiac activity can be detected at 6 to 6.5 weeks with an
embryonic length of 1 to 5 mm and a mean sac diameter of 13 to 18 mm. A
5-mm embryo with- out cardiac activity is likely dead (Goldstein, 1992; Levi,
1990).

Clinical Classification of
Spontaneous Abortion
Threatened Abortion versus Ectopic Pregnancy.
Management. Acetaminophen-based analgesia will help relieve discomfort
from cramping. If uterine evacuation is not indicated, bed rest is often
recommended but does not improve outcomes. Neither has treatment with a
host of medications that include chorionic gonadotropin (Devaseelan, 2010)
With persistent or heavy bleeding, the hematocrit is determined. If there is
significant anemia or hypovolemia, then pregnancy evacuation is generally
indicated. In these cases in which there is a live fetus, some choose
transfusion and further observation.

Clinical Classification of
Spontaneous Abortion
Threatened Abortion versus Ectopic Pregnancy.
Anti-D Immunoglobulin. With spontaneous miscarriage, 2 percent of Rh
D-negative women will become alloimmunized if not provided passive
isoimmunization. With an induced abortion, this rate may reach 5 percent.
The American College of Obstetricians and Gynecologists (2013c)
recommends anti- Rh0 (D) immunoglobulin given as 300 g
intramuscularly (IM) for all gestational ages, or 50 g IM for pregnancies
12 weeks and 300 g for 13 weeks.

Clinical Classification of
Spontaneous Abortion
Inevitable Abortion
In the first trimester, gross rupture of the membranes along with cervical
dilatation is nearly always followed by either uter ine contractions or
infection. A gush of vaginal fluid during the first half of pregnancy usually has
serious consequences. In some cases not associated with pain, fever, or
bleeding, fluid may have collected previously between the amnion and
chorion.
After 48 hours, if no additional amnionic fluid has escaped and if there is no
bleeding, cramping, or fever, then a woman may resume ambulation and
pelvic rest. With bleeding, cramping, or fever, abortion is considered
inevitable, and the uterus is evacuated.

Clinical Classification of
Spontaneous Abortion
Incomplete Abortion
Bleeding that follows 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. Before 10 weeks, they are frequently expelled together, but later, they
deliver separately.
Management options of incomplete abortion include curettage, medical
abortion, or expectant management in clinically stable women as discussed
on page 357. With surgical therapy, addi- tional cervical dilatation may be
necessary before suction curet tage. In others, retained placental tissue
simply lies loosely within the cervical canal and can be easily extracted with
ring forceps.

Clinical Classification of
Spontaneous Abortion
Complete Abortion
At times, expulsion of the entire pregnancy may be completed before a woman
presents to the hospital. A history of heavy bleeding, cramping, and passage of
tissue or a fetus is common. Importantly, during examination, the cervical os is
closed.
Patients are encouraged to bring in passed tissue, which may be a complete
gestation, blood clots, or a decidual cast. The last is a layer of endometrium in the
shape of the uterine cavity that when sloughed can appear as a collapsed sac.
If an expelled complete gestational sac is not identified, sonography is performed
to differentiate a complete abortion from threatened abortion or ectopic
pregnancy. Characteristic findings of a complete abortion include a minimally
thick ened endometrium without a gestational sac.

Clinical Classification of
Spontaneous Abortion
Missed Abortion
Also termed early pregnancy failure or loss, missed abortion, as originally defined,
is contemporaneously misused compared with its meaning many decades ago.
Historically, the term was used to describe dead products of conception that were
retained for days, weeks, or even months in the uterus with a closed cervical os.
Early pregnancy appeared to be normal with amenorrhea, nausea and vomiting,
breast changes, and uterine growth. Because suspected fetal death could not be
confirmed, expectant management was the sole option, and spontaneous
miscarriage would eventually ensue. And because the time of fetal death could
not be determined clinically, pregnancy durationand thus fetal agewas
erroneously calculated from the last menses.
To elucidate these disparities, Streeter (1930) studied aborted fetuses and reported
that the mean death-to- abortion interval was approximately 6 weeks.

Clinical Classification of
Spontaneous Abortion
Septic Abortion
Horrific infections and maternal deaths associated with criminal septic
abortions have become rare with legalized abortion. Still, perhaps 1 to 2
percent of women with threatened or incomplete miscarriage develop a
pelvic infection and sepsis syndrome. Elective abortion, either surgical or
medical, is also occasionally complicated by severe and even fatal infections
(Barrett, 2002; Ho, 2009).
Bacteria gain uterine entry and colonize dead con- ception products.
Organisms may invade myometrial tissues and extend to cause parametritis,
peritonitis, septicemia, and, rarely, endocarditis (Vartian, 1991). Particularly
worrisome are severe necrotizing infections and toxic shock syndrome
caused by group A streptococcusS pyogenes (Daif, 2009).

Clinical Classification of
Spontaneous Abortion
Septic Abortion
Similar infections are caused by Clostridium sordellii and have clinical
manifestations that begin within a few days after an abor tion. Women may be
afebrile when first seen with severe endothe lial injury, capillary leakage,
hemoconcentration, hypotension, and a profound leukocytosis.
In a very few women, severe sepsis syn- drome causes acute respiratory distress
syndrome, acute kidney injury, or disseminated intravascular coagulopathy. In
these cases, intensive supportive care is essential.
The American College of Obstetricians and Gynecologists (2011b) recom- mends
doxycycline, 100 mg orally 1 hr before and then 200 mg orally after a surgical
evacuation. At Planned Parenthood clin ics, for medical abortion, doxycycline 100
mg is taken orally daily for 7 days and begins with abortifacient administration
(Fjerstad, 2009b).

Clinical Classification of
Spontaneous Abortion
Management of Spontaneous Abortion
With embryofetal death now easy to verify with current sono graphic
technology, management can be more individualized. Unless there is serious
bleeding or infection with an incomplete abortion, any of three options are
reasonableexpectant, medical, or surgical management. Each has its own
risks and benefitsfor example, the first two are associated with
unpredictable bleeding, and some women will undergo unscheduled
curettage.

Recurrent Miscarriage
Most of these are embry onic or early losses, and the remainder either are
anembry- onic or occur after 14 weeks. Studies are difficult to compare
because of nonstandardized definitions. For example, some investigators
include women with two instead of three con- secutive losses, and yet others
include women with three nonconsecutive losses.
The American Society for Reproductive Medicine (2008) proposed that
recurrent pregnancy loss be defined as two or more failed clinical
pregnancies confirmed by either sono- graphic or histopathological
examination. A thorough evalu- ation certainly is warranted after three
losses, and treatment is initiated earlier in couples with concordant
subfertility.

Recurrent Miscarriage
Etiology
There are many putative causes of recurrent abortion, how- ever, only three
are widely accepted: parental chromosomal abnormalities, antiphospholipid
antibody syndrome, and a sub set of uterine abnormalities.
Other suspected but not proven causes are alloimmunity, endocrinopathies,
environmental toxins, and various infections. Infections seldom cause even
sporadic loss. Thus, most are unlikely to cause recurrent miscar- riage,
especially since maternal antibodies usually have devel oped. For years,
various inherited thrombophilia mutations that include factor V Leiden,
prothrombin G20210A, protein C and S deficiency, and antithrombin
deficiency were suspected.

Recurrent Miscarriage
Etiology
There is some evidence to support a role for various polymorphisms of gene
expression in miscarriages. Just a few exam ples include polymorphisms that
alter VEGF-A expression, those that exaggerate platelet aggregation, and
those with a spe- cific maternal type of Th1 and Th2 immune response.
Genetic factors usually result in early embryonic losses, whereas
autoimmune or uterine anatomical abnormalities more likely cause secondtrimester losses .

Recurrent Miscarriage
Parental Chromosomal Abnormalities
Although these account for only 2 to 4 percent of recurrent losses, karyotypic
evaluation of both parents is considered by many to be a critical part of
evaluation. In an earlier study, balanced
reciprocal translocations accounted for half of chromosomal abnormalities,
robertsonian translocations for a fourth, and X chromosome mosaicism
47,XXY or Klinefelter syndrome.

Recurrent Miscarriage
Immunological Factors
In their analysis of published studies, Yetman and Kutteh (1996) determined
that 15 percent of more than 1000 women with recurrent miscarriage had
recognized autoimmune factors. Two primary pathophysiological models are
the autoimmune theory immunity directed against self, and the alloimmune
theoryimmunity against another person.
With regard to alloimmunity, a provocative theory sug- gests that normal
pregnancy requires formation of blocking factors that prevent maternal
rejection of foreign fetal anti gens that are paternally derived (Chap. 5, p. 98).
Factors said to prevent this include human leukocyte antigen (HLA) similarity with the father, altered natural killer cell activity, regula tory T cell
stimulation, and HLA-G gene mutations (Berger, 2010; Williams, 2012).

Recurrent Miscarriage
Endocrine Factors
According to Arredondo and Noble (2006), 8 to 12 percent of recurrent
miscarriages are caused by endocrine factors. Studies to evaluate these have
been inconsistent and generally under powered. Two examples, both
controversial, are progesterone deficiency caused by a luteal-phase defect
and polycystic ovarian syndrome .

Midtrimester Abortion
Incidence and Etiology
Abortion becomes much less common by the end of the first tri mester, and its
incidence decreases successively thereafter. Overall, spontaneous loss in the
second trimester is estimated at 1.5 to 3 percent, and after 16 weeks, it is only
1 percent (Simpson, 2007; Wyatt, 2005). First-trimester bleeding doubles the
incidence of second-trimester loss.
Risk factors for second-trimester abortion include race, ethnicity, prior poor
obstetrical outcomes, and extremes of maternal age. First-trimester bleeding
was cited previously as a potent risk factor (Hasan, 2009). Edlow and
colleagues (2007) observed that 27 percent of women with such a loss in the
index pregnancy had a recurrent second-trimester
loss in their next
pregnancy. Moreover, a third of these women had a sub sequent preterm birth.

Midtrimester Abortion
Fetal and Placental Evaluation
Because etiology is closely linked to recurrence risk, a thor ough evaluation
of obstetrical and perinatal findings is war- ranted. Pathological examination
of the fetus and placenta is essential (Dukhovny, 2009). In women older than
35 years, chromosomal abnormalities explain 80 percent of recurrences
(Marguard, 2010). In a study of 486 women of all ages with second-trimester
miscarriages, fetal malformations were identi- fied in 13 percent (Joo, 2009).
In another, a third of otherwise normal fetuses had associated
chorioamnionitis that was judged to have preceded labor (Allanson, 2010).
Indeed, according to Srinivas and associates (2008), 95 percent of placentas
in midtrimester abortions are abnormal. Other abnormalities are vascular
thromboses and infarctions.

Midtrimester Abortion
Management
Midtrimester abortions are classified similarly to first-trimester abortions.
Management is also similar in many regards, and the schemes shown in
Table 18-3 are frequently successful with a dead fetus or an incomplete
midtrimester abortion.

Midtrimester Abortion
Cervical Inssuficiency
Also known as incompetent cervix, this is a discrete obstetri- cal entity
characterized classically by painless cervical dilata tion in the second
trimester. It can be followed by prolapse and ballooning of membranes into
the vagina, and ultimately, expulsion of an immature fetus.
Unless effectively treated, this sequence may repeat in future pregnancies.
Many of these women have a history and clinical findings that make it
difficult to verify classic cervical incompetence

Midtrimester Abortion
Risk Factors
Although the cause of incompetence is obscure, previous cervi- cal trauma
such as dilatation and curettage, conization, cau terization, or amputation
has been implicated. A Norwegian cohort study of more than 15,000 women
with prior cervi- cal conization found a fourfold risk of pregnancy loss before
24 weeks (Albrechtsen, 2008). Even though prior dilatation and evacuation
(D&E) has an incidence of cervical injury of 5 percent, neither it nor dilatation
and extraction (D&X) after 20 weeks increased the likelihood of an
incompetent cervix (Chasen, 2005).

Midtrimester Abortion
Cerclage Procedures
Of the two vaginal cerclage operations, most use the simpler procedure
developed by McDonald (1963) and shown in Figure 18-5. The more
complicated operation is a modification of the procedure described by
Shirodkar (1955) and shown in Figure 18-6. When either technique is
performed prophy- lactically, women with a classic history of cervical
incompe- tence have excellent outcomes (Caspi, 1990; Kuhn, 1977). As
emphasized by Karl and Katz (2012), it is important to place the suture as
high as possible and into the dense cervical stroma.

Midtrimester Abortion
Cerclage Procedures
Transabdominal cerclage with the suture placed at the uter ine isthmus can
be used if there are severe cervical anatomical defects or if there have been
prior transvaginal cerclage failures (Cammarano, 1995; Gibb, 1995). Zaveri
and associates (2002) reviewed 14 observational studies in which a prior
transvaginal cerclage had failed to prevent preterm delivery. The risk of peri
natal death or delivery before 24 weeks was only slightly lower following
transabdominal cerclage compared with the risk following repeat
transvaginal cerclage6 versus 13 percent, respectively..

Midtrimester Abortion
Cerclage Procedures
Complications. Principal complications of cerclage are membrane
rupture, preterm labor, hemorrhage, infection, or combinations thereof. All
are uncommon with prophylactic cerclage. In the multicenter study by Owen
and colleagues (2009), of 138 procedures, there was one instance each of
rup- tured membranes and bleeding. In the trial by MacNaughton and
associates (1993), membrane rupture complicated only 1 of more than 600
procedures done before 19 weeks. Thomason and coworkers (1982) found
that perioperative antimicrobial prophylaxis failed to prevent most infection,
and tocolytics failed to arrest most labor. In our view, clinical infection man
dates immediate removal of the suture with labor induced or augmented.
Similarly, with imminent abortion or delivery, the suture should be removed
at once because uterine contractions can tear through the uterus or cervix.

Induced Abortion
The term induced abortion is defined as the medical or surgical termination
of pregnancy before the time of fetal viabil-ty. Definitions to describe its
frequency include: (1) abortion ratiothe number of abortions per 1000 live
births, and (2) abortion ratethe number of abortions per 1000 women aged
15 to 44 years.

Induced Abortion
Classification
Therapeutic Abortion
There are several diverse medical and surgical disorders that are indications
for termination of pregnancy. Examples include persistent cardiac
decompensation, especially with fixed pul- monary hypertension; advanced
hypertensive vascular disease or diabetes; and malignancy. In cases of rape
or incest, most consider termination reasonable. The most common indica
tion currently is to prevent birth of a fetus with a significant anatomical,
metabolic, or mental deformity. The seriousness of fetal deformities is wide
ranging and usually defies social, legal, or political classification.

Induced Abortion
Classification
Elective or Voluntary Abortion
The interruption of pregnancy before viability at the request of the woman, but not
for medical reasons, is usually termed elective voluntary abortion. Regardless of
terminology, these are stigmatized in this country (Harris, 2012). Most abortions
done today are elective, and thus, it is one of the most com monly performed
medical procedures. The pregnancy-associated mortality rate is 14-fold greater than
the abortion-related mor tality rate8 versus 0.6 deaths per 100,000 (Raymond,
2012). From the Guttmacher Institute, Jones and Kavanaugh (2011) estimate that a
third of American women will have at least one elective abortion by age 45. The
Executive Board of the American College of Obstetricians and Gynecologists
(2013d) supports the legal right of women to obtain an abortion prior to fetal
viability and considers this a medical matter between a woman and her physician.

Techniques For Abortion


In the absence of serious maternal medical disorders, abortion procedures do
not require hospitalization. With outpatient abortion, capabilities for
cardiopulmonary resuscitation and for immediate transfer to a hospital must
be available.

Induced Abortion
Cervical preparation
There are several methods that will soften and slowly dilate the cervix to
minimize trauma from mechanical dilatation (Newmann, 2014). A Cochrane
review confirmed that hygroscopic dilators and cervical ripening medications
had similar efficacy in decreasing the length of first-trimester procedures
(Kapp, 2010).
Of these, hygroscopic dilators are devices that draw water from cervical
tissues and expand to gradually dilate the cervix. One type is derived from
various species of Laminaria algae that are harvested from the ocean floor

Induced Abortion
Surgical Abortion
Surgical pregnancy termination includes a transvaginal approach through an
appropriately dilated cervix or, rarely, laparotomy with either hysterotomy or
hysterectomy. With transvaginal evacuation, preoperative cervical ripening is
favored and is typi cally associated with less pain, a technically easier
procedure, and shorter operating times (Kapp, 2010). Curettage usually
requires intravenously or orally administered sedatives or anal gesics, and
some also use paracervical blockade with lidocaine (Allen, 2009; Cansino,
2009; Renner, 2012).

Induced Abortion
Dilatation and Curettage (D&C)
Transcervical approaches to surgical abortion require first dilating the
cervix and then evacuating the pregnancy by mechanically scraping out
the contentssharp curettage, by suctioning out the contentssuction
curettage, or both.
Vacuum aspiration, the most common form of suction curet tage, requires a
rigid cannula attached to an electric-powered vacuum source or to a
handheld syringe for its vacuum source (Goldberg, 2004; MacIsaac, 2000;
Masch, 2005).

Induced Abortion
Complications. The incidence of uterine perforation with elective abortion
is variable, and determinants include clinician skill and uterine position.
Perforation is more common with a retroverted uterus and is usually
recognized when the instru- ment passes without resistance deep into the
pelvis. Observation is usually sufficient if the uterine perforation is small, as
when produced by a uterine sound or narrow dilator. Although per- forations
through old cesarean incision or myomectomy scars are potentially possible,
Chen and colleagues (2008) reported no perforations through such scars in
78 women undergoing medical or surgical abortion.

Medical Abortion
According to the American College of Obstetricians and Gynecologists
(2011c), outpatient medical abortion is an acceptable alternative to
surgical pregnancy termination in appropriately selected pregnant women
less than 49 days men- strual age. After this time, available dataalbeit less
robust support surgical abortion as preferable. Throughout history, many
natural substances have been given for alleged abortifacient effects. In many
of these, serious illness and even death have resulted.
These are used either alone or in combination and include: (1) the
antiprogestin mifepristone, (2) the antimetabolite methotrexate, and (3) the
prostaglandin misoprostol

Consequences Of Elective
Abortion
Maternal Mortality
Even so, abortion-related deaths are likely underreported (Horon, 2005). With
this caveat in mind, legally induced abortion, performed by trained gynecologists
during the first 2 months of preg- nancy, has a mortality rate of less than 1 per
100,000 pro- cedures (Pazol, 2011).
In a report from Finland comprising nearly 43,000 abortions performed before 63
days, only one procedure-related death was documented (Niinimaki, 2009). Early
abortions are even safer, and the relative mortality risk of abortion approximately
doubles for each 2 weeks after 8 weeks gestation.
The Centers for Disease Control and Prevention identified 12 abortion-related
deaths in the United States in 2008 (Pazol, 2012). As emphasized by Raymond
and Grimes (2012), mortality rates are 14-fold greater for pregnancies that are
continued.

Consequences Of Elective
Abortion
Health and Future Pregnancies
Data relating abortion to overall maternal health and to sub- sequent pregnancy
outcome are limited. From studies, there is no evidence for excessive mental disorders
(Munk-Olsen, 2011; Steinberg, 2014). There are few data regarding sub- sequent
reproductive health, although the rates of infertility or ectopic pregnancy are not
increased.
There may be exceptions if there are postabortal infections, especially those caused
by chlamydiae. Also, other data suggest that some adverse pregnancy outcomes are
more common in women who have had an induced abortion (Maconochie, 2007).
Specifically, several studies note an approximate 1.5-fold increased incidence of
preterm delivery22 to 32 weeks (Hardy, 2013; Moreau, 2005; Swingle, 2009).
Multiple sharp curettage procedures may increase the subsequent risk of placenta
previa, whereas vacuum aspiration procedures likely do not (Johnson, 2003).

Contraception Followin
Miscarriage Or Abortion
Ovulation may resume as early as 2 weeks after an early pregnancy
termination. Lahteenmaki and Luukkainen (1978) detected surges of
luteinizing hormone (LH) 16 to 22 days after abortion in 15 of 18 women
studied. Plasma progester one levels, which had plummeted after the
abortion, increased soon after LH surges. These hormonal events agree with
histo logical changes observed in endometrial biopsies by Boyd and
Holmstrom. Thus, it is important that unless another pregnancy is desired
right away, effective contraception should be initiated very soon after
abortion.

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