75

Williams Obstetrics
Chapter 9 Abortion
OBGY R1 Lee Eun Suk
Abortion
Spontaneous abortion
Induced abortion
Pathology
Etiology
Fetal Factors
Maternal Factors
Paternal Factors
Categories of Spontaneous Abortion
History of abortion
Indications
Elective (Voluntary) Abortion
Presumption of ovulation after abortion
Abortion
Termination of pregnancy, either spontaneously or intentionally
Pregnancy termination prior to 20 weeks gestation or less than

500-g birthweight
Definition vary according to state laws for reporting abortions, fetal

deaths, and neonatal deaths
Abortion occurring without medical or mechanical means to empty

the uterus is referred to as spontaneous
Another widely used term is miscarriage
Pathology
Hemorrhage into the decidua basinalis, followed by necrosis of tissues

adjacent to the bleeding
If early, the ovum detaches, stimulating uterine contractions
that result in its ovulation
Gestational sac is opened , fluid surrounding a small macerated
fetus or alternatively no fetus is visible blighted ovum
Pathology
In later abortion, the retained fetus may undergo maceration
The skull bones collapse, the abdomen distends with bloodstained fluid, and the internal organs degenerate
The skin softens and peels off in utero or at the slightest tough
When amnionic fluid is absorbed, the fetus may become compressed

and desiccated fetal compressus
The fetus become so dry and compressed that it resembles parchment

- a fetus papyraceous
Etiology
More than 80 percent of abortions occur in the first 12 weeks of

pregnancy
At least half result from chromosomal anomalies
After the first trimester, both the abortion rate & the incidence of
chromosomal anomalies decrease
F9-1
Etiology
The risk of spontaneous abortion increases with parity as well as with

maternal and paternal age
The frequency of abortion increases from 12 percent in women younger

than 20 years to 26 percent in those older than 40 years
If a woman conceives within 3 months following a term birth

incidence of abortion
F9-2
Etiology
The exact mechanism responsible for abortion are not apparent
In the first 3 months of pregnancy
Death of the embryo or fetus nearly always precedes spontaneous

expulsion of the ovum
Finding of the cause of early abortion involves ascertaining
the cause of fetal death
In subsequent months
The fetus frequently does not die before expulsion
Other explanations for its expulsion should be sought
Spontaneous abortion - Fetal factors
Abnormal zygotic development
Early spontaneous abortion commonly display a developmental

abnormality of the zygote, embryo, early fetus, or placenta
1000 spontaneous abortions analyzed by Hertig and Sheldon
Half demonstrated degenerated or absent embryos, that is,

blighted ova
F9-3
Aneuploid abortion
Approximately 50 to 60 percent of embryos and early fetuses

that are spontaneously aborted contain chromosomal abnor-malities
accounting for most of early pregnancy wastage
Jacobs and Hassold (1980)
95 percent of chromosomal abnormalities
d/t maternal gametogenesis error
5 percent d/t paternal error
T9-1
Aneuploid abortion - Autosomal trisomy
The most frequently identified chromosomal anomaly associated with

first-trimester abortions
Most trisomies result from isolated nondisjunction , balanced

structural chromosomal rearrangements are present in one partner in 2
to 4 percent of couples with a history of recurrent abortions
Autosomes 13, 16, 18, 21, and 22 most commom
Monosomy X
The second frequent chromosomal abnormality

Usually results in abortion
Much less frequently in liveborn female infant (Turner syndrome)
Triploidy
Associated with hydropic placental (molar) degeneration

Incomplete (partial) hydatidiform moles may contain triploidy or
trisomy for only chromosome 16
Tetraploid abortuses
Rarely are liveborn and most often are aborted early in gestation
Chromosomal structural abnormalities
Identified only since the development of banding techniques,

infrequently cause abortion
Euploid abortion
Abort later in gestational than aneuploid
Three fourths of aneuploid abortions occurred before8 weeks
Euploid abortions peak at about 13 weeks
The incidence of euploid abortions increased dramatically after maternal

age exceeded 35 years
Spontaneous abortion Maternal factors
Infections
Uncommon causes of abortion in human
Listeria monocytogenes
Clamydia trachomatis
Mycoplasma hominis
Ureaplasma urealyticum
Toxoplasma gondii
Chronic debilitating diseases
In early pregnancy, fetuses seldom abort secondary to chronic wasting

disease such as tuberculosis or carcinomatosis
Celiac sprue
Cause both male and female infertility and recurrent abortions
Endocrine abnormalities
Hypothyroidism
Diabetes mellitus
Iodine deficiency associated with excessive miscarriages

Thyroid autoantibodies incidence of abortion
The rates of spontaneous abortion & major congenital malformations

Poor glucose control incidence of abortion
Progesterone deficiency
Luteal phase defect

Insufficient progesterone secretion by the corpus luteum or placenta
Poor glucose control incidence of abortion
Nutrition
Dietary deficiency of any one nutrients not important cause
Drug use and environmental factor
Tobacco
Alcohol
Risk for euploid abortion

More than 14 cigarettes a day the risk twofold greater
Spontaneous abortion & fetal anomalies result from frequent alcohol use
during the first 8 weeks of pregnancy
Drinking twice a week abortion rates doubled
Drinking daily abortion rates tripled
Caffeine
At least 5 cups of coffee per day slightly increased risk of abortion
Drug use and environmental factor
Radiation
Contraceptives
In sufficient doses abortifacient

When intrauterine devices fail to prevent pregnancy abortion
Environmental toxins
Anesthetic gases : exact fetal risk of chronic maternal exposure is

unknown
Arsenic, lead, formaldehyde, benzene, ethylene oxide abortifacient
Video display terminal & accompanying electromagnetic fields
short waves & ultrasound do not increase the risk of abortion
Immunological factors autoimmune factors
Recurrent pregnancy loss patients : 15%

Antiphospholipid antibody : most significant
LCA (lupus anticoagulant), ACA (anticardiolipin Ab)

Reduce prostacyclin production
facilitating thromboxane dominant milieu thrombosis
Prostacyclin : produced by vascular endothelial cell
potent vasodilator & inhibit platelet aggregation
Thromboxane A2 : produced by platelets
vasoconstrictor & platelet aggregator
Strong association with
Decidual vasculopathy , placental infarction, fetal growth restriction

Early-onset preeclampsia, recurrent abortion, fetal death
Immunological factors autoimmune factors
Therapy of antiphopholipid antibody syndrome

: low dose aspirin, prednisone, heparin, intravenous Ig
affect both immune & coagulation system
counteract the adverse action of antibodies
Immunological factors alloimmune factors
Allogeneity
Genetic dissimilarities between animals of the same species

Human fetus is allogenic transplant tolerated by mother
Several test for diagnosis of alloimmune factors
Maternal & paternal HLA comparison

Maternal serum test for blocking antibodies
: blocking antibodies to paternal antigens
: ig G origin
Maternal serum test for antipaternal antibodies
: cytotoxic antibodies to paternal leukocyte
Inherited thrombophilia
Laparotomy
Many studies of aggregated thrombophilias

excessive recurrent abortions
Surgery performed during early pregnancy

no evidence of tncreased abortion
Peritonitis increases the likelihood of abortion
Physical trauma
Major abdominal trauma abortion
Uterine defects acquired uterine defects
Uterine leiomyoma : usually do not cause abortion
Placental implantation over or in contact with myoma

placental abruption, abortion, preterm labor
location is more important than size
Uterine synechiae (Asherman syndrome)
Partial or complete obliteration of the uterine cavity by adherence of

uterine wall
Cause : destruction of large areas of endometrium by curettage
insufficient endometrium to support implantation & menstruation
recurrent abortion, amenorrhea, hypomenorrhea
Uterine defects acquired uterine defects
Diagnosis of uterine synechiae
Hysterosalpingogram characteristic multiple filling defects

Hysteroscopy most accurate & direct diagnosis
Treatment of uterine synechiae
Lysis of adhesions via hysteroscopy

Prevention of adherence : IUD
Promotion of endometrial proliferation
: Continuous high-dose estrogen (60-90 days)
Uterine defects developmental uterine defects
Consequence of abnormal mullerian duct formation or fusion
Spontaneously
Induced by in utero exposure to DES (diethylstilbestrol)
Incompetent cervix
Painless dilatation of cervix in the 2nd or early in the 3rd trimester

prolapse & ballooning of membranes into vagina
rupture of membrane & expulsion of immature fetus
Diagnosis in nonpregnant women
Unless effectively treated, tends to repeat in each pregnancy

Hysterography
Pull-through techniques of inflated Foley catheter balloons
Acceptance without resistance at the internal os of specifically sized cervical
dilators
The use of transvaginal ultrasound in pregnant women
Cervical length - shortening

Funneling
Incompetent cervix Etiology
Previous trauma to the cervix
Dilatation & curettage

Conization
Cauterization
Abnormal cervical development
Exposure to DES in utero
Incompetent cervix Treatment
The operation is performed to surgically

Reinforcement of weak cervix by some type of purse string suture
( Cerclage )
Prophylactic surgery : generally performed between 12 & 16weeks
Should be delayed until after 14 weeks gestation

Early abortion due to other factors will be completed
The more advanced the pregnancy, the more likely the risk that surgical
intervention stimulate preterm labor or membrane rupture
Usually do not perform after about 23 weeks
Incompetent cervix Preoperative evaluation
Sonography
: Confirm living fetus & exclude major fetal anomalies
Cervical cytology
Cultures for gonorrhea, chlamydia, group B streptococci
Obvious cervical infections treatment is given

For at least a week before & after surgery sexual intercourse should be
restricted
Incompetent cervix Cerclage procedures
Types of operations commonly used
McDonald
Modified Shirodkar
85~90% success rate
Incompetent cervix Transabdominal cerclage
Requries laparotomy for
Placement of cerclage at uterine isthmus level

Cerclage removal, delivery, or both
Indications
Anatomical defects of cervix

Failed transvaginal cerclage
Incompetent cervix Complications
High incidence when performed much after 20 weeks
Membranes ruptures
Chorioamnionitis
Intrauterine infection
Urgent removal of suture
Operation fails
Signs of imminent abortion or delivery
Spontaneous abortion Paternal factors
Little is known in the genesis of spontaneous abortion
Chromosomal translocations in sperm can lead to abortion
Categories of spontaneous abortion
Threatened abortion
Inevitable abortion
Complete or incomplete abortion
Missed abortion
Recurrent abortion
Threatened abortion
Definition
Any bloody vaginal discharge or bleeding during 1st half of pregnancy
Frequency
Bleeding is frequently slight, but may persist for days or weeks
Extremely common (one out of four or five pregnant women)
Prognosis
Approximately will abort

Risk of preterm delivery, low birthweight, perinatal death
Risk of malformed infant does not appear to be increased
Threatened abortion
Symptoms
Usually bleeding begins first

Cramping abdominal pain follows a few hours to several days later
Presence of bleeding & pain
Poor prognosis for pregnancy continuation
Treatment
Bed rest & acetaminophen-based analgesia

Progesterone (IM) or synthetic progestational agent (PO or IM)
Lack of evidence of effectiveness

Often results in no more than a missed abortion
D-negative women with threatened abortion
Probably should receive anti-D immunoglobulin
Threatened abortion
Treatment : slight bleeding persists for weeks
Vaginal sonography
Serial serum quantitative hCG
Serum progesterone
can help ascertain if the fetus is alive & its location
Vaginal sonography
Gestational sac(+) & hCG < 1000mIU/ml

gestation is not likely to survive
If any doubt(+), check the serum hCG level at intervals of 48hrs
if not increase more than 65%, almost always hopeless
Serum progesterone value < 5 ng/ml

dead conceptus
Threatened abortion
Treatment : after death of conceptus
Uterus should be emptied

examination of all passed tissue whether the abortion is complete
Ectopic pregnancy should be considered if gestational sac or

fetus are not identified
Inevitable abortion
Gross rupture of membrane,evidenced by leaking amnionic fluid, in

the presence of cervical dilatation, but no tissue passed during 1st
half of pregnancy
Placenta (in whole or in part) is retained in the uterus

Uterine contractions begin promptly or infection develops
The gush of fluid is accompanied by bleeding, pain, or fever, abortion

should be considered inevitable
Complete or incomplete abortion
Complete abortion
Following complete detachment & expulsion of the conceptus

The internal cervical os closes
Incomplete abortion
Expulsion of some but not all of the products of conception during 1st
half of pregnancy
The internal cervical os remains open & allows passage of blood
The fetus & placenta may remain entirely in utero or may partially
extrude through the dilated os
Remove retained tissue without delay
Missed abortion
Retention of dead products of conception in utero for several

weeks
Many women have no symptoms except persistent amenorrhea
Uterus remain stationary in size, but mammary changes usually

regress uterus become smaller
Most terminates spontaneously
Serious coagulation defect occasionally develop after prolonged

retention of fetus
Recurrent abortion
Definition : Three or more consecutive spontaneous abortions
Clinical investigation of recurrent miscarriage
Parental cytogenetic analysis

Lupus anticoagulant & anticardiolipin antibodies assays
Postconceptional evaluation
Serial monitoring of hCG from missed mens period
hCG>1500mIU/ml USG
Maternal serum -fetoprotein assessment (GA16-18wks)

Amniocentesis fetal karyotype
Prognosis
Depends on potential underlying etiology & number of prior losses
INDUCED ABORTION
Induced abortion
The medical or surgical termination of pregnancy before the time of

fetal viability
Therapeutic abortion
Termination of pregnancy before of fetal viability for the purpose

of saving the life of the mother
Induced abortion
Indication
Continuation of pregnancy may threaten the life of women or seriously

impair her health
Persistent heart disease after cardiac decompensation

Advanced hypertensive vascular disease
Invasive carcinoma of the cervix
Pregnancy resulted from rape or incest
Continuation of pregnancy is likely to result in the birth of child with

severe physical deformities or mental retardation
Induced abortion
Elective (voluntary) abortion
Interruption of pregnancy before viability at the request of the women,

but not for reasons of impaired maternal health or
fetal disease
Counseling before elective abortion
Continued pregnancy with its risks & parental responsibilities

Continued pregnancy with its risks & its responsibilities of arranged
adoption
The choice of abortion with its risks
Surgical techniques for abortion
Dilatation and curettage
Performed first by dilating the cervix & evacuating the product of

conception
Mechanically scraping out of the contents (sharp curettage)

Vacuum aspiration (suction curettage)
Both
Before 14 weeks, D&C or vacuum aspiration should be performed
After 16 weeks, dilatation & evacuation (D&E) is performed
Wide cervical dilatation

Mechanical destruction & evacuation of fetal parts
Dilatation and curettage
Hygroscopic dilators
: swell slowly & dilate cervix cervical trauma can be minimized
Laminaria tents
: stem of brown seaweed ( Laminaria digitata or japonica)
drawing water from proteoglycan complexes of cervix
dissociation allow the cervix to soften & dilate
Insertion technique : tip rests just at the level of internal os

Usually after 4-6hours, laminaria dilate the cervix sufficiently to allow
easier mechanical dilation & curettage
May cause cramping pain
easily managed with 60 mg codeine every 3-4 hours
Technique for dilatation & curettage
Remove laminaria Uterus is sounded carefully to
Identify the status of the internal os
Confirm uterus size & position
Further dilation of cervix with Hegar dilator
Complications : uterine perforation
2 important determinants
Skill of the physician

Position of the uterus (retroverted)
Small defects by uterine sound or narrow dilator

often heal without complication
Suction & sharp curettage
Considerable intra-abdominal damage risk
Laparotomy to examine abdominal content (safest action)
Other complications cervical incompetence or uterine synechiae
Menstrual aspiration
Aspiration of endometrial cavity using a flexible cannula and syringe

within 1-3 weeks after failure to menstruate
Several points at early stage of gestation
Woman not being pregnant

Implanted zygote may be missed by the curette
Failure to recognize an ectopic pregnancy
Infrequently, a uterus can be perforated
Laparotomy
Abdominal hysterotomy or hysterectomy
Indications
Significant uterine disease
Failure of medical induction during the 2nd trimester
Medical induction of abortion
Early abortion
Outpatient medical abortion is an acceptable alternative to surgical

abortion in women with pregnancies of less than 49 days gestation
(ACOG, 2001b)
Three medications for early medical abortion

Antiprogestin mifeprostone
Antimetabolite methotrexate
Prostaglandin misoprostol
Medical induction of abortion _ 2
nd
trimester abortion
Oxytocin
Successful induction of 2nd trimester abortion is possible with high

doses of oxytocin administered in small volumes of IV fluids
Satisfactory alternatives to PG E2 for midtrimester abortion
Laminaria tents inserted the night before
Chance of successful induction is greatly enhanced
Prostaglandins
Used extensively to terminate pregnancies, especially in the 2nd T
PG E1, E2, F2
Technique
: Can act effectively on the cervix & uterus (86~95% effectiveness)
Vaginal prostaglandin E2 suppository & prostaglandin E1 (misoprostol)

As a gel through a catheter into the cervical canal & lowermost uterus
Injection into the amnionic sac by amniocentesis
Parenteral injection
Oral ingestion
Intra-amnionic hyperosmotic solutions
20-25% saline or 30-40% urea injected into amnionic sac

stimulate uterine contraction & cervical dilatation
Action mechanism : prostaglandin mediated ?
Complications of hypertonic saline
Death
Hyperosmolar crisis (early into maternal circulation)
Cardiac failure
Septic shock
Peritonitis
Hemorrhage
DIC
Water intoxication
Hyperosmotic urea : less likely to be toxic
Antiprogesterone RU 486
Oral agent used alone in combination with oral PG to effect abortions

in early gestation
High receptor affinity for progesterone binding site
Block progesterone action
Abortion rate
If given within 72 hours
Single 600mg dose prior 6 weeks 85%

Addition of oral, vaginal or injected PG over 95%
Also highly effective as emergency postcoital contraception
Progressively less effective after 72 hours
Side effects
Nausea, vomiting, & gastrointestinal cramping

Major risk hemorrhage is a risk if abortion is incomplete
Epostane
3-hydroxysteroid dehydrogenase inhibitor

blocks the synthesis of endogenous progesterone
Frequent side effect nausea
Hemorrhage is a risk if abortion is incomplete
Consequences of elective abortion
Maternal mortality
Legally induced abortion
Relative safe during the first 2 months of pregnancy

( 0.6/100,000 procedures)
Doubled for each 2 weeks of delay after 8 weeks gestation
Impact on future pregnancies
Fertility : not altered by an elective abortion
Vacuum aspiration for a first pregnancy

: Do not increase the incidence of
2nd trimester spontaneous abortions
Preterm delivery
Ectopic pregnancy
LBW infants
Impact on future pregnancies
Dilatations & curettage for a first pregnancy

: Increased risks for
Ectopic pregnancy
2nd trimester spontaneous abortions
LBW infants
Multiple elective abortion :
Not increased the incidence of preterm delivery & LBW infants

Placenta previa
increased following multiple sharp curettage abortion procedures
Septic abortion
Most often associated with criminal abortion
Metritis is usual outcome, but parametritis, peritonitis, endocarditis,

and septicemia may all occur
Management
Prompt evacuation of products of conception

Broad-spectrum IV antimicrobials
Resumption of ovulation after abortion
Ovulation may resume as early 2 weeks after an abortion
Therefore, if pregnancy is to be prevented,

effective contraception should be initiated soon after abortion

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Williams Obstetrics

OBGY R1 Lee Eun Suk

Presumption of ovulation after abortion

Termination of pregnancy, either spontaneously or intentionally

Pregnancy termination prior to 20 weeks gestation or less than

Definition vary according to state laws for reporting abortions, fetal

Abortion occurring without medical or mechanical means to empty

Hemorrhage into the decidua basinalis, followed by necrosis of tissues

In later abortion, the retained fetus may undergo maceration

When amnionic fluid is absorbed, the fetus may become compressed

The fetus become so dry and compressed that it resembles parchment

More than 80 percent of abortions occur in the first 12 weeks of

At least half result from chromosomal anomalies

The risk of spontaneous abortion increases with parity as well as with

The frequency of abortion increases from 12 percent in women younger

If a woman conceives within 3 months following a term birth

The exact mechanism responsible for abortion are not apparent

In the first 3 months of pregnancy

Death of the embryo or fetus nearly always precedes spontaneous

The fetus frequently does not die before expulsion

Other explanations for its expulsion should be sought

Spontaneous abortion - Fetal factors

Abnormal zygotic development

Early spontaneous abortion commonly display a developmental

1000 spontaneous abortions analyzed by Hertig and Sheldon

Half demonstrated degenerated or absent embryos, that is,

Spontaneous abortion - Fetal factors

Approximately 50 to 60 percent of embryos and early fetuses

Jacobs and Hassold (1980)

95 percent of chromosomal abnormalities

d/t maternal gametogenesis error

5 percent d/t paternal error

Spontaneous abortion - Fetal factors

Aneuploid abortion - Autosomal trisomy

The most frequently identified chromosomal anomaly associated with

Most trisomies result from isolated nondisjunction , balanced

Autosomes 13, 16, 18, 21, and 22 most commom

Spontaneous abortion - Fetal factors

The second frequent chromosomal abnormality

Associated with hydropic placental (molar) degeneration

Spontaneous abortion - Fetal factors

Chromosomal structural abnormalities

Identified only since the development of banding techniques,

Spontaneous abortion - Fetal factors

Abort later in gestational than aneuploid

Three fourths of aneuploid abortions occurred before8 weeks

Euploid abortions peak at about 13 weeks

The incidence of euploid abortions increased dramatically after maternal

Spontaneous abortion Maternal factors

Uncommon causes of abortion in human

Spontaneous abortion Maternal factors

Chronic debilitating diseases

In early pregnancy, fetuses seldom abort secondary to chronic wasting

Cause both male and female infertility and recurrent abortions

Spontaneous abortion Maternal factors

Iodine deficiency associated with excessive miscarriages

The rates of spontaneous abortion & major congenital malformations

Luteal phase defect

Spontaneous abortion Maternal factors

Dietary deficiency of any one nutrients not important cause

Drug use and environmental factor

Risk for euploid abortion