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Abortion
Peggy Mancuso, PhD, CNM
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Definition of Abortion
Termination of pregnancy
Before 20 weeks
gestation
Based on LMP
Or delivery of fetus
Weight less than 500
grams
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Abortion Classifications
Spontaneous
Threatened
Inevitable
Missed
Therapeutic
Elective
Recurrent
Blighted ovum
Sperm and Egg
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Spontaneous Abortion
Occurring without
apparent cause
Occurs naturally
Miscarriage
Miscarriage in progress No
heartbeat Sac near os
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Threatened Abortion
Bleeding during early
pregnancy
Prognosis worse with
pain or cramping
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Threatened Abortion
Rule out other causes of
bleeding
Cervical lesions
Polyps
Implantation bleeding
Implantation
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Management of Threatened
Abortion
Serial hCG
Serial progesterone
Vaginal sonograms
Pelvic rest
Little research
Bed rest
NO research support
Six Week Gestation
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Inevitable Abortion
Certain to occur
Rupture of membranes
Cervical dilation
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Inevitable Abortion
Management is patients
choice
D&C
Expectant management at
home
Notify if excessive
bleeding or fever
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Stages of Spontaneous Abortion
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Missed Abortion
Retention of products
for several weeks
No increase in fundal
height
Absence of FHT
Regression of changes of
pregnancy
Loss of weight
9-week gestation
Fibroid over os
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Recurrent SAB
Three or more consecutive
spontaneous abortions
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Blighted Ovum
Fluid filled sac
Macerated or absent fetus
May need D & C
Blighted
Ovum
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Etiologies of SAB
80% in first 12 weeks
Abnormal development
noted in majority of
cases
Incompetent cervix
cause of second trimester
loss
10-week gestation
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Risks Associated with SAB
Increased risk
Parity
Advanced maternal age
Advanced paternal age
Susan Sarandon,
age 43
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Risks Associated with SAB
Maternal factors
Autoimmune
Alcohol
Smoking
Teratogenic drugs
Teratogen exposure
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Therapeutic Abortion
Termination before age
of viability
Pregnancy is threat to
maternal health
Congenital anomalies
incompatible with life
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Elective Abortion
Voluntary interruption of
pregnancy
Between implantation
and age of viability
Age of viability?
20 weeks to 26 weeks
EGA
4
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Incidence of Elective Abortion
1.2 million in 1997
43% of US women
By age 45
Incidence decreasing
26/1000 in 1992
20/1000 in 1997
Over 50% used
contraception at time of
insemination
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Elective Abortion
Safer than continuing
pregnancy
50% before 8 weeks
gestation
90% before 12 weeks
gestation
90% vacuum aspiration
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Counseling for Elective Abortion
Pregnancy alternatives
Relative risks and
benefits
Evaluation of support
system
Medical conditions?
Contact person?
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Counseling for Elective Abortion
Procedure
Anesthesia/analgesia
Informed consent
Contraceptive
information
No intercourse for 2-3
weeks after procedure
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Possible Contraindications
Uncontrolled diabetes
Hemophilia
Other uncontrolled
diseases
Seizures
Cardiac disease
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Possible Contraindications
Drug addiction
Sickle cell disease
Sickle cell trait not
contraindication
Fever day of procedure
100.4 F
5
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Possible Contraindications
Current psychosis
Symptomatic cardiac disease
PID
Intrauterine infection
Treat MCP and defer surgery for 1 week
Recurrent pulmonary embolism
Current intoxication
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Possible Contraindications
BP 160/100 or above
Within 4 weeks of cervical conization
HCT 29%, HGB 9.5%
Inability to tolerate procedure with available
anesthesia/analgesia
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Methods of Abortion
Medical abortion
Vacuum aspiration
Dilation and evacuation
Induction or saline
infusion
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Mifipristone and Misoprostol
Mifipristone (RU 486)
600 mg po
Misoprostol
2 days later
Bleeding
4 hours after misoprostol
63 days from LMP
98% effective
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Methotrexate and Misoprostol
Methotrexate IM
May need to repeat
Misoprostol 5-8 days
later
49 days from LMP
Success 90 - 94%
50% abort day of
misoprostol
35-40% within a week
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Vacuum Aspiration
First trimester
Dilate cervix
Insert cannula
Vacuum or syringe used
to evacuate contents
Curette after vacuum
Procedure takes 10
minutes
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Dilation and Evacuation
12-16 weeks
Requires more dilation
of cervix
Osmotic dilators often
used
Vacuum aspiration and
forceps used
Oxytocin given during or
after procedure
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Induction or Saline Infusion
16 weeks or more
Medication used to induce contractions
Prostaglandins
Urea
Saline solution
Labor occurs and fetus expelled
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Types of Dilators
Laminaria
Dried seaweed
12-24 hours
Synthetic osmotoic
Lamicil or Dilapan
Faster dilation
May break when removed
Manual dilators
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Physical Examination
Prior to Procedure
Height and weight
Vital signs
Auscultate heart and
lungs
Assess extremities
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Physical Examination
Prior to Procedure
Palpate abdomen
Gestational age
Breast exam
Pelvic with bimanual
Rectal exam
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Lab Studies
Hematorcrit
Consult if <29%
RH
If negative
Administer Mini-Gamulin
if < 12 weeks
Rho Gam if > 12 weeks
Pregnancy test
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Lab Studies
Pap smear if needed
Blood glucose if
indicated
Wet mount
GC and CT if indicated
Urine dipstick if
indicated
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Analgesia/Anesthesia
Prior to procedure if not
using sublimaze
Acetaminophen 650 mg
Ibuprofin 600 mg
Toradol 60 mg IM
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Analgesia and Anesthesia
Sublimaze
1-2 cc IV
Immediately prior to
procedure
Valium if anxious
5-10 mg po
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Analgesia and Anesthesia
Others
Nitrous oxide
Nubain
Versed
General anesthesia
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Post-Operative Care
Vital signs every 15 minutes
Monitor vaginal bleeding
Doxycycline
100 mg po BID x 7 if indicated
May start OCPs or Depo Provera
Give Rh immune globulin
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Anticipatory Guidance
Activity
Pelvic rest
Grief
Support group referral if needed
Resumption of menstrual cycle
Normal bleeding or discharge
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Anticipatory Guidance
Normal discomfort
Notify clinic
Abnormal bleeding
Fever
Pain
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Post-Procedure Examination
2 - 4 weeks following
procedure
Review symptoms
Lab tests
Pregnancy test
Pap smear
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Post-Procedure Examination
Physical exam
BP
Breast
Abdomen
Pelvic
Bimanual
Speculum
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Signs and Symptoms of
Complications
Continued heavy
bleeding
Uterus
Boggy, tender, enlarged,
Tissue at os
Dilated os
Cramping
Elevated temperature
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Image acknowledgements
pathguy.com
skinema.com
med.cornell.edu
medscape.com
virtualhospital.com
obgyn.net
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