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Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS,
Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics
24th edition; 2014; chapter 18 ABORTION
OUTLINE
NOMENCLATURE
FIRST-TRIMESTER SPONTANEOUS ABORTION
CLINICAL CLASSIFICATION OF SPONTANEOUS ABORTION
MANAGEMENT OF SPONTANEOUS ABORTION
MIDTRIMESTER ABORTION
CERVICAL INSUFFICIENCY
INMIDTRIMESTER ABORTION
DEFINITION OF ABORTION
More than 80 percent of spontaneous abortions occur within the first 12 weeks
of gestation.
Closely linked to fetal chrosomal anomalies
Death is usually accompanied by hemorrhage into the decidua basalis,
followed by adjacent tissue necrosis that stimulates uterine contractions and
expulsion.
the key to determining the cause of early miscarriage is to ascertain the cause
of fetal death.
specific assays for minute concentrations of maternal serum most frequently identified chromosomal anomaly. Although
β-hCG and reported that two thirds of these early losses were most trisomies result from isolated nondisjunction, balanced
clinically silent. structural chromosomal rearrangements are found in one
partner in 2 to 4 percent of couples with recurrent miscar-
Fetal Factors Currently, there are factors known to influence clinically
apparent spontaneous abortion, however, it is unknown riages. Trisomies have been identified in abortuses for all
except chromosome number 1, and those with 13, 16, 18, 21,
if these same factors affect clinically silent miscarriages.
By way of example, the rate of clinical miscarriages is
almost doubled when either parent is older than 40 years
60 (55%)
1. Maternal age
2. Maternal infection: Chlamydia trachomatis see in 4% of abortuses
3. Medical disorders: Diabetes mellitus, thyroid disease, celiac disease,
anorexia/bulimia nervosa. IBD, SLE
4. Medications
5. Cancer: Cancer survivors who were previously treated with abdomi-
nopelvic radiotherapy, chemotherapy
6. nutrition: severe dietary deficiency and morbid obesity
Maternal Factors
Other progesterone regimens include: (1) oral micronized progesterone 200 or 300 mg orally once
daily, or (2) 8-percent progesterone vaginal gel (Crinone) given intravaginally as one
premeasured applicator daily plus micronized progesterone 100 or 200 mg orally once daily
continued until 10 weeks’ gestation.
Maternal Factors
Cervical Insufficiency
SECTION 6
Cerclage Procedures
1. McDonald (1963)
FIGURE 18-5 McDonald cerclage A
procedure for incompetent cervix.
A. Start of the cerclage procedure B
with a No. 2 monofilament suture
being placed in the body of the
cervix very near the level of the
internal os. B. Continuation of suture
placement in the body of the cervix
so as to encircle the os. C. Encircle-
ment completed. D. The suture is
tightened around the cervical canal
sufficiently to reduce the diameter of
the canal to 5 to 10 mm, and then
the suture is tied. The effect of the
suture placement on the cervical
canal is apparent. A second suture
placed somewhat higher may be of
C
value if the first is not in close prox-
imity to the internal os. D
C
value if the first is not in close prox-
imity to the internal os. D
Cervical Insufficiency
Cerclage Procedures
2. Shirodkar (1955)
A
FIGURE 18-6 Modified Shirodkar cerclage for
incompetent cervix. A. A transverse incision
is made in the mucosa overlying the anterior B
cervix, and the bladder is pushed cephalad.
B. A 5-mm Mersilene tape on a swaged-on
or Mayo needle is passed anteriorly to poste-
riorly. C. The tape is then directed posteriorly
to anteriorly on the other side of the cervix.
Allis clamps are placed so as to bunch the
cervical tissue. This diminishes the distance
that the needle must travel submucosally and
aids tape placement. D. The tape is snugly
tied anteriorly, after ensuring that all slack
has been taken up. The cervical mucosa is
then closed with continuous stitches of chro- C
mic suture to bury the anterior knot. D
Cervical Insufficiency
Cerclage Procedures
3. Transabdominal cerclage: suture placed at the uterine isthmus AND
can be used if there are severe cervical anatomical defects or if there
have been prior transvaginal cerclage failure
CERCLAGE COMPLICATIONS:
membrane rupture, preterm labor, hemorrhage, infection, or combinations
thereof.
Membrane rupture during suture placement or within the first 48 hours
following surgery is an indication for cerclage removal because of the
likelihood of serious fetal or maternal infection
ortion train- In the absence of serious maternal medical disorders, abortion
assailed. The procedures do not require hospitalization. With outpatient
products of conception?
must include
Kenneth J.
ed in 1999
surgically by several methods that are listed in Table 18-7. Results
o work with
on and fam-
been started TABLE 18-7. Some Techniques Used for First-Trimester TABLE 18-8. Comparisons of Some Advantages and
2013). These Abortiona
Drawbacks to Medical versus Surgical
dence-based, Abortion
Surgical
ion methods
Dilatation and curettage Factor Medical Surgical
Vacuum aspiration
dents techni- Invasive Usually no Yes
Menstrual aspiration
omplete and Pain More Less
ion for fetal Medical Vaginal bleeding Prolonged, Light,
g medical or Prostaglandins E2, F2α, E1, and analogues
unpredictable predictable
0) rightfully Vaginal insertion
Incomplete abortion More common Uncommon
ning should Parenteral injection
Failure rate 2–5% 1%
Oral ingestion
Severe bleeding 0.1% 0.1%
ncy training Sublingual
Infection rate Low Low
l fellowships Antiprogesterones—RU-486 (mifepristone) and epostane
Methotrexate—intramuscular and oral Anesthesia Usually none Yes
ograms that, Time involved Multiple visits, Usually one
bstetrics and Various combinations of the above
follow-up visit, no
ry. Training a exam follow-up
All procedures are aided by pretreatment using
ith all meth-
hygroscopic cervical dilators. exam
have a high success rate—95 percent with medical and 99 per- first-trimester abortion. Half were given two 200-µg tablets
cent with surgical techniques. Further comparison of medical orally 3 hours preprocedure, and the other group was given pla-
products of conception?
2009; Robson, 2009). Likely for these reasons, only 10 percent is given orally. Other options include formulations of prosta-
of abortions in the United States are managed using medical glandins E2 and F2a, which have unpleasant side effects and are
methods (Templeton, 2011). usually reserved as second-line drugs (Kapp, 2010).
SECTION 6
ges
firs
inc
inf
rep
un
cen
inc
A B C
du
FIGURE 18-7 Insertion of laminaria before dilatation and curettage. A. Laminaria immediately after being appropriately placed with 36
its upper end just through the internal os. B. Several hours later the laminaria is now swollen, and the cervix is dilated and softened.
C. Laminaria inserted too far through the internal os; the laminaria may rupture the membranes.
A 22
Te
Management: How to
Abortion
evacuate
the products of conception? FIGURE 18-9 Dilatation of cervix with a Hegar dilator. Note that
the fourth and fifth fingers rest against the perineum and but-
tocks, lateral to the vagina. This maneuver is an important safety FIGURE 18-10 A suction curette has been placed through the
measure because if the cervix relaxes abruptly, these fingers pre- cervix into the uterus. The figure shows the rotary motion used to
vent a sudden and uncontrolled thrust of the dilator, a common aspirate the contents. (From Word, 2012, with permission.)
cause of uterine perforation.
and evacuation of fetal parts. With complete removal of the
fetus, a large-bore vacuum curette is used to remove the pla-
Complications. The incidence of uterine perforation with centa and remaining tissue. This is better accomplished using
Dilatation and Curettage (D&C) elective abortion is variable, and determinants include clinician
skill and uterine position. Perforation is more common with a
intraoperative sonographic imaging.
retroverted uterus and is usually recognized when the instru- Dilatation and Extraction (D&X)
dilating the cervix and then evacuating
ment passes without resistance deep into the pelvis. Observation
FIGURE 18-9
is usually sufficient if the uterine perforation Dilatation
is small,
This is similar to dilatation and evacuation except that a suc-
of cervix with a Hegar dilator. Note that
as when tion cannula is used to evacuate the intracranial contents after
the fourth and fifth fingers rest against the perineum and but-
produced by a uterine sound or narrow dilator. Although per-
the pregnancy by mechanically tocks, lateral to the vagina. This maneuver is an important safety FIGURE 18-10 A suction curette has been placed through the
forations through old cesarean incisionmeasure
or myomectomy
because if the scars
cervix relaxes abruptly, these fingers pre- cervix into the uterus. The figure shows the rotary motion used to
are potentially possible, Chen and colleagues (2008) reported no
vent a sudden and uncontrolled thrust of the dilator, a common aspirate the contents. (From Word, 2012, with permission.)
Midtrimester
Complications abortion Surgical
Dilatation and curettage (D&C)
In a 2-year review of more than 233,000 medical abortions
Dilatation and evacuation (D&E)
performed at Planned Parenthood affiliates, there were 1530
Dilatation and extraction (D&X)
(0.65 percent) significant adverse events. Most of these were
Laparotomy
ongoing pregnancy (Cleland, 2013). Bleeding and cramp-
Hysterotomy
ing with medical termination can be significantly worse than
Hysterectomy
menstrual cramps. Thus adequate analgesia, usually including
a narcotic, is provided. The American College of Obstetricians Medical
How to evacuate products
and Gynecologists (2011c) recommends that if there is enough Intravenous oxytocin
Intraamnionic hyperosmotic fluid
of conception?
blood to soak two or more pads per hour for at least 2 hours,
the woman is instructed to contact her provider to determine 20-percent saline
whether she needs to be seen. 30-percent urea
Unnecessary surgical intervention in women undergoing Prostaglandins E2, F2α, E1
medical abortion can be avoided if properly indicated follow-up Intraamnionic injection
sonographic results are interpreted appropriately. Specifically, Extraovular injection
if no gestational sac is seen and there is no heavy bleeding, Vaginal insertion
then intervention is unnecessary. This is true even when, as is Parenteral injection
common, the uterus contains sonographically evident debris. Oral ingestion
Another study reported that a multilayered sonographic pat- a
All procedures are aided by pretreatment using
tern indicated a successful abortion (Tzeng, 2013). Clark
hygroscopic cervical dilators.
and coworkers (2010) provided data that routine postabortal
Abortion