Abortion

ABORTION
 Defined as the spontaneous or induced termination of pregnancy before fetal viability
 Pregnancy termination before 20 weeks gestation or fetal weight <500g

TRANSVAGINAL SONOGRAPHY allows greater inspection of failed pregnancies, but recommendations vary as to terms
for:

 early conceptions in which no products are seen sonographically

 pregnancies that display a gestational sac but no embryo
 dead embryo

TERMS TO DEFINE PREGNANCY LOSSES:

1. Recurrent Abortion
 Defined as 3 or more consecutive pregnancy losses at <20 weeks or a fetal weight
<500g
 2 or more failed clinical pregnacies confirmed by either sonographic or
histopathological exam - American society for Reproductive Medicine
2. Spontaneous Abortion
o Threatened abortion
o Inevitable abortion
o Incomplete abortion
o Complete abortion
o Missed abortion
o Septic abortion
3. Induced Abortion
 Surgical or medical termination of a live fetus that has not reached viability

PREGNANCY OF UNKNOWN LOCATION (PUL) describes a

pregnancy identified by hCG testing but without a confirmed sonographic location.

 Five categories are proposed for early pregnancies:
o definite ectopic pregnancy
o probable ectopic
o probable IUP

ABORTION
80 percent of spontaneous abortions occur
within the first 12 weeks of gestation.

 demise of the embryo or fetus nearly always precedes spontaneous expulsion.

 Death is usually accompanied by hemorrhage into the decidua basalis.
 followed by adjacent tissue necrosis that stimulates uterine contractions and expulsion.
 An intact gestational sac is usually filled with fluid.
  ANEMBRYONIC MISCARRIAGE
 contains no identifiable embryonic elements.
 blighted ovum
 EMBRYONIC MISCARRIAGES
 Often display a developmental abnormality of the:
o Embryo
o Fetus
o yolk sac

FETAL FACTORS:

 Euploid abortions : half contains normal chromosomal complement

o other half has a chromosomal abnormality

 determined by TISSUE KARYOTYPING

 75 percent of chromosomally abnormal abortions occurred by 8 weeks’ gestation

 chromosomal abnormalities:
o 95% : maternal gametogenesis errors
o 5% : paternal errors
 Most common abnormalities:
o Trisomy: 50-60%
o Monosomy X: 9-13%
o Tripoloidy: 11-12 %

TRISOMIES o Isolated nondisjunction

o Rise with maternal age
o Trisomies of chromosomes 13, 16, 18,
21, and 22 are most common

MONOSOMY o Single most frequent specific

X chromosomal abnormality
o Turner syndrome,
o Autosomal monosomy is rare
and incompatible with life.

TRIPLOIDY o hydropic or molar placental

degeneration
o fetus within a partial hydatidiform
mole frequently aborts early
o Advanced maternal and paternal
ages do not increase the incidence
of
triploidy
TETRAPLOIDY o most often abort early in gestation,
and they are rarely liveborn
MATERNAL FACTORS

Infections o viruses, bacteria, and parasites that

invade the normal human can infect
the fetoplacental unit by blood-borne
transmission
o uncommonly cause early abortion
Medical o Diabetes mellitus
Disorders o Obesity
o Thyroid disease
o Systemic lupus erythematosus
Cancer o Therapeutic doses of radiation are
undeniably abortifacient
o Methotrexate exposure
o Abdominopelvic radiotherapy or
chemotherapy may later be at greater
risk for miscarriage

Surgical o Early removal of the corpus luteum or

Procedures the ovary
o Major trauma especially abdominal
can cause fetal loss, but is more likely
as pregnancy advances

Nutrition o Dietary quality may play a role, as

miscarriage risk may be reduced in
women who consume a diet rich in
fruits, vegetables, whole grains,
vegetable oils, and fish
o obesity does raise pregnancy loss rates

Social and o heavy use of legal substances

Behavioral o most commonly used is alcohol
Factors o cigarette smoking
o Excessive caeine consumption
Occupational o bisphenol A
and o phthalates
Environmental o polychlorinated biphenyls
Factors o dichlorodiphenyltrichloroethane
 PATERNAL FACTORS
 bloody vaginal discharge or bleeding appears
through a closed cervical os during the first 20  Increasing paternal age is
weeks. significantly associated with
 bleeding during early gestation that may persist an greater risk for abortion
for days or weeks  lowest before age 25
highest risks are for preterm delivery years, after which it
Signs and o Suprapubic discomfort progressively increased at 5-
Symptoms o Mild cramps year intervals
o Pelvic pressure, or persistent low  chromosomal abnormalities in
backache. spermatozoa likely play a role
o Bleeding is by far the most
predictive risk factor for
pregnancy loss SPONTANEOUS ABORTION CLINICAL
o CLASSIFICATION
Diagnostics o Β-hCG: 1500-2000mIU/mL
o Transvaginal Sonography: used to
locate the pregnancy and Threatened abortion
determine viability

Not 100% accurate so repeat evaluations

are often necessary

o Pseudogestational Sac:
the gestational sac appear
similar to other intrauterine fluid
o Yolk Sac: visible by 5.5 weeks
w/ a mean gestational sac of
10mm in diameter

Management o Observation
o Acetaminophen-based Analgesia:
to relieve discomfort from
cramping
o Bed Rest
o Hct and Blood Type is determined
: if anemia or
hypovolemia is significant
 pregnancy
evacuation
  Bleeding follows partial or complete placental
separation and dilatation of cervical os
 Tissue may remain entirely within the uterus or
partially extrude through the cervix
 Products lying loosely w/in the cervical canal 
easily extracted by RING FORCEPS

Management o Curettage
 Quick resolution
 95-100% successful
Incomplete abortion
o Expectant management
o Misoprostol (Cytotec):
prostaglandin E1 (PGE1)
 800µg –vaginal or 400 µg
oral or sublingual

Misoprostol and expectant management

are deferred in clinically unstable women
or those with uterine infection

COMPLETE ABORTION

 Cervical os subsequently closes

 Layer of endometrium is in the shape of the
uterine cavity that when sloughed can appear as
collapsed sac

Cannot be surely diagnosed unless:

1. True products of conception are grossly seen
2. Sonography confidently documents 1st an
intrauterine pregnancy
 Signs and o History of Heavy Bleeding
Symptoms o Cramping
o Passage of Tissue is typical

**patients are encouraged to bring in

passed tissue
Diagnostics o Seum hCG (drops quickly)
o Transvaginal Sonography
 If an expelled gestational sac
is not identified
 Differentiate complete from
threatened abortion or
Ectopic Pregnancy

o Minimally Thickened
Endometrium without a
gestational sac
Endometrial Thickness of < 15mm

Missed Abortion

 Describes the DEAD product of conception

retained for days/ weeks in the uterus with a
CLOSED cervical os
 At 5-6weeks AOG: 1-2MM embryo adjacent to
the yolk sac, absence of an embryo in a sac
with a mean sac diameter (MSD) >/= 25mm
signifies a dead fetus

Diagnosis o Transvaginal Sonography

INEVITABLE ABORTION

 Preterm Premature Rupture of Membranes

(PPROM) at a gestational age complicates 0.5
percent of pregnancies
 Rupture may be spontaneous or may follow an
invasive procedure such as amniocentesis or
fetal surgery

Risk Factors o PPROM

o Prior second-trimester delivery
o Tobacco use
 Diagnostics o Speculum Examination: gush
of vaginal fluid is seen pooling
(CONFIRMATORY DIAGNOSIS)
o pH >7
o amnionic fluid fern on a
microscope slide
o Sonography: Oligohydramnios
Signs and o Not associated with pain, fever,
Symptoms or bleeding, fluid may have
collected previously between
the amnion and chorion
Complications o Spontaneous rupture in the 1st
trimester is nearly always
followed by either uterine
contractions or infections and
termination
o Significant Materternal
complications attend previable
PPROM and include
chorioamnionitis, endometritis,
sepsis, placental abruption,
and
retained placenta
Management o W/out complications: Expectant
Management
o Antibiotics: 7 days

SEPTIC ABORTION
 Bacteria gain uterine entry and colonize dead
conception products

Causes o Parametritis
o Peritonitis
o Septicemia
Bacteria o Most bacteria causing septic
abortion is part of the vaginal
flora
o Group A strep (S.pyogenes):
severe necrotizing infection and
toxic shock syndrome
o Clostridium perfringens: TSS
o Clostridium sordelii have clinical
manifestations that begin w/in
few days after an abortion
 Managemen o Broad Spectrum Antibiotics
o Suction Curettage: retained
products
o Most women respond to
treatment within 1-2 days and
are discharge when afebrile

Anti-D Immunoglobulin
 w/ spontaneous miscarriage, 2% of Rh-D negative women will become
alloimunized if not provided passive isoimmunization
 ACOG recommends:
o Anti-Rho (D) 300µg IM for all gestational age
o Administered following surgical evacuation
o Planned or medical management injection is given within 72 hours of
pregnancy failure diagnosis
o
o RECURRENT MISCARRIAGE
 3 or more consecutive pregnancy losses <20weeks
AOG or with a fetal weight of <500g
 American Society for Reproductive medicine:
RPL as 2 or more failed pregnancies confirmed
by Sonographic or histopathologic examination

Primary RPL o Multiple losses in a woman

who has never delivered a
newborn
o Lower incidence of genetic
abnormalities than sporadic
miscarriage
Secondary RPL o Multiple pregnancy losses in a
patient with a prior live birth

Etiology o Chromosomal abnormalities

o Antiphospholipid antibody
syndrome
o Structural uterine abnormalities
o Timing occur near the same
gestational age
o Genetic Factors: early
embryonic loss
o Autoimmune/ Uterine
Abnormalities: 2nd trimester
losses
o Genital Tract Abnormalities
Parenteral o 2-4% of RPL
Chromosomal o Karyotyping of both parents is
Abnormalities essential
o Most common are reciprocal
translocations & followed by
Robertsonian translocations
o IVF is offered for parents w/
o abnormal karyotype
Genital Tract o Asherman Syndrome:
Abnormalities destruction of the
endometrium
o Characteristic multiple fillings
seen: Hysterosalphingoraphy
or Saline Infusion
Sonography
o TX: Hysteroscopic adhesiolysis
Uterine o Common and may cause
Leiomyomas miscarriage, especially if near
the placental implantation site
Congenital o Often originate from abnormal
Tract mullerian duct formation
Anomalies
Immunological o SLE : (+) antiphospholipid
Factors antibodies (a family of
antibodies that bind to
phospholipid-binding plasma
proteins)
o Antiphospholipid Antibody
Syndrome: causes varios
forms of reproductive loss and
increased risk for venous
thromboembolism