ABORTION

Christian Mark Pasicolan

Post Graduate Intern
Philippine National Police – General Hospital
 TOPIC OUTLINE
 Definition
 Incidence
 Pathophysiology
 Etiology
 Categories
 Complications
 Surgical & Medical Techniques
 ABORTION
 Is the expulsion of the product of conception or termination
of pregnancy before the period of viability
 Prior to 20 weeks AOG or at less than 500 grams
birthweight
 INCIDENCE
 15% of clinically evident pregnancies and 60% of chemically
evident pregnancies end in spontaneous abortions

 80% of spontaneous abortions occurs prior to 12 weeks age

of gestation
 INCIDENCE
Annual Number of Hospitalizations (Guttmacher Institute)
90,000
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
Spontaneous Abortion Induced Abortion
 INCIDENCE
 Chromosomal anomalies
• Cause at least ½ of spontaneous abortions

 Parity/Maternal and paternal age

 Pregnancy within 3 months of term birth

 INCIDENCE
Philippine Statistics
80,000
70,000
60,000
50,000
40,000
SAME
30,000 MORTALITY
RATE AS 2005
20,000
MORTALITY MORTALITY
RATE
10,000 RATE
SA – 0.82% SA – 0
IA –01.43% IA – 0.55%
2005 2006 2007
 PATHOPHYSIOLOGY
 Abortion can take place at any time after implantation of
the blastocyst

HEMORRHAGE IN THE OVUM DETACHES

TISSUE NECROSIS
DECIDUA BASALIS

UTERINE EXPULSION
CERVICAL DILATATION
CONTRACTIONS (COMPLETE/PARTIAL)
 PATHOPHYSIOLOGY
 Early miscarriages: often leads to complete expulsion

 From 6-14 weeks gestation: some placental tissues are

often retained

 Second trimester abortion is less common at 1-2% and the

fetus is often times normal and the presentation is labor-
like
 ETIOLOGY
 FETAL FACTORS

 MATERNAL FACTORS

 DRUGS, SUBSTANCE AND

ENVIRONMENTAL FACTORS
 FETAL FACTORS
 ABNORMAL ZYGOTE DEVELOPMENT
 ANEUPLOIDY
 FETAL FACTORS
 ABNORMAL ZYGOTE DEVELOPMENT
• Blighted Ovum/Anembryonic Pregnancy
• Morphological Disorganization
 FETAL FACTORS
 ANEUPLOIDY
• Most common genetic abnormality
• Is an abnormal chromosomal number
• Examples:
1. Monosomy X (Turner’s Syndrome)
2. Autosomal Trisomies
3. Polyploidy
 FETAL FACTORS
 ANEUPLOIDY
• Monosomy X (Turner’sSyndrome)
» Single most common aneuploidy accounting
for 20%
 FETAL FACTORS

 ANEUPLOIDY
• Autosomal Trisomies
» Accounts for half
of the aneuploid
losses
» Trisomy 16
(most
common)
 FETAL FACTORS
ANEUPLOIDY
• Polyploidy
» Triploidy (20%)
• Blighted Ovum
• PHM
 MATERNAL FACTORS
 SYSTEMIC DISEASE
• Infections
• Endocrine Diseases
• Uterine Defects
• Malnutrition and Obesity
• Immunologic Factors
 BREAST CANCER
• Abortion is not associated with breast cancer
 MATERNAL FACTORS
 SYSTEMIC DISEASE
• Infections
1. Treponema pallidum
2. Chlamydia trachomatis
3. Neisseria gonorrhea
4. Streptococcus agalactia
5. HSV
6. CMV
7. Listeria monocytogenes
 MATERNAL FACTORS
SYSTEMIC DISEASE
• Endocrine Diseases
1. Hyperthyroidism
2. Diabetes mellitus, poorly controlled
3. Luteal phase defect
 MATERNAL FACTORS
SYSTEMIC DISEASE
• Uterine Defects
– Congenital anomalies (25-59% risk)
– Acquired anomalies
 MATERNAL FACTORS
 SYSTEMIC DISEASE
• Uterine Defects
– Congenital anomalies (25-59% risk)
– Acquired anomalies
MATERNAL FACTORS
MATERNAL FACTORS
 SYSTEMIC DISEASE
• Immunologic Factors
1. ABO incompatibility
2. RH incompatibility
3. Similar maternal and paternal HLA status
(insufficient maternal immunologic
recognition of the fetus)
DRUGS, SUBSTANCE AND ENVIRONMENTAL
FACTORS
RADIATION
ANTINEOPLASTIC DRUGS
ANESTHETIC GAS
ALCOHOL
NICOTINE
DRUGS, SUBSTANCE AND ENVIRONMENTAL
FACTORS

 Caffeine especially those women who consume more than

5 cups daily threshold increases the risk for abortion
DRUGS, SUBSTANCE AND ENVIRONMENTAL
FACTORS

 Pesticide exposure
specially
organophosphates
and organochlorines
may increase the
risk for spontaneous
abortion.
 DRUGS, SUBSTANCE
AND
ENVIRONMENTAL
FACTORS

 Women who smoke

more than 14
cigarettes a day the
risk for abortion is
twofold.
DRUGS, SUBSTANCE AND ENVIRONMENTAL
FACTORS
 Frequent alcohol use during the first 8
weeks result in both spontaneous abortions
and fetal malformations.
 CATEGORIES OF ABORTION
 THREATENED ABORTION
 INEVITABLE ABORTION
 INCOMPLETE ABORTION
 COMPLETE ABORTION
 MISSED ABORTION
 HABITUAL ABORTION OR RECURRENT PREGNANCY LOSS
 SEPTIC ABORTION
 CATEGORIES OF ABORTION
 THREATENED ABORTION
 Clinical diagnosis:
1. Bloody vaginal discharge
2. Closed cervix
3. Uterine enlargement in the first half of
pregnancy

 Rule out ectopic pregnancy

 CATEGORIES OF ABORTION
 THREATENED ABORTION
 Clinical diagnosis:
1. Bloody vaginal discharge
2. Closed cervix
3. Uterine enlargement in the first half of pregnancy

 Rule out ectopic pregnancy

 CATEGORIES OF ABORTION
 THREATENED ABORTION
 Clinical diagnosis:
1. Bloody vaginal discharge
2. Closed cervix
3. Uterine enlargement in the first half of pregnancy

 Rule out ectopic pregnancy

 CATEGORIES OF ABORTION
 INEVITABLE ABORTION
 Gross rupture of the bag of waters in the
presence of cervical dilatation without
passage of products of conception or fetus

 Followed by more bleeding and expulsion

of the products of conception
 CATEGORIES OF ABORTION
 INEVITABLE ABORTION
 Gross rupture of the bag of waters in the presence of cervical
dilatation without passage of products of conception or fetus

 Followed by more bleeding and expulsion of the products of

conception
 CATEGORIES OF ABORTION
 INCOMPLETE ABORTION
 When part of the placenta or portions of
the products of conception is expelled in
the presence of an open cervix and
bleeding

 Rule out ectopic pregnancy

 CATEGORIES OF ABORTION
 INCOMPLETE ABORTION
 CATEGORIES OF ABORTION
 COMPLETE ABORTION
 Passage of embryonic and fetal parts, and
the pain and bleeding have subsided
 Cervical os is closed and the uterus is
empty
 CATEGORIES OF ABORTION
 COMPLETE ABORTION
 CATEGORIES OF ABORTION
 MISSED ABORTION
 When there is embryonal or fetal demise but no
expulsion of the products of conception instead
there is retention for 8 weeks or more
 Features:
 Closed cervix
 Minimal to absent vaginal bleeding
 Uterus incompatible to age of gestation
 CATEGORIES OF ABORTION
 MISSED ABORTION
 CATEGORIES OF ABORTION
 HABITUAL ABORTION OR RECURRENT
PREGNANCY LOSS
 Defined as three or more losses in a row
 15% of women: 1 loss
 2% of women: 2 losses
 0.34% of women: 3 or more losses

 Most miscarriages within 12 weeks of conception

 CATEGORIES OF ABORTION
 HABITUAL ABORTION OR RECURRENT
PREGNANCY LOSS
 Causes:
1. Immunologic factors
2. Antiphospholipid antibody syndrome
3. Thrombophilia
4. Incompetent cervix
 CATEGORIES OF ABORTION
 HABITUAL ABORTION OR RECURRENT
PREGNANCY LOSS
 Immunologic Factors
– Mother’s immune system mounts a cell
mediated response against the fetus
– Antibodies develop to block the response
– In the absence of antibodies, abortion always
occur
 CATEGORIES OF ABORTION
 HABITUAL ABORTION OR RECURRENT
PREGNANCY LOSS
 Antiphospholipid Antibody Syndrome
– Antiphospholipid antibodies (one or the other is
present in 5-15% of women) with RPLs:
1. Anticardiolipin antibodies
2. Lupus anticoagulant
– Cause placental infarction or impaired trophoblast
functions
 CATEGORIES OF ABORTION
 HABITUAL ABORTION OR RECURRENT
PREGNANCY LOSS
 Antiphospholipid Antibody Syndrome
– Treatment:
1. Low molecular weight heparin
2. Aspirin 80mg
3. Prednisone
 CATEGORIES OF ABORTION
 HABITUAL ABORTION OR
RECURRENT PREGNANCY LOSS
 Thrombophilia
– 2 most common inherited disorder:
1. Factor V Leiden mutation
2. Prothrombin G20210A mutation
– Patients with inherited
thrombophilia may have RPL due to
coagulopathy
 CATEGORIES OF ABORTION
 HABITUAL ABORTION OR RECURRENT
PREGNANCY LOSS
 Thrombophilia
– Treatment: Low-molecular weight heparin
 CATEGORIES OF ABORTION
 HABITUAL ABORTION OR RECURRENT PREGNANCY
LOSS
 Incompetent Cervix

• Characterized by relatively painless vaginal bleeding and

cervical dilatation occurring in the second trimester or
early third trimester

• Accompanied by ballooning of the membranes into the

vagina
 CATEGORIES OF ABORTION
 HABITUAL ABORTION OR RECURRENT
PREGNANCY LOSS
 Incompetent Cervix
 Treatment: CERCLAGE
 Surgical reinforcement by suturing around the
cervix
 CATEGORIES OF ABORTION
 HABITUAL ABORTION OR RECURRENT PREGNANCY LOSS
 Incompetent Cervix
 Treatment: CERCLAGE
 Surgical reinforcement by suturing around the cervix
 CATEGORIES OF ABORTION
 SEPTIC ABORTION
 Clinical features:
1. Vaginal bleeding
2. Fever
3. Chills
4. Foul smelling discharge
 CATEGORIES OF ABORTION
SEPTIC ABORTION
 Anaerobes (most common pathogens,
63%)
1. Peptostreptococcus

2. Bacteroides
3. Clostridium
 CATEGORIES OF ABORTION
SEPTIC ABORTION
 Other causative agents:
1. E.coli
2. Pseudomonas
3. Beta hemolytic streptococcus
 CATEGORIES OF ABORTION
SEPTIC ABORTION
 Treatment:
1. Intravenous antibiotics
2. Curettage
3. Hysterectomy
CATEGORIES OF ABORTION

SEPTIC ABORTION
Treatment:
1. Intravenous antibiotics
2. Curettage
3. Hysterectomy
CATEGORIES OF ABORTION
 SEPTIC ABORTION
COMPLICATIONS
 ANEMIA
 INFECTION
 DIC
 ACUTE RENAL FAILURE
 Uterine Bleeding Cervical Uterine BOW Other Mgt
Contractions Dilatation Size vs Fx
AOG
Threatened + +/- +/- Compatible + + FHT Bed rest
Uterine
Abortion relaxant

Inevitable +++ + + Compatible + +/- Watchful

expectancy
Abortion FHT Oxytocin
Curettage

Incomplete +/- + +/- Incompatible - - FHT Curettage

Abortion

Complete - +/- - Incompatible NA - Signs Observation

Abortion of
pregnancy

Prostaglandins
Missed Abortion - Spotting/ - Incompatible NA - FHT D&C
-

Habitual +/- + + Compatible Fast +/- Correct

progress probable
Abortion to Short I. cause
delivery cervix Cerclage
Curettage
MANAGEMENT
Medical vs Surgical
Surgical Techniques

Dilatation and Evacuation (D&E)

• Beginning at 16 weeks, fetal size and structure
dictate use of this technique.
• Wide mechanical cervical dilatation, achieved with
metal or hygroscopic dilators, precedes mechanical
destruction and evacuation of fetal parts.
• With complete removal of the fetus,
• a large-bore vacuum curette is used to remove the
placenta and remaining tissue.
Surgical Techniques

Dilatation and Extraction (D&X

• This is similar to dilatation and evacuation
• except that suction evacuation of the
intracranial contents after delivery of the fetal
body through the dilated cervix aids extraction
• minimizes uterine or cervical injury from
instruments or fetal bones.
Surgical Techniques

Hygroscopic Dilators
• Trauma from mechanical dilatation can be minimized
by using devices that slowly dilate the cervix.
• The stems are cut, peeled, shaped, dried, sterilized,
and packaged according to size-small,
• The strongly hygroscopic laminaria presumably act
by drawing water from proteoglycan complexes,
causing the complexes to dissociate, and thereby
allowing the cervix to soften and dilate.
Surgical Techniques

Menstrual Aspiration
• Aspiration of the endometrial cavity can be
completed using a flexible 5- or 6-mm Karman
cannula that is attached to a syringe.
• At this early stage of gestation, pregnancy can
be misdiagnosed, an implanted zygote can be
missed by the curette, ectopic pregnancy can be
unrecognized, or infrequently, a uterus can be
perforated.
Surgical Techniques

Laparotomy
• If significant uterine disease is present,
hysterectomy may provide ideal treatment
• A failed medical induction during the second
trimester may necessitate hysterotomy or
hysterectomy.
Surgical Abortion

• Manual Vacuum Aspiration

• used for early pregnancy failures as well as
elective termination up to 12 weeks.
• pregnancy terminations in the office with this
method be limited to 10 weeks or less.
Medical Techniques

Regimens for Medical Termination of Early Pregnancy

Mifepristone/Misoprostol
• Mifepristone, 100-600 mg orally followed by:
Misoprostol, 200-600 g orally or 800 g vaginally
in multiple doses over 6-72 hours
Medical Techniques

Regimens for Medical Termination of Early Pregnancy

• Methotrexate/Misoprostol
Methotrexate, 50 mg/m2 intramuscularly or
orally followed by Misoprostol, 800 g vaginally in
3-7 days. Repeat if needed 1 week after
methotrexate initially given.
• Misoprostol alone
800 g vaginally, repeated for up to three doses
Medical Techniques

• Second-Trimester Abortion
Noninvasive methods are high-dose intravenous
oxytocin and vaginal prostaglandin
administration
• including prostaglandin E2 suppositories and
prostaglandin E1 (misoprostol) pills.
Oxytocin
• Given as a single agent in high doses, oxytocin
will effect second- trimester abortion in 80 to
90 percent of cases.
Prostaglandin E2
• Suppositories of 20 mg prostaglandin E2
placed in the posterior vaginal fornix are a
simple and effective means of effecting
second-trimester abortion.
• This method is not more effective than high-
dose oxytocin, and it causes more frequent
side effects such as nausea, vomiting, fever,
and diarrhea
• If prostaglandin E2 is used, an antiemetic such
as metoclopramide, an antipyretic such as
acetaminophen, and an antidiarrheal such as
diphenoxylate/atropine are given either to
prevent or to treat symptoms.
Prostaglandin E1
• Misoprostol can be used easily and
inexpensively as a single agent for second-
trimester pregnancy termination.
• Misoprostol achieved abortion within 24
hours in 95 percent of women compared with
85 percent in the other group.
CONTRACEPTION FOLLOWING MISCARRIAGE
OR ABORTION
• Ovulation may resume as early as 2 weeks
after an early pregnancy is terminated,
whether spontaneously or Induced.
• Plasma progesterone levels, which had
plummeted after the abortion, increased soon
after LH surges.
• Therefore, if pregnancy is to be prevented,
effective contraception should be initiated
soon after abortion.
END
 REFERENCE
• WILLIAMS OBSTETRICS 24TH EDITION