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Abortion Abortion
by by adugnaw,mDadugnaw,mDstudentstudent
Current prevalce of mathernal deaht related to abortion is 6% in ethiopia
Introduction
Abortion whether induced or spontaneous is a common health problem. At least 15% of all pregnancies end in spontaneous abortion. end in spontaneous abortion.
Unsafe abortion is a major public health problem and at least 20 million women undergo unsafe abortion each year.
Abortion complications are responsible for around 14% of the approximately 500,000 maternal deaths that occur each year and with millions of others suffering chronic morbidities and suffering chronic morbidities and disabilities.
In Ethiopia maternal losses from abortion and its complication account for 25-50%.
The term "fetus" will be used throughout this discussion, although the term "embryo" is the correct developmental term at ≤10 weeks of gestation
Smoking cessation should be recommended for its overall health benefitsoverall health benefits
Nonsteroidal antiinflammatory drugs — The use of nonsteroidal antiinflammatory drugs (NSAIDs), but not acetaminophen , may be associated with an increased risk of miscarriage if used around the time of conception .used around the time of conception .
The postulated mechanism is that prostaglandin inhibitors interfere with the role prostaglandins play in implantation, thus potentially leading to abnormal implantation and pregnancy failure
Prolonged ovulation to implantation interval — Early losses have also been related to a prolonged interval (ie, >10 days) between ovulation and implantation
There is no specific evidence that folate There is no specific evidence that folatesupplementation reduces the risk of miscarriage in women with hyperhomocysteinemia, although this has been suggested .
However, folate supplements are routinely recommended for all pregnant women anyway for prevention of neural tube defects
maternal weight — Prepregnancy body mass index less than 18.5 or above 25 kg/m2has been associated with an increased risk of infertility and SAB
Chromosomal abnormalities — Chromosomal Chromosomal abnormalities — Chromosomal abnormalities account for approximately 50 percent of all miscarriages.
Most of these abnormalities are aneuploidies; structural abnormalities and mosaicism are responsible for relatively few abortions.
Trisomy 16 is the most common autosomal trisomy and is always lethal.
Most chromosomal abnormalities in the embryo arise de novo. Rarely, these defects are inherited as a consequence of parental karyotypic abnormalities, consequence of parental karyotypic abnormalities, such as balanced translocations
Congenital anomalies
— Congenital anomalies are caused by genetic or chromosomal abnormalities, extrinsic factors (eg, amniotic bands), and exposure to teratogens. Potential teratogens include maternal disorders (eg, diabetes mellitus with poor glycemic control), drugs diabetes mellitus with poor glycemic control), drugs (eg, isotretinoin ), physical stresses (eg, fever), and environmental chemicals (eg, mercury)
Trauma — Invasive intrauterine procedures/trauma, such as chorionic villus sampling and amniocentesis, increase the risk of abortion
Host factors — Pregnancy loss may also be related Host factors — Pregnancy loss may also be related to the host environment.
As an example, congenital or acquired uterine abnormalities (eg, uterine septum, submucosal leiomyoma, intrauterine adhesions) can interfere with optimal implantation and growth
Acute maternal infection with any of a large number of organisms (eg, Listeria monocytogenes, Toxoplasma gondii, parvovirus B19, rubella, herpes simplex, cytomegalovirus, lymphocytic choriomeningitis virus can lead to abortion from choriomeningitis virus can lead to abortion from fetal or placental infection.
Maternal endocrinopathies (eg, thyroid dysfunction, Cushing's syndrome, polycystic ovary syndrome) can also contribute to a suboptimal host environment
PHARMACOKINETICS, METABOLISM, AND PHYSIOLOGIC EFFECTS
General population — Caffeine (methylated xanthine 1,3,7-trimethylxantine) is a highly soluble compound that readily crosses cell membranes compound that readily crosses cell membranes throughout the body.
It is rapidly absorbed in the stomach and small intestine and can be detected in human tissues 30 to 45 minutes after ingestion, with peak blood concentration reached within two hours.
Clearance values are 1 to 3 mL/kg/min in both men and women after low caffeine intake; however, clearance is diminished with higher doses, largely because of saturable metabolism of caffeine metabolites that accumulate in plasma and reduce metabolites that accumulate in plasma and reduce caffeine clearance .
The volume of distribution of caffeine is 0.7 to 1.3 L/kg and elimination half life is 4.1 to 6.4 hours.
Caffeine is metabolized in the liver by the cytochrome P450 family. Cytochrome P450 1A2 (CYP 1A2) is the predominant isoform, accounting for 95 percent of primary caffeine metabolism
The primary metabolites of caffeine, paraxanthine (1,7 dimethylxanthine), theophylline(1,3 dimethylxanthine) and theobromine (3,7 dimethylxanthine), share many of the biological activities of caffeine and also occur independently in activities of caffeine and also occur independently in natural products .
Paraxanthine is the main metabolite in humans and is present in coffee beans; theophylline is a significant xanthine in tea leaves; and theobromine, the weakest of xanthines, is present in cacao beans.
Metabolism of these metabolites leads to the formation of monomethylxanthines and methyluracils.
Caffeine is excreted by the kidneys, mainly in the form of different metabolites; only 5 to 10 percent is form of different metabolites; only 5 to 10 percent is excreted unchanged
Maternal and fetal kinetics — Caffeine and its metabolites readily cross the placenta and can be found in substantial quantities in the amniotic fluid and fetal blood .
Maternal caffeine metabolism declines significantly Maternal caffeine metabolism declines significantly during pregnancy; the half life increases three-fold in the third trimester, reaching a t 1/2 of 11.5 to 18 hours
The fetus metabolizes caffeine very slowly, mainly due to immaturity of caffeine-metabolizing hepatic microsomeenzymes and lack of CYP 1A2 activity in the placenta.
Therefore, even low maternal caffeine consumption can be expected to lead to prolonged fetal caffeine exposure, be expected to lead to prolonged fetal caffeine exposure, particularly when the mother is a genetically slow caffeine metabolizer.
Infants of smokers have lower umbilical cord blood caffeine concentrations and higher concentrations of caffeine metabolites than infants of non-smokers, reflecting faster caffeine metabolism
The increased risk was observed with even small amounts of caffeine consumption (above 10 mg/day) and did not appear to be dose-dependent.
The highest caffeine intake (above 300 mg/day) was The highest caffeine intake (above 300 mg/day) was associated with anorectal atresia
The March of Dimes recommends that women who are pregnant or trying to become pregnant consume no more than 200 mg of caffeine per day .
Health Canada suggests daily caffeine intake of no more than 300 mg/day in women who are planning to become than 300 mg/day in women who are planning to become pregnant, pregnant women, and breastfeeding mothers
Given the limitations and inconsistencies of available data, we suggest women who are attempting to conceive or who are pregnant or breastfeeding limit caffeine consumption to less than 200 to 300 mg per day
Intrauterine adhesions — Intrauterine adhesions or synechiae lead to pregnancy loss because there is insufficient endometrium to support fetoplacental growth .
The main cause of intrauterine adhesions is The main cause of intrauterine adhesions is curettage for pregnancy complication
Defective endometrial receptivity — Estrogen and progesterone prepare the endometrium for pregnancy
Immunologic factors
— Each step in the establishment of normal pregnancy has been implicated as a possible site of immune-mediated reproductive failure.
Both autoimmune and alloimmune mechanisms have been proposedbeen proposed
Antiphospholipid syndrome — Several autoimmune diseases have been linked to poor obstetric outcome, but antiphospholipid syndrome (APS) is the only immune condition in which pregnancy loss is a diagnostic criteria for the disease.
Endocrine factors — Endocrine factors may account for 15 to 60 percent of RPL.
Luteal phase defect — Progesterone is essential for successful implantation and maintenance of pregnancy; therefore, disorders related to impaired pregnancy; therefore, disorders related to impaired progesterone production or action are likely to affect pregnancy success
Diabetes mellitus — Although rare, poorly controlled diabetes mellitus is associated with early (and late) pregnancy loss
The increased risk in poorly controlled diabetic women is believed to be secondary to hyperglycemia, maternal vascular disease, and possibly immunologic factors.
Polycystic ovary syndrome
— The miscarriage rate in women with polycystic ovary syndrome (PCOS) may be as high as 20 to 40 percent, which is higher than the baseline rate in the general obstetric population (10 to 20 percent) .
The mechanism for excess pregnancy loss in these The mechanism for excess pregnancy loss in these patients is unknown, but may be related to elevated serum luteinizing hormone (LH) levels, high testosterone and androstenedione concentrations (which may adversely affect the endometrium), or insulin resistance
Genetic factors — Abnormalities of chromosome number or structure are the most common cause of sporadic early pregnancy loss, accounting for at least 50 percent of such losses in multiple studies
Environmental chemicals and stress —Although a frequent concern of patients, there is no high-quality evidence showing a relationship between RPL and occupational factors, stress, or low level exposure to most environmental chemicals . level exposure to most environmental chemicals . Chemicals that have been associated with sporadic spontaneous pregnancy loss include anesthetic gases (nitrous oxide ), arsenic, aniline dyes, benzene, ethylene oxide, formaldehyde, pesticides, lead, mercury, and cadmium
Male factor — There is a trend toward repeated miscarriages in women whose male partner has abnormal sperm (eg, fewer than 4 percent normal forms, sperm chromosome aneuploidy) .
Paternal HLA sharing is not a risk factor for RPL, Paternal HLA sharing is not a risk factor for RPL, both maternal HLA allele type may play a role . Advanced paternal age may be a risk factor for miscarriage
Infection — Some infections, such as Listeria monocytogenes, Toxoplasma gondii, cytomegalovirus, and primary genital herpes, are known to cause sporadic pregnancy loss, but no infectious agent has been proven to cause RPLinfectious agent has been proven to cause RPL
the relationship between untreated celiac disease and pregnancy loss is not well defined.
Although some controlled studies have observed a significant association between poor reproductive performance, including miscarriage, and celiac disease
Unexplained — The etiology of abortion of chromosomally and structurally normalembryos/fetuses in apparently healthy women is unclear.
Risk factor
Cocaine
Gravidity
Nonsteroidal antiinflammatory drugs
Fever — Fevers of 100°F (37.8°C) or more may Fever — Fevers of 100°F (37.8°C) or more may increase the risk of miscarriage
Caffeine
Prolonged ovulation to implantation interval
Prolonged time to pregnancy
Low-folate level
maternal weight
Celiac disease
Chromosomal abnormalities
Leiomyoma Leiomyoma
Endometrial polyps
Intrauterine adhesions
Cervical insufficiency
DefinitionDefinitionDefinitionDefinition
The termination of pregnancy before the 28th
week, when the fetus weight is less than 1000 grams.
Early abortion: <12th week of pregnancy
Late abortion: 12th-28th week of pregnancy
Spontaneous abortion
Artificial abortion
EtiologyEtiologyEtiologyEtiology
Genetic factors:
chromosomal abnormal accounts 50～60%
of the early abortionsof the early abortions
• Numeral abnormalities:
polyploidy, triploidy, monosomy
• Structural abnormalities:
break, translocation, deletion
EtiologyEtiologyEtiologyEtiology
Extrinsic factors
• Chemical: mercury, lead, cadmium,
smoking, smoking,
• Physical: video display terminals,
radioactive materials, noise,
hyperthermia
EtiologyEtiologyEtiologyEtiology
Maternal factors
• General diseases:
infection, heart diseases, hypertension, anemia
• Reproductive organic diseases:
congenital uterine malformation, pelvic tumor, cervical incompetence
• Endocrine disorders:
hypothyroidism
• Injuries
EtiologyEtiologyEtiologyEtiology
Defects in the developing placenta
Immunologic factors: paternal histo-Immunologic factors: paternal histo-compatibility antigen , maternal cellular immunity regular disorder, deficiency of maternal blocking antibody
PathologyPathologyPathologyPathology
The death of the embryo or rudimentary analog
Hemorrhage into the decidua basalisHemorrhage into the decidua basalis
Uterine contraction, dilation of the cervix
Expulsion of the products conception
DEFINITION — RPL classically refers to the occurrence of three or more consecutive losses of clinically recognized pregnancies prior to the 20th week of gestation (ectopic, molar, and biochemical pregnancies are not included).pregnancies are not included).
However, many investigators use variations of this definition
RPL can be considered a primary or secondary process: primary RPL refers to repeated miscarriages in which a pregnancy has never been carried to viability, while in secondary RPL, a live birth has occurred at some time . occurred at some time .
The prognosis for successful pregnancy is better with secondary RPL
There is no specific term for describing women who have had multiple spontaneous miscarriages interspersed with normal pregnancies (ie, nonconsecutive pregnancy losses)
eneral etiological categories of RPL include anatomic, immunological, genetic, endocrine, infectious, thrombophilic, and environmental factors
Previous pregnancy loss — In a first pregnancy, the risk of miscarriage is 11 to 13 percent .the risk of miscarriage is 11 to 13 percent .
After one miscarriage, this rate rises slightly to 14 to 21 percent. After two or three miscarriages, the rate is 24 to 29 percent and 31 to 33 percent, respectively. However, several factors influence these rates
PathologyPathologyPathologyPathology
Before the 8th week of the pregnancy, the abortus can be expelled completely
During the 8th-12th week of the During the 8th-12th week of the pregnancy, retention of the tissue is common
After the 12th week of the pregnancy, the abortus may be expelled totally
Clinical subgroups Clinical subgroups of abortionof abortionClinical subgroups Clinical subgroups of abortionof abortion
Threatened abortion
Inevitable abortion
Incomplete abortion
Complete abortion
Septic abortion
Missed abortion
Threatened abortion— Bleeding through a closed cervical os in the first half of pregnancy is quite common and is termed threatened abortion. The bleeding is often painless, but may be accompanied by minimal/mild suprapubic pain
On examination, the uterine size is appropriate for gestational age and the cervix is long and closed. Fetal cardiac activity is detectable by ultrasound or Doppler examination if the gestation is sufficiently advanced. The exact etiology of bleeding often cannot be determined and is frequently attributed to marginal of bleeding often cannot be determined and is frequently attributed to marginal separation of the placenta
Inevitable abortion — When abortion is imminent, bleeding increases, painful uterinecramps/contractions reach peak intensity, and the cervix is dilated. The gestational tissue can often be felt or visualized through the internal cervical os
Complete and incomplete abortion — When an abortion occurs before 12 weeks of gestation, it is common for the entire contents of the uterus to be expelled, thereby resulting in a complete abortion. Over one third of all cases are complete, rather than incomplete, abortions.
If a complete abortion has occurred, the uterus is small and well contracted with a If a complete abortion has occurred, the uterus is small and well contracted with a closed cervix, scant vaginal bleeding, and only mild cramping.After 12 weeks, the membranes often rupture and the fetus is passed, but significant amounts of placental tissue may be retained, leading to an incomplete abortion, also called an abortion with retained products of conception
On examination the cervical os is open, gestational tissue may be observed in the vagina/cervix, and the uterine size is smaller than expected for gestational age, but not well contracted. The amount of bleeding varies, but can be severe enough to cause varies, but can be severe enough to cause hypovolemic shock. Painful cramps/contractions are often present
Missed abortion — A missed abortion refers to in-utero death of the embryo or fetus prior to the 20th week of gestation, with retention of the pregnancy for a prolonged period of time. Women may notice that symptoms associated with early pregnancy (eg, that symptoms associated with early pregnancy (eg, nausea, breast tenderness) have abated and they don't "feel pregnant" anymore; vaginal bleeding may occur. The cervix is usually closed.
Septic abortion — Common clinical features of septic abortion include fever, chills, malaise, abdominal pain, vaginal bleeding, and discharge, which is often sanguinopurulent. Physical examination may reveal tachycardia, tachypnea, examination may reveal tachycardia, tachypnea, lower abdominal tenderness, and a boggy, tender uterus with dilated cervix
Infection is usually due to Staphylococcus aureus, Gram negative bacilli, or some Gram positive cocci. Mixed infections, anaerobic organisms, and fungi, can also be encountered. The infection may spread, leading to salpingitis, generalized peritonitis, and leading to salpingitis, generalized peritonitis, and septicemia
DIFFERENTIAL DIAGNOSIS
Physiologic (ie, believed to be related to implantation)
Ectopic pregnancy
Impending or complete miscarriage
Cervical, vaginal, or uterine pathology
Diagnosis
Ultrasonography A definite diagnosis of nonviable intrauterine pregnancy
(missed abortion) can be made based upon either of the following criteria:
Absence of embryonic cardiac activity in an embryo with crown-rump length greater than 5 mm .
Absence of a yolk sac when the mean sac diameter is 13 Absence of a yolk sac when the mean sac diameter is 13 mm .
Absence of an embryonic pole when the mean sac diameter (average of diameters measured in each of three orthogonal planes) is greater than 25 mm measured transabdominally or greater than 18 mm by the transvaginal technique
When embryonic heart motion was detected at 5 to 6 weeks of gestation in women less than 36 years of age, the risk of subsequent SAb was 4.5 percent; however, the risk of miscarriage despite previous detection of embryonic heart activity increased to 10 detection of embryonic heart activity increased to 10 percent in women aged 36 to 39 years and 29 percent in women greater than or equal to 40 years of age
In women with recurrent pregnancy loss, the risk of spontaneous pregnancy loss after observation of embryonic heart activity remains high, about 22 percent
Findings potentially predictive of pregnancy loss
1 Abnormal yolk sac - An abnormal yolk sac may be large for gestational age, irregular, free floating in the gestational sac rather than at the periphery, or calcified.
2 Slow fetal heart rate - Embryonic heart rate below 100 beats per minute (bpm) at 5 to 7 weeks of gestation is slow
3 Small sac - Small mean sac size (MSS) is diagnosed when the difference between the MSS and crown-when the difference between the MSS and crown-rump length (CRL) is less than 5 mm (MSS - CRL < 5)
4 Subchorionic hematoma – A subchorionic hematoma is a risk factor for SAb
management
THREATENED ABORTION
Bed rest
Avod sexual
SEPTIC ABORTION
Stabilizing the patient
Obtaining blood and endometrial cultures
Promptly administering parenteral broad spectrum antibiotics (eg, clindamycin 900 mg every eight hours and gentamicin 5 mg/kg daily with or without ampicillin 2 g every four hours;g every four hours;
or ampicillin and gentamicin and metronidazole 500 mg every eight hours;
or levofloxacin 500 mg daily and metronidazole;
or single agents such as ticarcillin-clavulanate 3.1 g every four hours, piperacillin-tazobactam 4.5 g every six hours,
or imipenem 500 mg every six hours).
Intravenous antibiotics are administered until the patient has improved and been afebrile for 48 hours, then are typically followed by oral antibiotics to complete a 10- to 14-day course.
The need to complete a full course with oral antibiotics after clinical improvement has been antibiotics after clinical improvement has been questioned, based upon data from a randomized trial that found no difference in women who received only a short course of intravenous therapy .
Evacuation of the uterus should begin promptly after initiating antibiotics and stabilizing the patient in cases of suspected septic abortion or retained products of conception as delay in evacuation may be fatal.
Suction curettage is less traumatic than sharp Suction curettage is less traumatic than sharp curettage.
Indications for surgery and possible hysterectomy
failure to respond to uterine evacuation and antibiotics, pelvic abscess, and clostridial necrotizing myonecrosis (gas gangrene).
A discolored, woody appearance of the uterus and adnexa, suspected clostridial sepsis, crepitation of the adnexa, suspected clostridial sepsis, crepitation of the pelvic tissue, and radiographic evidence of air within the uterine wall are indications for total hysterectomy and adnexectomy
On the other hand, mild endometritis (low grade fever, mild uterine tenderness, empty uterus on ultrasound examination) after a complete spontaneous abortion can be managed with oral broad spectrum antibioticsbroad spectrum antibiotics
COMPLETE ABORTION
Tissue that is passed should be examined to confirm that it is (or is not) the product of conception
Placental villi can be difficult to distinguish from organized clot.
One method is to rinse with water and then float the tissue in a dish of water, preferably with a good light tissue in a dish of water, preferably with a good light source underneath.
Villi have a frond-like appearance, which has been described as similar to seaweed floating in the ocean .
Ultrasound examination may be useful for confirming the absence of significant amounts of retained intrauterine tissue
In our experience, if the ultrasound shows an empty uterus and the bleeding is minimal, no further action is needed.
INCOMPLETE, INEVITABLE, AND MISSED ABORTION
— Women with an incomplete, inevitable, or missed abortion documented by ultrasound examination can be managed surgically, medically, or expectantly.
Surgical management
— The conventional treatment of first or early second — The conventional treatment of first or early second trimester failed pregnancy is dilatation and curettage (D&C) or dilatation and evacuation (D&E) to prevent potential hemorrhagic and infectious complications from the retained products of conception
Surgical management is appropriate for women who do not want to wait for spontaneous or medically induced evacuation of the uterus and those with heavy bleeding or intrauterine sepsis in whom delaying therapy could be harmful
We recommend doxycycline (100 mg orally for two doses 12 hours apart on the day of the surgical procedure) to reduce the risk of postabortal sepsis
Medical treatment
— The availability of effective medical therapies for inducing abortion has created new options for women who want to avoid surgery and in areas where surgical intervention is notpractical.
Misoprostol (a prostaglandin E1 analog) is the most Misoprostol (a prostaglandin E1 analog) is the most commonly used such agent
The expulsion rate was even higher with a dose of 600 to 800 mcg given vaginally (70 to 90 percent) This may be due to the local effect of misoprostol on the uterine cervix, the high drug concentration achieved in uterine tissue, and the increased bioavailability with vaginal administration bioavailability with vaginal administration
Buccal administration appears to be as effective as vaginal administration, but is associated with more side effects, probably related to differences in pharmacokinetics for the two routes of administration
For missed abortion – 800 mcg per vaginam OR 600 mcg sublingually (each of these is a single dose)
For incomplete abortion – 600 mcg orally (single dose)
Our preference is to use misoprostol 400 mcg per Our preference is to use misoprostol 400 mcg per vaginam every four hours for four doses to take advantage of the increased effectiveness of the vaginal route while minimizing the risk of side effects, which are dose and route dependent.
The expulsion rate is 70 to 90 percent within 24 hours; thus, some women will still require surgical evacuation.
Expectant management
— Expectant management (EM) is an alternative for women with early pregnancy failure at less than 13 weeks of gestation who have stable vital signs and no evidence of infection
The majority of expulsions occur in the first two weeks after diagnosis; however, some women may require prolonged follow-up .
Incomplete miscarriage is more likely to proceed to expulsion within two weeks than a missed abortion. expulsion within two weeks than a missed abortion. An interval of three to four weeks between diagnosis of nonviable pregnancy and expulsion is not unusual. Most women are willing to wait when appropriately counseled and prepared for what to expect
If spontaneous expulsion does not occur, medical or surgical treatment can be administered.
Following spontaneous or medically induced expulsion,
There are no universally defined criteria for an empty There are no universally defined criteria for an empty uterus.
One option is to proceed with surgical evacuation if retained tissue with a diameter of more than 15 mm is found .
Others use a homogeneous intrauterine dimension less than 11 cm2 in combined transverse and sagittal planes to define an empty uterus
POSTABORTION CARE AND COUNSELING
— Women are advised to maintain pelvic rest (ie, nothing per vagina) until two weeks after evacuation or passage of the products of conception, at which time coitus and use of tampons may be resumed.
It is customary to advise that pregnancy be deferred It is customary to advise that pregnancy be deferred for two to three months, although several studies have shown no greater risk of adverse outcome with a shorter interpregnancy interval .
Any type of contraception, including placement of intrauterine contraception , may be started immediately after the abortion has been completed
Alloimmunization prevention
— Women who are Rh(D)-negative and unsensitized should receive Rh(D)-immune globulin following surgical evacuation or upon diagnosis if medical management or EM is planned. A dose of 50 mcg is effective through the 12th week of gestation due to effective through the 12th week of gestation due to the small volume of red cells in the fetoplacental circulation (mean red cell volume at 8 and 12 weeks is 0.33 mL and 1.5 mL, respectively), although there is no harm in giving the standard 300 microgram dose, which is more readily available
Resolution of positive hCG — Serum hCG values typically return to normal within two to four weeks after a completed abortion
Grief counseling
— Grief counseling is appropriate .
It is important to acknowledge the patient's (and partner's) grief and provide empathy and support.
Risk factors for abnormal grief following a miscarriage includeinclude
A history of or current depression, anxiety, or other psychiatric disorder
Neurotic personality traits
Lack of social support
FUTURE REPRODUCTIVE ISSUES
— The overall risk of miscarriage in future pregnancy is approximately 20 percent after one miscarriage, 28 percent after two miscarriages, and 43 percent after three or more miscarriages
If the etiology of the loss is known or suspected, the couple should be informed and counseled about recurrence risks.
If reversible risk factors for spontaneous abortion are present, these can be addressed, as appropriate, in a present, these can be addressed, as appropriate, in a nonjudgmental way.
When an etiology cannot be determined, it is important to reassure the woman that there is no evidence that something she might have done (eg, sexual intercourse, heavy lifting, bumping her abdomen, stress) caused the miscarriage.
The developing processesThe developing processesof the abortionof the abortionThe developing processesThe developing processesof the abortionof the abortion
Threatened abortion
Normal pregnancy Inevitable abortion
Complete abortion Incomplete abortion
Classifications and Classifications and characteristicscharacteristicsClassifications and Classifications and characteristicscharacteristics
conceptus Vaginal abdominal Cervix os Uterine Subgroups expulsion bleeding pain dilation enlargement
Threatened no ＋ －＋ － compatible
abortion
Inevitable no ＋＋ ＋＋ ＋－ compatible or abortion smalleror abortion smaller
Incomplete part ＋＋＋ ＋ ＋－ smaller
abortion
Complete all ＋－ － － normal
abortion
Classification of abortion
Normal pregnancyBlighted
ovum
Missedabortion
Threatenedabortion
Inevitableabortion
Continuingpregnancy
Incompleteabortion
Completeabortion
Special subgroups:Special subgroups:
Missed Missed abortionSpecial subgroups:Special subgroups:
Missed Missed abortion
Expulsion of the conceptus does not occur despite a prolonged period after embryonic death.
Symptoms of pregnancy regress
Pregnancy test becomes negative
No fetal heart motion is detected
Uterine enlargement ceases
Special subgroups:
Recurrent Recurrent abortionSpecial subgroups:
Recurrent Recurrent abortion(Habitual abortion)
Three or more consecutive spontaneous losses
of pregnancyof pregnancy
First-trimester: hypothyroidism, chromosomal abnormalities, immunologic factors
Second-trimester: uterine malformations, cervical incompetence, myomas
Special subgroups:
Septic Septic abortionSpecial subgroups:
Septic Septic abortion
Any type of spontaneous abortion is
complicated by infectioncomplicated by infection
Endometritis, parametritis, peritonitis
Fever, abdominal tenderness, uterine pain
Septicemia, septic shock
DiagnosisDiagnosisDiagnosisDiagnosis
History: amenorrhea, symptoms of pregnancy, vaginal bleeding……
Examination: general and pelvic
Ultrasounograph Ultrasounograph
Pregnancy test, ß-HCG
Others:
Differential diagnosisDifferential diagnosisDifferential diagnosisDifferential diagnosis
Ectopic pregnancy
Molar pregnancy
Dysfunctional uterine bleeding (DUB) Dysfunctional uterine bleeding (DUB)
Pelvic infective diseases (PID)
Acute appendicitis
ManagementManagementManagementManagement
Threatened abortion :
rest, follow-up
Inevitable & incomplete abortion :Inevitable & incomplete abortion :Evacuation of the uterus,vacuum or suction curettage, oxytocin iv, antibiotics
Complete abortion :
no further therapy is necessary.
Management
Missed Missed abortionManagement
Missed Missed abortion
First- trimester:
suction curettage
The second-trimester:The second-trimester:
D&E(dilation and evacuation)
D&C(dilation and curettage)
Induction of labor with intravaginal prostaglandin E2 or misoprostol
Management
Recurrent Recurrent abortionManagement
Recurrent Recurrent abortion
A workup for possible causes of recurrent pregnancy loss (RPL): anatomic, hormonal,genetic,and autoimmune factors (underlying maternal factors)(underlying maternal factors)
Incompetent cervix: cerclage designed to reinforce the cervix at the level of the internal os at the end of the first trimester, the suture is removed after 37 weeks’ gestation
Management
Septic Septic abortionManagement
Septic Septic abortion
Evacuation of the uterus within a few hours after antibiotics iv
High-dose, broad-spectrum coverage antibiotics, aggressive use before, during, and after removal of necrotic tissue by curettage
hysterectomy
The key element of post abortion care are:
Emergency treatment of incomplete abortion and potentially life threatening complications
Post-abortion family planning counseling and services
Links between post-abortion emergency Links between post-abortion emergency services and the reproductive health care system
HIV and STI
Emotional support
Summary pointsSummary pointsSummary pointsSummary points
The most frequent etiology of abortion is a chromosomal abnormality of the conceptus and most of the abortions occur in the first-trimester.
The processes of the pathology decide the The processes of the pathology decide the characteristics of the subgroups.
Ultrasound is helpful in diagnosis.
Treatment
PREOPERATIVE CONSIDERATIONS
Laboratory tests — The patient's hematocrit (or hemoglobin) and Rh(D) statu
Imaging — Preoperative ultrasonography should be considered if there is a discrepancy between be considered if there is a discrepancy between uterine size and gestational age, uncertain fetal viability, or the diagnosis is in doubt (possible ectopic pregnancy or hydatidiform mole)
Antibiotic prophylaxis — Antibiotic prophylaxis is recommended for surgical abortion as postabortal endometritis occurs in 5 to 20 percent of women not given antibiotics .
Doxycycline (100 mg orally twice per day on the day Doxycycline (100 mg orally twice per day on the day of the procedure), ofloxacin(400 mg orally twice per day on the day of the procedure), or ceftriaxone (1 g intravenously 30 minutes prior to the procedure) can be used to help prevent these infections.
Cervical preparation — Dilation of the cervix to allow insertion of instruments and removal of the products of conception is usually necessary prior to surgical procedures for pregnancy termination. This can be accomplished mechanically using osmotic can be accomplished mechanically using osmotic dilators (eg, laminaria) or rigid dilators, or by using pharmacological agents (eg, misoprostol
Osmotic dilators — Osmotic dilators (natural: seaweed Laminaria japonica; synthetic: Dilapan-S, Lamicel) absorb cervical moisture, gradually enlarging the endocervical canal and softening the cervix. Osmotic dilator-induced cervical change also cervix. Osmotic dilator-induced cervical change also results from the release of endogenous prostaglandins, which further soften the cervix and facilitate the dilation process.
Use of osmotic dilators helps prevent cervical injury and may also decrease the risk of uterine perforation
In rare cases, a patient may have a hypersensitivity or anaphylactic reaction to laminaria
How to use laminaria — Proper use of laminaria tents requires that they be inserted and left in place for 12 to 18 hours to achieve optimal cervical dilation for 12 to 18 hours to achieve optimal cervical dilation (women can be sent home following insertion of the laminaria tents), although they can be removed earlier, after six hours, often with sufficient dilation
Insertion of a large number of small diameter laminaria (2 or 3 mm) is preferable to using a few large ones (6 mm) because placement is easier and there is better cervical dilation.
Some post-insertion cramping is common; a paracervicalblock or other analgesic approach may be required .
The laminaria are kept in place with two 4 by 4 gauze The laminaria are kept in place with two 4 by 4 gauze sponges tucked into the fornices and the number of laminaria inserted recorded in the woman's chart.
She should avoid intercourse and return to the office when instructed or if she develops bleeding, rupture of membranes, or fever.
Failure to remove the laminaria within 48 hours of placement can result in severe infection.
Prostaglandin E1 analogs — Misoprostol can also be used
When misoprostol was used in first trimester procedures, 97 percent of patients had cervical dilation of at least 8 mmdilation of at least 8 mm
Mifepristone — The antiprogesterone mifepristone promotes cervical dilation for uterine evacuation, and may facilitate manual and osmotic dilation
Isosorbide dinitrate — Isosorbide dinitrate has also been used for cervical ripening, with mixed results compared to prostaglandins .
The major side effect is headache
preoperative cervical dilation with osmotic dilators preoperative cervical dilation with osmotic dilators or misoprostol is safe and effective for second-trimester uterine evacuation procedures
Local anesthesia
— Local anesthesia (eg, paracervical or uterosacral block) with or without intravenous sedation is sufficient for most first trimester procedures.
Most second trimester procedures require some sedation.sedation.
Options for conscious sedation include midazolam
(2 mg IV) or fentanyl (100 mcg IV).
Sedation administered orally medications is not as effective as intravenously
Analgesia — Administration of a nonsteroidal antiinflammatory drug (eg, ibuprofen600 to 800 mg) one hour prior to the procedure appears to diminish intraoperative and postoperative discomfortdiscomfort
Paracervical block
— Paracervical block is placed by injecting a total dose of approximately 10 to 20 mL of anesthetic agent (eg, 1 percent lidocaine or 0.25 percentbupivacaine ) deep into the cervical stroma at the 12, 4, and 8 o'clock positions .
The dose of 10 mL of 1 percent lidocaine (100 mg) [maximum dose 4.5 mg/kg body weight or 20 mL for a 50 [maximum dose 4.5 mg/kg body weight or 20 mL for a 50 kg woman] achieves a peak plasma level well below the toxic range and occurs 10 to 15 minutes following the injection .
If laminaria or synthetic dilators were inserted, the paracervical block can be deferred until after their removal.
Surgical — Dilation and evacuation (D&E) procedures involve mechanically opening the uterine cervix followed by evacuation of intrauterine contents.
They can be performed in a uterus of almost any size They can be performed in a uterus of almost any size for removal of most types of intrauterine contents (eg, placenta, molar tissue, fetal tissue).
These procedures are the most common method of pregnancy termination at ≤14 weeks of gestation
Nonsurgical — Nonsurgical methods may be employed in very early (<7 to 9 weeks) and late pregnancy terminations (≥15 weeks); surgical methods are recommended for pregnancies between these gestational ages.these gestational ages.
POSTOPERATIVE CARE
Women who are Rh(D)-negative and unsensitized should receive 300 mcg Rh(D)-immune globulin following the procedure (50 mcg is sufficient for procedures in the first trimester)
Methylergonovine maleate (0.2 mg orally every four Methylergonovine maleate (0.2 mg orally every four hours for as many as five doses) is given by some providers to decrease postabortal bleeding resulting from uterine atony and to help prevent the development of hematometra
COMPLICATIONS
1 Early complications
Hemorrhage
Uterine perforation
Hematometra — Immediate postoperative pain without overt bleeding from the vagina may indicate without overt bleeding from the vagina may indicate development of hematometra.
Hematometra (also known as uterine distension syndrome or postabortal syndrome) usually presents with complaints of dull, aching lower abdominal pain, sometimes accompanied by tachycardia, diaphoresis, or nausea
Delayed complications
— Late complications of suction curettage are those occurring more than 72 hours after the procedure; they develop in approximately 1 percent of cases. Fever, infection, hemorrhage, and retained products of conception are the most common delayed of conception are the most common delayed complications
Ongoing pregnancy
— Ongoing pregnancy is more likely to be a complication of early rather than late abortion.
All women will continue to have an elevated level of hCG for a short period following pregnancy termination.
Return of the serum hCG concentration to undetectable following pregnancy termination varies widely from 7 to 60 days .
The period of time depends primarily upon the hCG concentration at the time of termination. the time of termination.
The hCG concentration peaks at 8 to 11 weeks at approximately 90,000 mIU.
This is in contrast with term pregnancy, for which the hCGconcentration is lower.
The decline in serum hCG is rapid for the first several days (half-life 9 to 31 hours) and then proceeds more slowly (half-life 55 to 64 hours)
An ongoing intrauterine pregnancy may occur after an attempted pregnancy termination if the products of conception are not closely examined by an experienced clinician at the time of the procedure (and by a pathologist) to verify successful completion(and by a pathologist) to verify successful completion
Alternatively, ongoing pregnancy may rarely result from a multiple gestation in which only one of the sacs was aborted.
WOMEN'S FEELINGS AFTER PREGNANCY TERMINATION
— The most common emotional reactions after pregnancy termination are relief, transient guilt, sadness, and a sense of loss
SUMMARY AND RECOMMENDATIONS
Physicians performing any uterine evacuation procedure should obtain a comprehensive patient history, perform a complete physical examination with special attention to the uterine size and position, and obtain confirmation of pregnancy.
The gestational age should be determined by both menstrual history and bimanual examination; ultrasound examination is history and bimanual examination; ultrasound examination is useful if there is any uncertainty and at advanced gestational ages.
Antibiotic prophylaxis is recommended because it significantly reduces the frequency of postabortal endometritis. Options include doxycycline (100 mg orally twice per day on the day of the procedure), ofloxacin (400 mg orally twice per day on the day of the procedure), or ceftriaxone (1 g intravenously 30 minutes prior to the procedure).
The patient's hematocrit (or hemoglobin) and Rh(D) status should be determined. Rh(D)-negative patients should receive anti-D immune globulin after the procedure.
Mifepristone (RU-486), an antiprogestin, can be used for the medical termination of early pregnancies (typically up to 63 days of gestation). to 63 days of gestation).
Cervical preparation may be performed with osmotic dilators or prostaglandins, depending on clinician and patient preference.
Physicians who use nonsurgical methods for pregnancy termination must be prepared themselves or in conjunction with another physician to employ surgical techniques for evaluation and treatment of complications such as hemorrhage and retained products of conception
The The The EndThe End
