ABORTION

- Abortion: spontaneous or induced termination of pregnancy before fetal viability

- Induced abortion describes surgical or medical termination of a live fetus that has not reached viability
- Abortion: pregnancy termination or loss before 20 weeks' gestation or with a fetus delivered weighing < 500 g
- Early pregnancy lost:
 empty gestational sac or a gestational sac containing an embryo or fetus without fetal heart
activity within the first 12 6/7 weeks of gestation
- Spontaneous abortion includes threatened, inevitable, incomplete, complete, and missed abortion
- Recurrent pregnancy loss meant to identify women with repetitive miscarriage
- Pregnancy of unknown location (PUL) describes a pregnancy identified by hCG testing but without a
confirmed sonographic location (definite ectopic pregnancy, probable ectopic, PUL, probable IUP, and definite IUP)

First trimester spontaneous abortion

- Pathogenesis
 80 % occur within the first 12 weeks of gestation
 demise of the embryo or fetus nearly always precedes spontaneous expulsion
 Death is accompanied by hemorrhage into the decidua basalis adjacent tissue
necrosis stimulates uterine contractions and expulsion.
 Intact gestational sac:filled with fluid.
 Anembryonic miscarriage: no identifiable embryonic elements; blighted
 Embryonic miscarriages: display developmental abnormality of the embryo, fetus, yolk sac, and, at times, the
placenta.
 Later pregnancy losses, the fetus usually does not die before expulsion, and other sources
for abortion are sought
- Incidence
 5-20 weeks
- Fetal Factors
 ½ euploid abortions: normal chromosomal complement
 Other half has a chromosomal abnormality
 Both abortion and chromosomal anomaly rates decline with advancing gestational age
 Most common abnormalities are trisomy, found in 50 to 60 percent; monosomy X, in 9 to 1 3 percent; and
triploidy, in 1 1 to 1 2 percent
 Trisomies typically result from isolated nondisjunction which rise with maternal age
 Monosomy X (45,X) is the single most frequent specific chromosomal abnormality. This is Turner syndrome
 Triploidy is often associated with hydropic or molar placental degeneration. Advanced maternal and paternal
ages do not increase the incidence of triploidy.
 Tetraploid fetuses most often abort early in gestation, and they are rarely liveborn
- Maternal factors
 chromosomally normal pregnancy losses, maternal influences play a role
 Infections
 Medical disorders
o risks are associated with poorly controlled diabetes
mellitus, obesity, thyroid disease, and systemic lupus erythematosus
 Cancer
o therapeutic doses of radiation are undeniably abortifacient
 Surgical procedure
o uncomplicated surgical procedures performed during early pregnancy are unlikely
to increase the abortion risk
o Trauma seldom causes first-trimester miscarriage. Major trauma-especially abdominal can cause
fetal loss, but is more likely as pregnancy advances
 Nutrition
o Sole deficiency of one nutrient or moderate deficiency of all does not appear to increase risks for
abortion.
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
 Social and behavioral factors
o higher miscarriage risks are most often related to chronic and especially heavy use of legal
substance
 a. alcohol: potent teratogenic effects; increased miscarriage risk is only seen
with regular or heavy use
b. Smoking
c. Illicit drugs
d. moderate consumption likely is not a major abortion risk and that any associated risk with
higher intake is unsettled
 Occupational and Environmental Factors
o Environmental toxins: bisphenol A, phthalates, polychlorinated biphenyls, and
dichlorodiphenyltrichloroethane (DDT)
o slightly increased miscarriage risks:exposed to sterilizing agents, x-rays, and antineoplastic drugs
o higher miscarriage risk was found for dental assistants exposed to more than 3 hours of nitrous
oxide daily if there was no gas-scavenging equipment
- Paternal factors
 Increasing paternal age is significantly associated with greater risk for abortion
 chromosomal abnormalities in spermatozoa likely play a role

Spontaneous abortion Clinical classification

1.Threatened Abortion
 Dx: bloody vaginal discharge or bleeding appears through a closed cervical os during the first
20 weeks
 Differentiated with implantation or bleeding during early gestation
 accompanied by suprapubic discomfort, mild cramps, pelvic pressure, or persistent low backache. Bleeding is
by far the most predictive risk factor for pregnancy loss.
 Even if miscarriage does not follow threatened abortion, later adverse pregnancy outcomes are increased
 Preterm delivery
 Recurrence
 B-hCG levels: uterine pregnancy: increase by 53-66% every 48 hrs
 Progesterone concentration: <5ng/ml suggest a dying pregnancy; .>20 ng/ml support a dx of healthy one
 TVS
 Gestational sac: seen by 4.5 weeks; B-hCG 1500-2000mIU/ml
 Pseudogestational sac: blood derived from bleeding ectopic pregnancy; exclude once yolk sac is
seen
 Yolk sac: visible by 5.5 weeks and gestational sac diameter of 10mm
 Management:
 Observation
 Acetaminophen for cramping
 If anemia and hypovolemia: pregnancy evacuation; if live fetus: transfusion and observation
2.Incomplete abortion
 bleeding follows partial or complete placental separation and dilation of the cervical os
 tissue may remain entirely within the uterus or partially extrude through the cervix
 Products lying loosely within the cervical canal can be easily extracted with ring forceps
 Management
 Curettage
 expectant management or misoprostol (Cytotec) (PGEI)
 deferred in clinically unstable women or with uterine infection
 associated with unpredictable bleeding
3. Complete abortion
 complete expulsion of the entire pregnancy may and the cervical os subsequently close
 history of heavy bleeding, cramping, and passage of tissue is typical
 Patients are encouraged to bring in passed tissue; discerned from blood clots or a decidual cast.
 If an expelled complete gestational sac is not identified, transvaginal sonography is performed
 Minimally thickened endometrium without a gestational sac; does not guarantee uterine pregnancy
 Complete abortion cannot be surely diagnosed unless:
1. true products of conception are seen grossly
2. unless sonography confidently documents first an intrauterine pregnancy and then later an empty
cavity
 serial serum hCG level measurements aid clarification. Complete abortion: levels drop quickly