Abortion: Maxima Vera Pinalgan, MD

Abortion
Williams Obstetrics and Gynecology 25th ed
Maxima Vera Pinalgan, MD

Nomenclature
 Abortion
 Pregnancy termination or loss before 20weeks or with fetus delivered weighing <500g
 spontaneous abortion
 Includes threatened, inevitable, complete , incomplete or missed
 Septic abortion
 Complicated by infection
 Recurrent pregnancy Loss
 2 or more failed pregnancies <20weeks AOG or fetal weight <500g
 Pregnancy off unknown location
 Pregnancy identified by bHCG without a confirmed sonographic location
Pathogenesis
 80% of spontaneous abortions occur within 12 weeks AOG

 Death usually accompanied by hemorrhage into the decidua basalis, followed by adjacent
tissue necrosis that stimulates uterine contractions and expulsion
 Incidence
 Pregnancies aged 5 to 20weeks incidence ranges from 11 to 22%
Etiology
Etiology
Fetal factors • Chromosomal anomalies
Maternal factors • Age >35yrs old
• Infections
• Medical disorders
• Anatomical factors
• Exposure to chemotherapy/radiation
• Social and behavioral factors
• Occupational and environmental
factors
Paternal factors Age

Spermatozoa anomalies
Fetal Factors
 chromosomal abnormality
 Most common in first trimester, 50%
 75% occurred by 8wks gestation
 95% are caused by maternal gametogenesis errors
 Most common abnormalities are trisomies
 Chromosome 13, 16, 18, 21, 22 are most common
 Monosomy X (45,X) single most frequent specific chromosomal abnormality

Maternal factors
 Anatomical
 Congenital genital tract anomalies
 Asherman syndrome
 Uterine leiomyoma
 Incompetent cervix
Cervical Insufficiency/incompetent cervix
 Painless cervical dilatation in 2nd trimester

 Can be followed by prolapsed and ballooning of membrane into vagina then expulsion of
immature fetus
Indications
 unequivocal history of second-trimester painless delivery, prophylactic cerclage placement is an option
and reinforces a weak cervix by an encircling suture.
 physical finding of early dilation of the internal cervical os
 presence of funneling in transvaginal sonography; membranes into a dilated internal os, but with a
closed external os
 cervical length measurement

 16 and 24weeks- every 2 weeks
 CL 25-29mm weekly interval
 CL <25mm cerclage is offered
 Contraindications
 Bleeding, contractions, ruptured membrane
Spontaneous Abortion Clinical Classification
 Threatened abortion
 Incomplete abortion
 Complete abortion
 Missed abortion
 Inevitable abortion
 Septic abortion
Threatened abortion
 Bleeding appears through a close cervical os

 Must be differentiated from that implantation bleeding
 Maybe accompanied the suprapubic discomfort, mild cramps, pelvic pressure or persistent
low backache
 Management
 Bed rest Early pregnancy + vaginal bleeding + pain =
primary goal is prompt diagnosis of ectopic
 HCT, HGB and BT requested
pregnancy, serial BhCG and TVS
Incomplete Abortion
 Bleeding follows partial or complete placental separation and dilatation of the cervical os
 Before 10weeks AOG- placenta are frequently expelled together
 Management
 Curettage- quick resolution, 95-100% successful
 Misoprostol- 800ug vaginal, 400ug oral/SL
 Expectant
Complete Abortion
 Complete expulsion of entire pregnancy and cervical os subsequently closes
 History of heavy bleeding, cramping and passage of tissue
 TVS
 Minimally thickened endometrium without GS
 Empty uterus with endometrial thickness <15mm
 Complete abortion cannot be surely diagnosed unless
 True products of conception are seen
 Sonography confidently documents 1st an intrauterine pregnancy then later an empty cavity
 serial serum BHCG level measurements aid clarification
Missed abortion
 Dead products of conception that have been retained for days or weeks in the uterus with
closed cervical os
 TVS
 At 5 to 6 weeks- 1-2mm embryo adjacent to the yolk sac can be seen
 6-6.5weeks
 fetal cardiac activity typically detected
 CRL 1-5mm
 MSD 13-18mm
Guidelines for Early pregnancy Loss
 Yolk sac diameter ≥6mm in pregnancies <10 wks AOG

 Slower heart rate <85bpm
 <5mm difference between MSD and CRL
 Subchrionic hematoma
Inevitable Abortion
 Preterm premature rupture of membrane(PPROM) at a previable gestational age
 Nearly always followed by either uterine contractions, infection and termination
 Risk factors
 Prior PPROM
 Prior 2nd trimester delivery
 Tobacco use
 2nd trimester spontaneous PPROM at previable age, 70-80% will deliver within 2-5weeks
 Evacuation
 If with bleeding, cramping and fever
 Expectant
 Antibiotics are considered and given for 7days to extend latency
Types Cervix Uterus BOW FHT Plan
Threatened closed Compatible + + Bed rest
abortion Tocolysis
Missed closed Compatible + - Cervical
abortion ripening
±curettage
Complete closed Incompatible - - Observe
abortion TVS
Measure HCG
Incomplete Open Incompatible - - Expectantly

abortion Curettage
Medical(misop
rostol)
Inevitable Open Compatible - +/- Expectant

abortion Oxytocin
Curettage
Septic abortion
 With spontaneous or induced abortion organism may invade myometrial tissues and
extend to cause parametritis, peritonitis and septicemia
 Most bacteria are part of the normal vaginal flora
 Severe necrotizing infections and toxic shock syndrome – group A streptococcus- S.
pyogenes
 Management
 Broad spectrum antibiotic
 Suction curettage
 Most patient respond 1-2days treatment, discharged once afebrile
Induced Abortion
 Therapeutic abortion
 Termination of pregnancy for medical indications
 Fetus with significant anatomical, metabolic or mental deformity
 In cases of incest or rape
 Elective/voluntary abortion
 Interruption of pregnancy before viability at the request of the woman
Postabortal contraception
 Ovulation may resume as early as 8days but average time is 3 weeks

 Effective contraception is initiated
 For those who desire another pregnancy, conception should be delayed with interval of
6months
Thank you. 

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Abortion

Williams Obstetrics and Gynecology 25th ed

Maxima Vera Pinalgan, MD

 80% of spontaneous abortions occur within 12 weeks AOG

Paternal factors Age

 Monosomy X (45,X) single most frequent specific chromosomal abnormality

 Painless cervical dilatation in 2nd trimester

 cervical length measurement

 Bleeding appears through a close cervical os

 Yolk sac diameter ≥6mm in pregnancies <10 wks AOG

Incomplete Open Incompatible - - Expectantly

Inevitable Open Compatible - +/- Expectant

 Ovulation may resume as early as 8days but average time is 3 weeks

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