Abortion

spontaneous and induced abortion

1. ABORTION ROD PRASAD GROUP 3A

2. INTRODUCTION Abortion is defined as the spontaneous or induced termination of pregnancy before fetal viability . Abortion is the process of partial or complete separation of the product of conception from the uterine wall with or without partial or complete expulsion from the uterine cavity before the age of viability . World Health Organization define abortion as pregnancy termination before 20 weeks’ gestation or with a fetus born weighing < 500 g.

3. CLASSIFICATION

4. SPONTANEOUS ABORTION Spontaneous abortion is the most common complication of pregnancy and is defined as the passing of a pregnancy prior to completion of the 20th gestational week . It implies delivery of all or any part of the products of conception, with or without a fetus weighing less than 500g. 80% of spontaneous abortions occur prior to 12 weeks' gestation . The incidence of abortion is influenced by the age of the mother and by a number of pregnancy-related factors , including: a history of a previous full-term normal pregnancy, the number of previous spontaneous abortions, a previous stillbirth, and a previous infant born with malformations or known genetic defects.

5. ETIOLOGY An abnormal karyotype is present in approximately 50% of spontaneous abortions occurring during the first trimester. The incidence decreases to 20–30% in second-trimester losses and to 5–10% in third trimester losses. A pproximately half of miscarriages are anembryonic , that is, with no identifiable embryonic elements . Blighted ovum - represents a failed development of the embryo so that only a gestational sac, with or without a yolk sac, is present. The other 50 percent are embryonic miscarriages, which commonly display a developmental abnormality of the zygote , embryo, fetus , or at times, the placenta .

6. EMBRYONIC ANEUPLOID VS EUPLOID Aneuploid Abortion - occurs at earlier gestational ages. 75 percent of aneuploid abortions occurred by 8 weeks . Euploid Abortion - Chromosomally normal fetuses abort later than those that are aneuploid . Specifically, the rate of euploid abortions peaks at approximately 13 weeks .

7. MATERNAL FACTORS INFECTIONS - Organisms such as Treponema pallidum , Chlamydia trachomatis, Neisseria gonorrhoeae , Streptococcus agalactiae , herpes simplex virus, cytomegalovirus, and Listeria monocytogenes have been implicated in spontaneous abortion. OTHER MEDICAL CONDITIONS - Endocrine disorders such as hyperthyroidism and poorly controlled diabetes mellitus ; cardiovascular disorders , such as hypertensive or renal disease ; and connective tissue disease, such as systemic lupus erythematosus . UTERINE DEFECTS - Congenital anomalies that distort or reduce the size of the uterine cavity, such as unicornuate,bicornuate , or septate uterus , carry a 25–50% risk of miscarriage. Previous scarring of the uterine cavity following dilatation and curettage ( D&C), myomectomy , or unification procedures has been implicated in spontaneous miscarriage.

8. MATERNAL FACTORS IMMUNOLOGICAL DISORDERS - Blood group incompatibility due to ABO , Rh, Kell , or other less common antigens has been associated with spontaneous abortions . MALNUTRITION - severe dietary deficiency and morbid obesity are associated with increased miscarriage risks . SOCIAL & BEHAVIORAL FACTORS - increased miscarriage risk are most commonly related to chronic and especially heavy use of legal substances . Eg , alcohol, cigarette smoking and caffeine . TOXIC FACTORS - Agents such as radiation , antineoplastic drugs, anesthetic gases, lead , ethylene oxide, and formaldehyde may be embryotoxic . TRAUMA - Direct trauma, such as injury to the uterus from a gunshot wound, or indirect trauma, such as surgical removal of an ovary containing the corpus luteum of pregnancy, may result in spontaneous abortion

9. PATHOLOGY OF PREGNANCY In spontaneous abortion, hemorrhage into the decidua basalis often occurs. Necrosis and inflammation appear in the area of implantation. The pregnancy becomes partially or entirely detached. Uterine contractions and dilatation of the cervix result in expulsion of most or all of the products of conception.

10. THREATENED ABORTION DEFINITION B leeding of intrauterine origin occurring before the 20th completed week, with or without uterine contractions, without dilatation of the cervix, and without expulsion of the products of conception . CLINICAL FEATURE Bleeding (minimal, painless) C learly rhythmic cramps P ersistent low backache with pelvic pressure D ull and midline suprapubic discomfort. EXAMINATION Size of uterus is correspond to period of amenorrhea (POA ) Closed cervical os U/S : well-formed, rounded gestational sac with fetus within it MANAGEMENT  Bed rest Folic acid supplements Avoid coitus

11. INEVITABLE ABORTION DEFINITION Bleeding of intrauterine origin before the 20th completed week, with dilatation of the cervix without expulsion of the products of conception. It can progress to complete/ incomplete abortion depending on whether or not all fetal & placental tissues have been expelled from uterus. CLINICAL FEATURE Vaginal bleeding (painful) Associated with cramping pain at lower abdomen Abortion isinevitable when cervical effacement, cervical dilatation, and/or rupture of the membranes EXAMINATION Size of uterus is correspond to/less than POA Dilated cervical os   MANAGEMENT Hospitalization Analgesics for control of pain 

12. INCOMPLETE ABORTION DEFINITION E xpulsion of some, but not all, of the products of conception CLINICAL FEATURE Vaginal bleeding (heavy, passed out POC as fleshy masses) Associated with colicky pain at lower abdomen +/- signs of shock EXAMINATION Size of uterus is smaller than POA Open cervical os U/S : reveal retained POC in uterine cavity MANAGEMENT Resuscitate if bleeding is severe, do blood group and cross match Give analgesia for pain Evacuation retained product of conception

13. COMPLETE ABORTION DEFINITION E xpulsion of all of the products of conception before the 20th completed week of gestation CLINICAL FEATURE History of pain and passage of product of conception Followed by absent of pain, minimal bleeding  EXAMINATION Size of uterus is smaller than POA Closed cervical os U/S : empty uterine cavity MANAGEMENT  Do U/S to look for empty of uterine cavity

14. MISSED ABORTION DEFINITION T he embryo or fetus dies, but the products of conception are retained in utero. CLINICAL FEATURE Decreased in pregnancy symptoms Vaginal bleeding (absent, minimal) EXAMINATION Size of uterus is smaller than POA • Closed cervical os • U/S : crumpled gestational sac and/or revealed fetal pole but no signs of activity ( no heart activity ) MANAGEMENT Wait for spontaneous expulsion Evacuation of retained product of conception

15. SEPTIC ABORTION DEFINITION I nfection of the uterus and sometimes surrounding structures occur. CLINICAL FEATURE F ever M alodorous vaginal discharge P elvic and abdominal pain EXAMINATION CBC, urinalysis, endometrial cultures, blood cultures, chest x-ray, and abdominal x-ray to rule out uterine perforation. U/S: rule out retained products of conception MANAGEMENT H ospitalization and intravenous antibiotic therapy D&C and hysterectomy if the infection does not respond to treatment.

16. TYPES OF SPONTANEOUS ABORTION

17. RECURRENT ABORTION Recurrent abortion in its broadest definition is defined as 2 to 3 or more consecutive pregnancy losses before 20 weeks of gestation, each with a fetus weighing less than 500g. Most of these are embryonic or early losses, and the remainder either are anembryonic or occur after 14 weeks . Prognosis for a successful subsequent pregnancy is correlated with the number of previous abortions. The risk of having a spontaneous abortion for the first time is about 15%, and this risk is at least doubled in women experiencing recurrent abortion.

18. ETIOLOGY There are many putative causes of recurrent abortion, however,only three are widely accepted: Parental Chromosomal Abnormalities A ccount for only 2 to 4 percent of recurrent losses K aryotypic evaluation of both parents is considered by many to be a critical part of evaluation. Balanced reciprocal translocations – 50% R obertsonian translocations – 25% X chromosome mosaicism - 47,XXY or Klinefelter syndrome - 12 % These chromosomal abnormalities are repetitive for consecutive losses

19. ETIOLOGY Anatomical Factors Several genital tract abnormalities have been implicated in recurrent miscarriage and other adverse pregnancy outcomes, but not infertility. Asherman syndrome usually result from destruction of large areas of endometrium following uterine curettage or ablative procedures. C ervical incompetence, submucous leiomyomas , abnormalities due to Diethylstilbestrol ( DES ) exposure in utero. Septate uteri account for the vast majority of patients with uterine malformations and recurrent pregnancy loss. Submucous leiomyomas are responsible for a much smaller percentage of repeated losses

20. UTERINE MALFORMATIONS

21. ETIOLOGY Antiphospholipid Syndrome A ntiphospholipid antibodies, a family of autoantibodies that bind to phospholipid-binding plasma proteins. Women with recurrent spontaneous pregnancy loss have a higher frequency of these antibodies compared with normal pregnancies. Antiphospholipid antibodies may damage platelets and vascular endothelium, resulting in thrombosis. Other suspected but not proven causes are alloimmunity , endocrinopathies , environmental toxins , and various infections.

22. DIAGNOSIS AND TREATMENT

23. INDUCED ABORTION The term induced abortion is defined as the medical or surgical termination of pregnancy before the time of fetal viability . Definitions to describe its frequency include: abortion ratio - the number of abortions per 1000 live births, and abortion rate - the number of abortions per 1000 women aged 15 to 44 years . An estimated 1 of every 4 pregnancies in the world is terminated by induced abortion, making it perhaps the most common method of reproduction limitation. Midtrimester abortion techniques still are problematic and are associated with a higher mortality rate.

24. LEGAL ASPECTS OF INDUCED ABORTION The United States Supreme Court ruled in 1973 that the restrictive abortion laws in the United States were invalid, largely because these laws invaded the individual's right to privacy, and that an abortion could not be denied to a woman in the first 3 months of pregnancy . The Court indicated that after 3 months a state may "regulate the abortion procedure in ways that are reasonably related to maternal health" . A fter the fetus reaches the stage of viability (approximately 24 weeks) the states may refuse the right to terminate the pregnancy except when necessary for the preservation of the life or health of the mother. The patient must be informed regarding the nature of the procedure and its risks, including possible infertility or even continuation of pregnancy. The rights of the spouse, parents, or guardian also must be considered and permission obtained when indicated.

25. CLASSIFICATION Therapeutic Abortion There are several diverse medical and surgical disorders that are indications for termination of pregnancy. Examples include: persistent cardiac decompensation , especially with fixed pulmonary hypertension ; advanced hypertensive vascular disease or diabetes ; and malignancy. In cases of rape or incest, most consider termination reasonable. The most common indication currently is to prevent birth of a fetus with a significant anatomical , metabolic, or mental deformity.

26. CLASSIFICATION Elective or Voluntary Abortion The interruption of pregnancy before viability at the request of the woman, but not for medical reasons, is usually termed elective or voluntary abortion . Most abortions done today are elective, and thus, it is one of the most commonly performed medical procedures. The pregnancy-associated mortality rate is 14-fold greater than the abortion-related mortality rate - 8 versus 0.6 deaths per 100,000.

27. MEDICAL VS SURGICAL

28. TECHNIQUES FOR ABORTION In the absence of serious maternal medical disorders, abortion procedures do not require hospitalization. First-trimester abortions can be performed either medically or surgically by several methods. Medical therapy has more drawbacks in that it is more time consuming ; it has an unpredictable outcome extending for days up to a few weeks; and bleeding is usually heavier and unpredictable.

29. CERVICAL PREPARATION There are several methods that will soften and slowly dilate the cervix to minimize trauma from mechanical dilatation. Hygroscopic dilators and cervical ripening medications have similar efficacy in decreasing the length of first-trimester procedures. H ygroscopic dilators are devices that draw water from cervical tissues and expand to gradually dilate the cervix. One type is derived from various species of Laminaria algae that are harvested from the ocean floor. In contrast to these devices, there are medications used for cervical preparations. The most common is misoprostol. The dose is 400 to 600 μg administered orally , sublingually, or placed into the posterior vaginal fornix. Marginal benefits ascribed to misoprostol included easier cervical dilatation and a lower composite complication rate . Another effective cervical-ripening agent is the progesterone antagonist mifepristone. Other options include formulations of prostaglandins E 2 and F 2a, which have unpleasant side effects and are usually reserved as second-line drugs

30. HYGROSCOPIC DEVICE

31. DILATION and CURETTAGE (D&C ) Transcervical approaches to surgical abortion require first dilating the cervix and then evacuating the pregnancy by mechanically scraping out the contents - sharp curettage, by suctioning out the contents - suction curettage, or both. Curettage, either sharp or suction is recommended for gestations ≤ 15 weeks. Complication rates increase after the first trimester . Perforation , cervical laceration, hemorrhage , incomplete removal of the fetus or placenta, and postoperative infections are among these.

32. DILATION and CURETTAGE (D&C)

33. DILATION 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. This is better accomplished using intraoperative sonographic imaging.

34. Dilation and Evacuation (D&E)

35. DILATION and EXTRACTION (D&X) This is similar to dilation and evacuation except that a suction cannula is used to evacuate the intracranial contents after delivery of the fetal body through the dilated cervix. This aids extraction and minimizes uterine or cervical injury from instruments or fetal bones.

36. MENSTRUAL ASPIRATION This is done within 1 to 3 weeks after a missed menstrual period and with a positive serum or urine pregnancy test result. It is performed with a flexible 5 or 6mm Karman cannula that is attached to a syringe . A distinct drawback is that because the pregnancy is so small, an implanted zygote can be missed by the curette, or an ectopic pregnancy can be unrecognized. This procedure has been referred to as menstrual extraction , menstrual induction, instant period, traumatic abortion , and mini-abortion .

37. MANUAL VACUUM EVACUATION This procedure is similar to menstrual aspiration but is used for early pregnancy failures or elective termination up to 12 weeks. For pregnancies ≤ 8 weeks, preprocedure cervical ripening is usually not necessary. After this time, some recommend that osmotic dilators be placed the day prior or misoprostol given 2 to 4 hours before the procedure. Paracervical blockade with or without sedation is used. The technique employs a hand-operated 60-Ml syringe and cannula. A vacuum is created in the syringe attached to the cannula, which is inserted transcervically into the uterus. The vacuum produces up to 60 mm Hg suction. Complications are similar to other surgical methods

38. MEDICAL ABORTION O utpatient medical abortion is an acceptable alternative to surgical pregnancy termination in appropriately selected pregnant women less than 49 days menstrual age. Currently, there are only three medications for early medical abortion that have been widely studied : the antiprogestin mifepristone the antimetabolite methotrexate the prostaglandin misoprostol Mifepristone and methotrexate increase uterine contractility by reversing progesterone induced inhibition , whereas misoprostol directly stimulates the myometrium.

39. MEDICAL ABORTION

40. CONTRAINDICATIONS & COMPLICATIONS Contraindications In many cases, contraindications to medical abortion evolved from exclusion criteria that were used in initial clinical trials . Thus, some are relative contraindications: I n situ intrauterinedevice S evere anemia C oagulopathy , or anticoagulant use Significant medical conditions such as active liver disease, cardiovasculardisease U ncontrolled seizure disorders Complications Bleeding and cramping with medical termination can be significantly worse than menstrual cramps . I f there is enough blood to soak two or more pads per hour for at least 2 hours, the woman is instructed to contact her provider to determine whether she needs to be seen.

41. CONSEQUENCES OF ELECTIVE ABORTION Maternal Mortality M ortality rate of less than 1 per 100,000 procedures Early abortions are even safer, and the relative mortality risk ofabortion approximately doubles for each 2 weeks after 8 weeks’gestation . Health and Future Pregnancies R ates of infertility or ectopic pregnancy are not increased . There may be exceptions if there are postabortal infections, especially those caused by chlamydiae . Multiple sharp curettage procedures may increase the subsequent risk of placenta previa CONTRACEPTION AFTER ABORTION Ovulation resumes as early as 2 weeks following early pregnancy termination. An IUD can be inserted after the procedure is completed

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