ABORTION

Deviana S. Riu

Definition

Abortion is the termination of pregnancy by any
means, resulting in the expulsion of an immature,
nonviable fetus.
A fetus of less than 20 weeks' gestation, counting from
the first day of the last menstrual period, or a fetus
weighing less than 500 g, is considered an abortus.
The term miscarriage, although imprecise, has been
used for all types of pregnancy losses. Often, its use is
preferred in discussions with patients, as the word
abortion has undesirable connotations for many
people


Etiology

Although spontaneous abortion has multiple
etiologies, chromosome abnormalities are
present in up to 60% of abortuses in some
studies.
Abortuses after 12 weeks are less likely to be
karyotypically abnormal


Epidemiology

The incidence of spontaneous abortion is
believed to be 15% to 20% of all pregnancies.
Some have estimated the true incidence to be
as high as 50% to 78% .

Threatened Abortion
Clinical Manifestations
Vaginal bleeding, with or without menstrual-like
cramps, in the first 20 weeks of pregnancy is the most
common manifestation of threatened abortion. There
is frequently no history of passage of tissue or rupture
of membranes.
Symptoms of pregnancy are often decreased in
intensity.
Physical exam is normal, except that the speculum
exam may reveal a small amount of bleeding with a
closed cervix and no more than mild discomfort


Differential Diagnosis
Benign and malignant lesions of the genital tract:
The pregnant cervix often develops an ectropion that is highly
vascular, friable, and bleeds easily. Apply pressure for several
minutes with a large swab to stop bleeding; if this fails, cautery
with silver nitrate sticks is usually successful.
Atypical or suspicious cervical lesions should be evaluated with
colposcopy or biopsy.
Anovulatory bleeding:
Patients with irregular menses or amenorrhea may have irregular
bleeding that can be confused with threatened abortion. The
patient should be questioned about a history of similar episodes
of irregular bleeding.
Early symptoms of pregnancy are absent, and the pregnancy test
is negative.
On pelvic exam, the uterus is of normal size and firm; the cervix is
firm and not cyanotic.

Laboratory Tests
Blood count if bleeding has been heavy.
Serum human chorionic gonadotropin (hCG) level if pregnancy is undocumented.
Positive tests may occur in nonviable gestations because hCG may persist in the
serum for several weeks after fetal death . Serum levels of -hCG also help
discriminate intrauterine from extrauterine pregnancy.
Levels of hCG >2500 IU per ml should reflect a >90% chance of intrauterine pregnancy seen by
transvaginal ultrasound. Levels >6500 IU per ml should reflect the same capability for
transabdominal scans.
In a normal pregnancy, the serum hCG level should double every 48 to 72 hours, but the
increase may be as low as 50% over same time (4).
Fetal cardiac activity is normally identifiable by ultrasonography at 6 to 7 weeks of gestation
by crownrump length measurement.
Absence of fetal heart motion in gestations of 9 weeks or longer predicted nonviable fetuses
100% of the time; 92% of patients with fetal heart motion continue pregnancy to term.
Irregular menses and poor or uncertain dates may confuse this evaluation. In such cases,
ultrasound should be used to date the pregnancy by crown rump length and correlated with
the expected rise in hCG (serum).
Other hormone measurements are generally not helpful in establishing pregnancy viability.

Treatment
Traditional treatment is bed rest and abstinence
from intercourse; however, controlled studies
supporting the efficacy of bed rest are lacking .
Symptoms are best managed on an outpatient
basis with hospital admission reserved for heavy
bleeding and/or pain relief.

Medications
There is no evidence that any hormones or
medications alter or improve the outcome of
threatened abortion in the first and early second
trimester.
Medications given during the period of
organogenesis (days 18 to 55 after conception)
may have teratogenic effects on the fetus.
A regimen of bed rest and abstinence from sexual
intercourse seems more rational for late
threatened abortions (after 12 weeks of
gestation).

Patient Education
Patients can be reassured that bleeding during early
pregnancy is very common and that the prognosis for a
normal child in those who do not abort is excellent.
However, some studies have reported that bleeding early
in pregnancy is associated with an increase in abruptio
placenta, placenta previa, prematurity and its
complications, and a slight increase in anomalies, although
perinatal mortality is not affected.
If there is no cramping, the chances are 50% to 75% that
the pregnancy will continue successfully.
The patient should be told to report increased bleeding
(greater than a normal menses), cramping, passage of
tissue, or fever.
Tissue passed should be saved for examination.

Inevitable Abortion

The symptoms of threatened abortion are
present and the internal cervical os is dilated.
The patient usually complains of menstrual-
like cramps or pelvic pressure.

Differential Diagnosis
Threatened abortion:
The internal cervical os is closed.
The cervix should not be examined with instruments, as bleeding may also
occur with a normal pregnancy.
Incomplete abortion:
The cervix is dilated and either
Some tissue has already has passed (by history), or
Tissue is present in the vagina or the endocervical canal.
Complete abortion:
Positive pregnancy test with history of
Abortion symptoms
Passage of tissue via vagina.
No evidence of tissue or gestational sac in the uterus on ultrasound.
Ectopic pregnancy is a possibility if no tissue is present.
Incompetent cervix:
Cervical dilation without pain or contractions that occur only in the second
trimester after 15 weeks of gestation.
Transvaginal ultrasound of the cervix may show Funneling of the internal os or
shortening (<2.5 cm) of the cervical length

Treatment
Medications
Surgical evacuation of the uterus is advised in
nearly all cases because
Progression to complete abortion will occur in a few
hours to days
Placental tissue is likely to be retained in gestations of
10 to 14 weeks.

Incomplete Abortion
Clinical Manifestations
Along with cramping and bleeding, the patient
may report the passage of tissue. Caution should
be taken not to mistake organized clots for tissue.
Speculum examination reveals a dilated internal
os with tissue present in the vagina or
endocervical canal.

Treatment :
Medications
Procedures
Stabilization
If the patient has signs and symptoms of heavy bleeding, at
least one large-bore intravenous catheter suitable for blood
transfusion (16 gauge or larger) is started immediately.
Ringer's lactate or normal saline with 30 U oxytocin per 1000 ml
is started at 200 ml per hour and increased if necessary to
obtain uterine tone (the uterus is less sensitive to oxytocin in
early pregnancy). Such doses may depress urine output because
of the antidiuretic hormonelike activity of oxytocin and should
be discontinued as soon as appropriate.
Products of conception should be removed from the
endocervical canal and uterus with ring forceps or suction. This
maneuver often dramatically decreases the bleeding.
Curettage ( complication : perforation)


Postcurettage
The patient is observed for several hours.
Repeat blood count is ordered if bleeding has been
excessive.
Avoid coitus, douching, or the use of tampons for 2
weeks.
Oral ferrous sulfate is prescribed if blood loss has
been significant.
Analgesics other than ibuprofen are rarely required.
Methylergonovine (0.2 mg orally every 4 hours for 6
doses) may be prescribed in normotensive patients.
Follow-up is scheduled in 2 weeks.

Complete Abortion
Clinical Manifestations
The passage of products of conception appears to
be complete.
Bleeding is minimal.
The cervix may be closed or mildly dilated.
The uterus, on bimanual examination, is well
contracted and small.

Treatment
Observation without surgical intervention is
appropriate if
The patient's vital signs are stable
The passage of tissue appears to be complete
Bleeding is minimal
Ectopic pregnancy is not suspected.
If these conditions are not present, then
uterine curettage is appropriate.

Missed Abortion
Definition
Missed abortion is defined as the retention of
products of conception (POC) after death of
the fetus.
There is no definition of the length of time of
retention of the POC.
Missed abortion may occur without the
presence of an identifiable fetus or fetal pole.

DIAGNOSIS
Laboratory Tests
Ultrasonography is essential in confirming the
diagnosis of missed abortion.
Clinical Manifestations
The pregnant uterus fails to enlarge as expected.
Amenorrhea may persist or intermittent vaginal
bleeding, spotting, or brown discharge may occur.
Rarely disseminated intravascular coagulopathy
(DIC) may rarely develop with a missed abortion
that extends for more than 4 or 5 weeks.

Treatment
Dilation and curettage
Oxytocin induction
Intra-amniotic Prostaglandin F
2
Prostaglandin E
2
vaginal suppositories
Vaginal misoprostol




Habitual Abortion
Definition
Habitual abortion is defined as three or more consecutive spontaneous abortions

Etiology
Uterine anatomic defects that are implicated causes (10) (note that if one of these anatomic causes
is found, it should be treated before proceeding with other treatments):
Double uterus
Septate uterus
Asherman syndrome
Endometrial polyps
Leiomyomas that impinge on the endometrial cavity.
Cervical anatomic defects:
Incompetent cervix (15 weeks and beyond).
Other possible causes that are less well-documented:
Hypothyroidism and hyperthyroidism
Toxoplasmosis and ureaplasma endometritis
Luteal phase defect and oligomenorrhea (19)
Maternal Fetal human leukocyte antigen (major histocompatibility complex).

Epidemiology
Habitual abortion accounts for approximately 5% of all spontaneous
abortions (20).
Cytogenetic studies of abortion specimens have demonstrated
chromosomal anomalies in 20% to 60% of abortuses
Approximately 95% of chromosomally abnormal fetuses are less
than 8 weeks developmental age, although they often are retained
in utero for much longer periods of time.
Chromosomal anomalies are uncommon among abortuses past 12
weeks of development .
Incidence of chromosomal anomalies in habitual aborters (including
losses of fetuses of all developmental ages) is estimated at 6.2%.

Septic Abortion
Septic abortion with renal failure, disseminated
intravascular coagulation, and acute lung injury/acute
respiratory distress syndrome (ALI/ARDS) were a source of
considerable maternal morbidity and mortality during the
1950s and early 1960s.
When septic abortion occurs, progression to multiple organ
failure and death is a serious risk even today.
Complication rates with septic abortion are high:
Acute renal failure in 73% of patients
DIC in 31%
Septic shock in 32%
Septic shock mortality in 19%.
Sepsis should be considered even in the absence of shock

Evaluation
Patients experiencing septic abortion should be managed in an
intensive care setting and evaluated rapidly but thoroughly in
collaboration with an intensive care physician familiar with
septic shock if available.
The following findings are associated with a poor prognosis
and the need for aggressive treatment:
High-spiking fever
Hypotension
Hypothermia
Oliguria
Advanced gestational age of pregnancy
Signs of infection beyond the uterus

History and Physical
History of nonsterile uterine instrumentation may be
difficult to elicit but should always be considered.
Physical examination is used to define the extent of
infection :
Stage 1 endometrial-myometrial involvement
Stage 2 adnexal spread
Stage 3 generalized peritonitis.

Evaluation of the patient's clinical status should include
Vital signs and urine output
Pulmonary function
Assessment of peripheral circulation
Central hemodynamics
Central nervous system function.
Laboratory Tests
If clinically indicated, obtain:
Complete blood count
Urinalysis
Serum electrolytes
Blood urea nitrogen
Creatinine
Lactate
Blood type and Rh factor
Crossmatch
Platelet count
Prothrombin time
Partial thromboplastin time
Fibrinogen
Fibrin split products
D-dimer assay
Arterial blood gases
Lipase.

Diagnosis
The diagnosis of septic abortion is made when a
temperature of at least 38C exists in the presence of
signs and symptoms of abortion in any stage, assuming
other sources of fever have been excluded.
Septic abortion generally is seen with
Prolonged, neglected ruptured membranes
Intrauterine pregnancy with an intrauterine device in place
History of attempts of the patient to terminate the
pregnancy herself

Treatment
Management should take place in an intensive care unit
setting with appropriate consultation by experienced
specialists
Consideration should be given to use of central
hemodynamic monitoring
Bolus fluid resuscitation with crystalloids (2 to 4 l in the first
hour) may be required. Subsequent fluid resuscitation is
given at a rate such that urinary output of at least 30 ml per
hour is maintained (often 150 to 250 mL per hour).
Watch for pulmonary edema secondary to fluid overload.
Whole-blood transfusions may be given to maintain the
hematocrit between 30% and 35% .

Operative intervention may be necessary.
Infected tissue may be removed by D&C or D&E.
The operative timing is critical as an increased postoperative incidence of
sepsis and hypotension has been reported when curettage is performed on
febrile patients
Alternatively, laparotomy and total abdominal hysterectomy with bilateral
salpingo-ophorectomy may be necessary
Care can be individualized for low-risk patients:
Low-risk patients are those with a temperature <38C a small uterus, localized
infection only, and no indications of shock
These patients are best managed with intensive antibiotics.
Curettage should be done only if needed, but incomplete abortions should be
evacuated as soon as effective antibiotic levels have been achieved.
Profuse or continued hemorrhage requires rapid intervention and awareness
of possible DIC

Medications
Give tetanus toxoid, 0.5 ml subcutaneously, to immunized patients with a
history of self-induced abortion.
Antibiotics for seriously ill patients include
Penicillin G sodium, 4 to 8 million U intravenously every 4 hours
Ampicillin, 1 to 2 g intravenously every 4 hours
Gentamicin sulfate, 1.5 mg/kg/dose, intravenously, slowly every 8 hours, with
careful monitoring of renal and eighth cranial nerve function. Peak (30 min
after dose is given) and trough (just before dose is given) serum gentamicin
levels should be ordered, and dosage adjusted as necessary. If possible, the
use of nephrotoxic drugs in oliguric patients should be avoided
Clindamycin, 600 mg intravenously every 6 hours.
For less seriously ill patients:
Cefoxitin, 2 g intravenously every 6 hours
If Chlamydia is suspected, add doxycycline, 100 mg intravenously every 12
hours.

Procedures
Closely monitor vital signs including blood pressure,
heart rate, SpO
2
, respiratory rate, temperature, and
urine output with an indwelling Foley catheter.
If bulging of the cul-de-sac is detected, consider
culdocentesis.
Administer intravenous fluids (normal saline) through
at least one large-bore catheter.
If lactate is >4 mmol per L (36 mg per dl). consider
inserting an internal jugular or subcutaneous central
venous catheter for fluid administration and
measurement of central mixed venous O
2
saturation
Septic Shock
Septic shock is suggested by the following,
usually preceded by chills and fever :
Oliguria
Hypotension
Tachypnea and tachycardia
Mental confusion
Warmth and dryness of the extremities (low
peripheral resistance) or cold and cyanotic
extremities (increased resistance).

Treatment
Early goal-directed resuscitation therapy with
crystalloid fluid whole blood, vasoactives, and
inotropes
Respiratory support, from airway maintenance and
administration of oxygen by nasal cannula as a
minimal treatment, to endotracheal intubation with
assisted ventilation, as necessary
A decrease in the endotoxin load with antibiotics
directed against the infecting organisms
Surgical removal of necrotic tissue where indicated.

Thank You