Dr.

Chanda Karki
MBBS. DGO. MD. FRCOG. FICS

Prof and Head

Dept of Ob/ Gyn
 Spontaneous abortion
 Pathology
 Etiology
 Fetal Factors
 Maternal Factors
 Paternal Factors
 Categories of Spontaneous Abortion
 Induced abortion
 History of abortion
 Indications
 Elective (Voluntary) Abortion

 Presumption of ovulation after abortion

 Termination of pregnancy, either spontaneously or
intentionally

 Pregnancy termination prior to 20 weeks’ gestation or

less than 500-g birthweight

 Definition vary according to state laws for reporting

abortions, fetal deaths, and neonatal deaths
 Abortion occurring without medical or mechanical
means to empty the uterus is referred to as
spontaneous
 Another widely used term is miscarriage

 Pathology
 Hemorrhage into the decidua basinalis, followed by necrosis of
tissues adjacent to the bleeding
 If early, the ovum detaches, stimulating uterine contractions

that result in its ovulation

 Gestational sac is opened , fluid surrounding a small macerated
fetus or alternatively no fetus is visible → blighted ovum
 Pathology

 In later abortion, the retained fetus may undergo

maceration
 The skull bones collapse, the abdomen distends with blood -
stained fluid, and the internal organs degenerate
 The skin softens and peels off in utero or at the slightest tough

 When amnionic fluid is absorbed, the fetus may become

compressed and desiccated → fetal compressus

 The fetus become so dry and compressed that it resembles

parchment - a fetus papyraceous
 Etiology

 More than 80 percent of abortions occur in the first 12

weeks of pregnancy

 At least half result from chromosomal anomalies

 After the first trimester, both the abortion rate & the
incidence of chromosomal anomalies decrease
 Etiology

 The risk of spontaneous abortion increases with parity as

well as with maternal and paternal age

 The frequency of abortion increases from 12 percent in

women younger than 20 years to 26 percent in those older
than 40 years

 If a woman conceives within 3 months following a term birth

→ incidence of abortion ↑
 Etiology

 The exact mechanism responsible for abortion are not

apparent

 In the first 3 months of pregnancy

 Death of the embryo or fetus nearly always precedes spontaneous
expulsion of the ovum
 Finding of the cause of early abortion involves ascertaining
the cause of fetal death

 In subsequent months
 The fetus frequently does not die before expulsion
 Other explanations for its expulsion should be sought
 Abnormal zygotic development

 Early spontaneous abortion commonly display a

developmental abnormality of the zygote, embryo, early
fetus, or placenta

 1000 spontaneous abortions analyzed by Hertig and Sheldon

 Half demonstrated degenerated or absent embryos, that is,

blighted ova
 Aneuploid abortion

 Approximately 50 to 60 percent of embryos and early

fetuses
that are spontaneously aborted contain chromosomal abnor-
malities accounting for most of early pregnancy wastage

 Jacobs and Hassold (1980)

 95 percent of chromosomal abnormalities

 d/t maternal gametogenesis error

 5 percent → d/t paternal error

 Aneuploid abortion - Autosomal trisomy

 The most frequently identified chromosomal anomaly

associated with first-trimester abortions

 Most trisomies result from isolated nondisjunction ,

balanced structural chromosomal rearrangements are
present in one partner in 2 to 4 percent of couples with a
history of recurrent abortions

 Autosomes 13, 16, 18, 21, and 22 – most commom

 Monosomy X

 The second frequent chromosomal abnormality

 Usually results in abortion
 Much less frequently in liveborn female infant (Turner
syndrome)

 Triploidy

 Associated with hydropic placental (molar) degeneration

 Incomplete (partial) hydatidiform moles may contain
triploidy or trisomy for only chromosome 16
 Tetraploid abortuses

 Rarely are liveborn and most often are aborted early in

gestation

 Chromosomal structural abnormalities

 Identified only since the development of banding

techniques, infrequently cause abortion
 Euploid abortion

 Abort later in gestational than aneuploid

 Three fourths of aneuploid abortions occurred before8 weeks

 Euploid abortions peak at about 13 weeks

 The incidence of euploid abortions increased dramatically

after maternal age exceeded 35 years
 Infections

 Uncommon causes of abortion in human

 Listeria monocytogenes
 Clamydia trachomatis
 Mycoplasma hominis
 Ureaplasma urealyticum
 Toxoplasma gondii
 Chronic debilitating diseases

 In early pregnancy, fetuses seldom abort secondary to

chronic wasting disease such as tuberculosis or
carcinomatosis

 Celiac sprue

 Cause both male and female infertility and recurrent abortions

 Endocrine abnormalities

 Hypothyroidism
 Iodine deficiency associated with excessive miscarriages
 Thyroid autoantibodies → incidence of abortion ↑

 Diabetes mellitus
 The rates of spontaneous abortion & major congenital
malformations
 Poor glucose control → incidence of abortion↑

 Progesterone deficiency
 Luteal phase defect
 Insufficient progesterone secretion by the corpus luteum or
placenta
 Poor glucose control → incidence of abortion↑
 Nutrition
 Dietary deficiency of any one nutrients → not important
cause

 Drug use and environmental factor

 Tobacco
 ↑ Risk for euploid abortion
 More than 14 cigarettes a day → the risk twofold greater ↑
 Alcohol
 Spontaneous abortion & fetal anomalies → result from frequent
alcohol use during the first 8 weeks of pregnancy
 Drinking twice a week → abortion rates doubled ↑
 Drinking daily → abortion rates tripled ↑
 Caffeine
 At least 5 cups of coffee per day → slightly increased risk of
abortion
 Drug use and environmental factor

 Radiation
 In sufficient doses → abortifacient
 Contraceptives
 When intrauterine devices fail to prevent pregnancy → abortion ↑
 Environmental toxins
 Anesthetic gases : exact fetal risk of chronic maternal exposure is
unknown
 Arsenic, lead, formaldehyde, benzene, ethylene oxide →
abortifacient
 Video display terminal & accompanying electromagnetic fields
short waves & ultrasound do not increase the risk of abortion
 Immunological factors – autoimmune factors
 Recurrent pregnancy loss patients : 15%
 Antiphospholipid antibody : most significant
 LCA (lupus anticoagulant), ACA (anticardiolipin Ab)
 Reduce prostacyclin production
→ facilitating thromboxane dominant milieu → thrombosis
 Prostacyclin : produced by vascular endothelial cell
→ potent vasodilator & inhibit platelet aggregation
 Thromboxane A2 : produced by platelets
→ vasoconstrictor & platelet aggregator
 Strong association with
 Decidual vasculopathy , placental infarction, fetal growth restriction
Early-onset preeclampsia, recurrent abortion, fetal death
 Immunological factors – autoimmune factors

 Therapy of antiphopholipid antibody syndrome

: low dose aspirin, prednisone, heparin, intravenous Ig
→ affect both immune & coagulation system
→ counteract the adverse action of antibodies
 Immunological factors – alloimmune factors

 Allogeneity
 Genetic dissimilarities between animals of the same species
 Human fetus is allogenic transplant tolerated by mother
 Several test for diagnosis of alloimmune factors
 Maternal & paternal HLA comparison
 Maternal serum test for blocking antibodies
: blocking antibodies to paternal antigens
: ig G origin
 Maternal serum test for antipaternal antibodies
: cytotoxic antibodies to paternal leukocyte
 Inherited thrombophilia
 Many studies of aggregated thrombophilias
→ excessive recurrent abortions

 Laparotomy
 Surgery performed during early pregnancy
→ no evidence of tncreased abortion
 Peritonitis increases the likelihood of abortion

 Physical trauma
 Major abdominal trauma → abortion↑
 Uterine defects – acquired uterine defects
 Uterine leiomyoma : usually do not cause abortion
 Placental implantation over or in contact with myoma
→ placental abruption, abortion, preterm labor ↑
→ location is more important than size

 Uterine synechiae (Asherman syndrome)

 Partial or complete obliteration of the uterine cavity by
adherence of uterine wall
 Cause : destruction of large areas of endometrium by curettage
→ insufficient endometrium to support implantation &
menstruation
→ recurrent abortion, amenorrhea, hypomenorrhea
 Uterine defects – acquired uterine defects

 Diagnosis of uterine synechiae

 Hysterosalpingogram → characteristic multiple filling defects
 Hysteroscopy → most accurate & direct diagnosis

 Treatment of uterine synechiae

 Lysis of adhesions via hysteroscopy
 Prevention of adherence : IUD
 Promotion of endometrial proliferation
: Continuous high-dose estrogen (60-90 days)
 Uterine defects – developmental uterine defects

 Consequence of abnormal mullerian duct formation or

fusion
 Spontaneously
 Induced by in utero exposure to DES (diethylstilbestrol)
 Incompetent cervix
 Painless dilatation of cervix in the 2nd or early in the 3rd
trimester
→ prolapse & ballooning of membranes into vagina
→ rupture of membrane & expulsion of immature fetus
 Unless effectively treated, tends to repeat in each pregnancy
 Diagnosis in nonpregnant women
 Hysterography
 Pull-through techniques of inflated Foley catheter balloons
 Acceptance without resistance at the internal os of specifically sized
cervical dilators
 The use of transvaginal ultrasound in pregnant women
 Cervical length - shortening
 Funneling
 Incompetent cervix – Etiology

 Previous trauma to the cervix

 Dilatation & curettage
 Conization
 Cauterization

 Abnormal cervical development

 Exposure to DES in utero
 Incompetent cervix – Treatment

 The operation is performed to surgically

 Reinforcement of weak cervix by some type of purse string suture

( Cerclage )

 Prophylactic surgery : generally performed between 12 &

16weeks
 Should be delayed until after 14 weeks’ gestation
→ Early abortion due to other factors will be completed

 The more advanced the pregnancy, the more likely the risk
that surgical intervention stimulate preterm labor or
membrane rupture
 Usually do not perform after about 23 weeks
 Incompetent cervix – Preoperative evaluation

 Sonography
: Confirm living fetus & exclude major fetal anomalies

 Cervical cytology

 Cultures for gonorrhea, chlamydia, group B streptococci

 Obvious cervical infections → treatment is given
 For at least a week before & after surgery → sexual intercourse
should be restricted
 Incompetent cervix – Cerclage procedures

 Types of operations commonly used

 McDonald

 Modified Shirodkar

→ 85~90% success rate

 Incompetent cervix – Transabdominal cerclage

 Requries laparotomy for

 Placement of cerclage at uterine isthmus level
 Cerclage removal, delivery, or both

 Indications
 Anatomical defects of cervix
 Failed transvaginal cerclage
 Incompetent cervix – Complications

 High incidence when performed much after 20 weeks

 Membranes ruptures
 Chorioamnionitis
 Intrauterine infection

 Urgent removal of suture

 Operation fails
 Signs of imminent abortion or delivery
 Little is known in the genesis of spontaneous abortion

 Chromosomal translocations in sperm can lead to

abortion
 Threatened abortion

 Inevitable abortion

 Complete or incomplete abortion

 Missed abortion

 Recurrent abortion
Categories of spontaneous abortion

 Definition
 Any bloody vaginal discharge or bleeding during 1 st half of
pregnancy
 Bleeding is frequently slight, but may persist for days or weeks

 Frequency
 Extremely common (one out of four or five pregnant women)

 Prognosis
 Approximately ½ will abort
 Risk of preterm delivery, low birthweight, perinatal death ↑
 Risk of malformed infant does not appear to be increased
Categories of spontaneous abortion

 Symptoms
 Usually bleeding begins first
 Cramping abdominal pain follows a few hours to several days
later
 Presence of bleeding & pain
→ Poor prognosis for pregnancy continuation

 Treatment
 Bed rest & acetaminophen-based analgesia
 Progesterone (IM) or synthetic progestational agent (PO or IM)
 Lack of evidence of effectiveness
 Often results in no more than a missed abortion
 D-negative women with threatened abortion
 Probably should receive anti-D immunoglobulin
Categories of spontaneous abortion

 Treatment : slight bleeding persists for weeks

 Vaginal sonography
 Serial serum quantitative hCG
 Serum progesterone
→ can help ascertain if the fetus is alive & its location

 Vaginal sonography
 Gestational sac(+) & hCG < 1000mIU/ml
→ gestation is not likely to survive
→ If any doubt(+), check the serum hCG level at intervals of 48hrs
→ if not increase more than 65%, almost always hopeless
 Serum progesterone value < 5 ng/ml
→ dead conceptus
Categories of spontaneous abortion

 Treatment : after death of conceptus

 Uterus should be emptied

→ examination of all passed tissue whether the abortion is complete

 Ectopic pregnancy should be considered if gestational sac or

fetus are not identified
Categories of spontaneous abortion

 Gross rupture of membrane,evidenced by leaking

amnionic fluid, in the presence of cervical dilatation,
but no tissue passed during 1st half of pregnancy

 Placenta (in whole or in part) is retained in the uterus

→ Uterine contractions begin promptly or infection
develops

 The gush of fluid is accompanied by bleeding, pain, or fever,

abortion should be considered inevitable
Categories of spontaneous abortion

 Complete abortion
 Following complete detachment & expulsion of the conceptus
 The internal cervical os closes

 Incomplete abortion
 Expulsion of some but not all of the products of conception
during 1st half of pregnancy
 The internal cervical os remains open & allows passage of
blood
 The fetus & placenta may remain entirely in utero or may
partially extrude through the dilated os
→ Remove retained tissue without delay
Categories of spontaneous abortion

 Retention of dead products of conception in utero for

several weeks

 Many women have no symptoms except persistent amenorrhea

 Uterus remain stationary in size, but mammary changes usually

regress → uterus become smaller

 Most terminates spontaneously

 Serious coagulation defect occasionally develop after

prolonged retention of fetus
Categories of spontaneous abortion

 Definition : Three or more consecutive spontaneous

abortions

 Clinical investigation of recurrent miscarriage

 Parental cytogenetic analysis
 Lupus anticoagulant & anticardiolipin antibodies assays

 Postconceptional evaluation
 Serial monitoring of ß–hCG from missed mens period
 ß–hCG>1500mIU/ml → USG
 Maternal serum α-fetoprotein assessment (GA16-18wks)
 Amniocentesis → fetal karyotype

 Prognosis
 Depends on potential underlying etiology & number of prior
losses
INDUCED ABORTION
 The medical or surgical termination of pregnancy before
the time of fetal viability

 Therapeutic abortion

 Termination of pregnancy before of fetal viability for the

purpose
of saving the life of the mother
 Indication

 Continuation of pregnancy may threaten the life of women

or seriously impair her health
 Persistent heart disease after cardiac decompensation
 Advanced hypertensive vascular disease
 Invasive carcinoma of the cervix

 Pregnancy resulted from rape or incest

 Continuation of pregnancy is likely to result in the birth of

child with severe physical deformities or mental retardation
 Elective (voluntary) abortion

 Interruption of pregnancy before viability at the request of

the women, but not for reasons of impaired maternal health
or
fetal disease

 Counseling before elective abortion

 Continued pregnancy with its risks & parental responsibilities

 Continued pregnancy with its risks & its responsibilities of
arranged adoption
 The choice of abortion with its risks
 Dilatation and curettage

 Performed first by dilating the cervix & evacuating the

product of conception
 Mechanically scraping out of the contents (sharp curettage)
 Vacuum aspiration (suction curettage)
 Both

 Before 14 weeks, D&C or vacuum aspiration should be

performed

 After 16 weeks, dilatation & evacuation (D&E) is performed

 Wide cervical dilatation
 Mechanical destruction & evacuation of fetal parts
 Dilatation and curettage
 Hygroscopic dilators
: swell slowly & dilate cervix → cervical trauma can be
minimized

 Laminaria tents
: stem of brown seaweed ( Laminaria digitata or japonica)
→ drawing water from proteoglycan complexes of cervix
→ dissociation allow the cervix to soften & dilate
 Insertion technique : tip rests just at the level of internal os
 Usually after 4-6hours, laminaria dilate the cervix sufficiently to
allow easier mechanical dilation & curettage
 May cause cramping pain
→ easily managed with 60 mg codeine every 3-4 hours
 Technique for dilatation & curettage

 Remove laminaria → Uterus is sounded carefully to

 Identify the status of the internal os

 Confirm uterus size & position

 Further dilation of cervix with Hegar dilator

 Complications : uterine perforation
 2 important determinants
 Skill of the physician
 Position of the uterus (retroverted)

 Small defects by uterine sound or narrow dilator

→ often heal without complication
 Suction & sharp curettage

→ Considerable intra-abdominal damage risk↑

→ Laparotomy to examine abdominal content (safest action)

 Other complications – cervical incompetence or uterine

synechiae
 Menstrual aspiration

 Aspiration of endometrial cavity using a flexible cannula and

syringe within 1-3 weeks after failure to menstruate

 Several points at early stage of gestation

 Woman not being pregnant

 Implanted zygote may be missed by the curette
 Failure to recognize an ectopic pregnancy
 Infrequently, a uterus can be perforated
 Laparotomy

 Abdominal hysterotomy or hysterectomy

 Indications

 Significant uterine disease

 Failure of medical induction during the 2 nd trimester

 Early abortion

 Outpatient medical abortion is an acceptable alternative to

surgical abortion in women with pregnancies of less than 49
days’ gestation
(ACOG, 2001b)

 Three medications for early medical abortion

 Antiprogestin mifeprostone

 Antimetabolite methotrexate

 Prostaglandin misoprostol
 Oxytocin

 Successful induction of 2nd trimester abortion is possible

with high doses of oxytocin administered in small volumes of
IV fluids

 Satisfactory alternatives to PG E2 for midtrimester abortion

 Laminaria tents inserted the night before

 Chance of successful induction is greatly enhanced
 Prostaglandins

 Used extensively to terminate pregnancies, especially in the

2nd T
 PG E1, E2, F2α

 Technique
: Can act effectively on the cervix & uterus (86~95%
effectiveness)
 Vaginal prostaglandin E2 suppository & prostaglandin E1
(misoprostol)
 As a gel through a catheter into the cervical canal & lowermost
uterus
 Injection into the amnionic sac by amniocentesis
 Parenteral injection
 Oral ingestion
 Intra-amnionic hyperosmotic solutions
 20-25% saline or 30-40% urea injected into amnionic sac
→ stimulate uterine contraction & cervical dilatation
 Action mechanism : prostaglandin mediated ?
 Complications of hypertonic saline
 Death
 Hyperosmolar crisis (early into maternal circulation)
 Cardiac failure
 Septic shock
 Peritonitis
 Hemorrhage
 DIC
 Water intoxication
 Hyperosmotic urea : less likely to be toxic
 Antiprogesterone RU 486
 Oral agent used alone in combination with oral PG to effect
abortions in early gestation
 High receptor affinity for progesterone binding site
→ Block progesterone action
 Abortion rate
 Single 600mg dose prior 6 weeks → 85%
 Addition of oral, vaginal or injected PG → over 95%
 If given within 72 hours
 Also highly effective as emergency postcoital contraception
 Progressively less effective after 72 hours
 Side effects
 Nausea, vomiting, & gastrointestinal cramping
 Major risk → hemorrhage is a risk if abortion is incomplete
 Epostane

 3ß-hydroxysteroid dehydrogenase inhibitor

→ blocks the synthesis of endogenous progesterone

 Frequent side effect – nausea

 Hemorrhage is a risk if abortion is incomplete

 Maternal mortality

 Legally induced abortion

 Relative safe during the first 2 months of pregnancy

( 0.6/100,000 procedures)

 Doubled for each 2 weeks of delay after 8 weeks’ gestation

 Impact on future pregnancies

 Fertility : not altered by an elective abortion

 Vacuum aspiration for a first pregnancy

: Do not increase the incidence of
 2nd trimester spontaneous abortions

 Preterm delivery

 Ectopic pregnancy

 LBW infants
 Impact on future pregnancies

 Dilatations & curettage for a first pregnancy

: Increased risks for
 Ectopic pregnancy
 2nd trimester spontaneous abortions
 LBW infants

 Multiple elective abortion :

 Not increased the incidence of preterm delivery & LBW infants
 Placenta previa
→ increased following multiple sharp curettage abortion
procedures
 Septic abortion

 Most often associated with criminal abortion

 Metritis is usual outcome, but parametritis, peritonitis,

endocarditis, and septicemia may all occur

 Management
 Prompt evacuation of products of conception
 Broad-spectrum IV antimicrobials
 Ovulation may resume as early 2 weeks after an
abortion

 Therefore, if pregnancy is to be prevented,

effective contraception should be initiated soon after
abortion