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Chapter 9 Abortion
Spontaneous abortion
Etiology
F9-1
Spontaneous abortion
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
Infections
Listeria monocytogenes Clamydia trachomatis Mycoplasma hominis Ureaplasma urealyticum Toxoplasma gondii
In early pregnancy, fetuses seldom abort secondary to chronic wasting disease such as tuberculosis or carcinomatosis Celiac sprue
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
Tobacco
Risk for euploid abortion More than 14 cigarettes a day the risk twofold greater
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 At least 5 cups of coffee per day slightly increased risk of abortion
Alcohol
Caffeine
Radiation
In sufficient doses abortifacient When intrauterine devices fail to prevent pregnancy abortion 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
Contraceptives
Environmental toxins
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
Therapy of antiphopholipid antibody syndrome : low dose aspirin, prednisone, heparin, intravenous Ig affect both immune & coagulation system counteract the adverse action of antibodies
Allogeneity
Genetic dissimilarities between animals of the same species Human fetus is allogenic transplant tolerated by mother 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
Laparotomy
Surgery performed during early pregnancy no evidence of tncreased abortion Peritonitis increases the likelihood of abortion
Physical trauma
Placental implantation over or in contact with myoma placental abruption, abortion, preterm labor location is more important than size
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
Hysterosalpingogram characteristic multiple filling defects Hysteroscopy most accurate & direct diagnosis
Lysis of adhesions via hysteroscopy Prevention of adherence : IUD Promotion of endometrial proliferation : Continuous high-dose estrogen (60-90 days)
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 Hysterography Pull-through techniques of inflated Foley catheter balloons Acceptance without resistance at the internal os of specifically sized cervical dilators Cervical length - shortening Funneling
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
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
Indications
Threatened abortion
Inevitable abortion
Recurrent abortion
Threatened abortion
Definition
Frequency
Prognosis
Approximately will abort Risk of preterm delivery, low birthweight, perinatal death Risk of malformed infant does not appear to be increased
Threatened 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)
Threatened abortion
Vaginal sonography
Threatened abortion
Ectopic pregnancy should be considered if gestational sac or fetus are not identified
Inevitable 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
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
Missed abortion
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
Recurrent abortion
Parental cytogenetic analysis Lupus anticoagulant & anticardiolipin antibodies assays Serial monitoring of hCG from missed mens period
Postconceptional evaluation
hCG>1500mIU/ml USG
Maternal serum -fetoprotein assessment (GA16-18wks) Amniocentesis fetal karyotype Depends on potential underlying etiology & number of prior losses
Prognosis
INDUCED ABORTION
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
Induced abortion
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
Induced abortion
Interruption of pregnancy before viability at the request of the women, but not for reasons of impaired maternal health or fetal disease
Continued pregnancy with its risks & parental responsibilities Continued pregnancy with its risks & its responsibilities of arranged adoption The choice of abortion with its risks
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
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
Identify the status of the internal os Confirm uterus size & position
2 important determinants
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
Significant uterine disease Failure of medical induction during the 2nd 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
Prostaglandins
PG E1, E2, F2
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
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
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% Also highly effective as emergency postcoital contraception Progressively less effective after 72 hours Nausea, vomiting, & gastrointestinal cramping Major risk hemorrhage is a risk if abortion is incomplete
Side effects
Epostane
3-hydroxysteroid dehydrogenase inhibitor blocks the synthesis of endogenous progesterone Frequent side effect nausea Hemorrhage is a risk if abortion is incomplete
Maternal mortality
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
Vacuum aspiration for a first pregnancy : Do not increase the incidence of 2nd trimester spontaneous abortions Preterm delivery Ectopic pregnancy LBW infants
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