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.
 Approximately 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
 Bleeding 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)
 Clearly rhythmic cramps
 Persistent low backache with pelvic
pressure
 Dull 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
 Expulsion 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
 Expulsion 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
 The 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
 Infection of the uterus and sometimes
surrounding structures occur.
 CLINICAL FEATURE
 Fever
 Malodorous vaginal discharge
 Pelvic 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
 Hospitalization 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:
1. Parental Chromosomal Abnormalities
 Account for only 2 to 4 percent of recurrent losses
 Karyotypic evaluation of both parents is considered by many to be a critical
part of evaluation.
 Balanced reciprocal translocations – 50%
 Robertsonian translocations – 25%
 X chromosome mosaicism - 47,XXY or Klinefelter syndrome - 12 %
 These chromosomal abnormalities are repetitive for consecutive losses

19. ETIOLOGY
2. 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.
 Cervical 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
3. Antiphospholipid Syndrome
 Antiphospholipid 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:
(1) abortion ratio - the number of abortions per 1000 live births, and
(2) 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" .
 After 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
1. 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
2. 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.
 Hygroscopic 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 E2 and F2a, 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
 Outpatient 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 :
1. the antiprogestin mifepristone
2. the antimetabolite methotrexate
3. 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:
 In situ intrauterinedevice
 Severe anemia
 Coagulopathy, or anticoagulant use
 Significant medical conditions such as
active liver disease, cardiovasculardisease
 Uncontrolled seizure disorders
Complications
 Bleeding and cramping with medical
termination can be significantly worse
than menstrual cramps.
 If 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
• Mortality 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
• Rates 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

42. THANK YOU!!!