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Williams Obstetrics: OBGY R1 Lee Eun Suk
Williams Obstetrics: OBGY R1 Lee Eun Suk
Chapter 9 Abortion
Abortion
Spontaneous abortion
o
Pathology
Etiology
Fetal Factors
Maternal Factors
Paternal Factors
Induced abortion
o
History of abortion
Indications
Abortion
Definition vary according to state laws for reporting abortions, fetal deaths, and neonatal
deaths
Spontaneous abortion
Abortion occurring without medical or mechanical means to empty the uterus is referred to
as spontaneous
Pathology
o
Hemorrhage into the decidua basinalis, followed by necrosis of tissues adjacent to the bleeding
Spontaneous abortion
Pathology
In later abortion, the retained fetus may undergo maceration
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
Spontaneous abortion
Etiology
o
After the first trimester, both the abortion rate & the incidence of chromosomal anomalies decrease
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
incidence of abortion
F9-2
Spontaneous abortion
Etiology
o
Death of the embryo or fetus nearly always precedes spontaneous expulsion of the ovum
In subsequent months
Early spontaneous abortion commonly display a developmental abnormality of the zygote, embryo, early fetus, or placenta
blighted ova
F9-3
Aneuploid abortion
o
that are spontaneously aborted contain chromosomal abnor-malities accounting for most of early pregnancy wastage
o
T9-1
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
Monosomy X
o
Triploidy
o
Incomplete (partial) hydatidiform moles may contain triploidy or trisomy for only chromosome 16
Tetraploid abortuses
o
Rarely are liveborn and most often are aborted early in gestation
Identified only since the development of banding techniques, infrequently cause abortion
Euploid abortion
o
The incidence of euploid abortions increased dramatically after maternal age exceeded 35 years
Infections
o
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
o
Hypothyroidism
Diabetes mellitus
Progesterone deficiency
Nutrition
o
Tobacco
Alcohol
Spontaneous abortion & fetal anomalies result from frequent alcohol use during the first 8 weeks of pregnancy
Caffeine
Radiation
Contraceptives
Environmental toxins
Allogeneity
Inherited thrombophilia
o
Laparotomy
o
Physical trauma
o
Spontaneously
Incompetent cervix
Hysterography
Funneling
Conization
Cauterization
( Cerclage )
The more advanced the pregnancy, the more likely the risk that surgical intervention stimulate preterm labor or
membrane rupture
Sonography
Cervical cytology
For at least a week before & after surgery sexual intercourse should be restricted
McDonald
Modified Shirodkar
Indications
Membranes ruptures
Chorioamnionitis
Intrauterine infection
Operation fails
Threatened abortion
Inevitable abortion
Missed abortion
Recurrent abortion
Threatened abortion
o
Definition
Frequency
Prognosis
Symptoms
Treatment
Threatened abortion
Categories of spontaneous abortion
Threatened abortion
o
Vaginal sonography
Serum progesterone
Vaginal sonography
dead conceptus
Threatened abortion
o
Inevitable abortion
o
The gush of fluid is accompanied by bleeding, pain, or fever, abortion should be considered inevitable
Complete abortion
Incomplete abortion
Expulsion of some but not all of the products of conception during 1 st half of pregnancy
The fetus & placenta may remain entirely in utero or may partially extrude through the dilated os
Missed abortion
Postconceptional evaluation
hCG>1500mIU/ml USG
Prognosis
Recurrent abortion
INDUCED ABORTION
The medical or surgical termination of pregnancy before the time of fetal viability
Therapeutic abortion
Induced abortion
Induced abortion
Indication
o
Continuation of pregnancy may threaten the life of women or seriously impair her health
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 & its responsibilities of arranged adoption
Performed first by dilating the cervix & evacuating the product of conception
Both
Hygroscopic dilators
Laminaria tents
Usually after 4-6hours, laminaria dilate the cervix sufficiently to allow easier mechanical dilation & curettage
2 important determinants
Menstrual aspiration
o
Aspiration of endometrial cavity using a flexible cannula and syringe within 1-3 weeks after failure to menstruate
Laparotomy
o
Indications
Early abortion
o
Outpatient medical abortion is an acceptable alternative to surgical abortion in women with pregnancies of less than 49
days gestation
(ACOG, 2001b)
Antiprogestin mifeprostone
Antimetabolite methotrexate
Prostaglandin misoprostol
Oxytocin
o
Successful induction of 2nd trimester abortion is possible with high doses of oxytocin administered in small volumes of IV
fluids
Prostaglandins
o
PG E1, E2, F2
Technique
As a gel through a catheter into the cervical canal & lowermost uterus
Parenteral injection
Oral ingestion
Death
Cardiac failure
Septic shock
Peritonitis
Hemorrhage
DIC
Water intoxication
Antiprogesterone RU 486
o
Oral agent used alone in combination with oral PG to effect abortions in early gestation
Abortion rate
Side effects
Epostane
o
Maternal mortality
o
( 0.6/100,000 procedures)
Preterm delivery
Ectopic pregnancy
LBW infants
Ectopic pregnancy
LBW infants
Placenta previa
Septic abortion
Metritis is usual outcome, but parametritis, peritonitis, endocarditis, and septicemia may all occur
Management
Broad-spectrum IV antimicrobials