ABORTION

Najera | Naval | Odal

Opamin | Orendain

Southern Philippines Medical Center

 OUTLINE
● Nomenclature
● First-trimester
Spontaneous Abortion
● Clinical Classification of
Spontaneous Abortion
● Recurrent Miscarriage
● Midtrimester Abortion
● Cervical Insufficiency
● Induced Abortion
● First-trimester Abortion
Methods
● Second-trimester
Abortion Methods

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 What is Abortion?
Spontaneous or induced termination of pregnancy before
fetal viability
Spontaneous or induced termination of pregnancy before
fetal viability
NCHS, CDC, WHO:
pregnancy termination or loss before 20 weeks’ gestation,
or with a fetus delivered weighing <500g
Spontaneous or induced termination of pregnancy before
fetal viability
NCHS, CDC, WHO:
pregnancy termination or loss before 20 weeks’ gestation,
or with a fetus delivered weighing <500g

abortion = miscarriage ≠ induced abortion

spontaneous loss surgical or medical termination
ABORTUS
expulsion at 20 weeks or less, weighing <500g

EARLY PREGNANCY LOSS

nonviable, intrauterine pregnancy with either:
1. empty gestational sac
2. a gestational sac containing an embryo or fetus without
fetal heart activity within the first 12 weeks of gestation

RECURRENT PREGNANCY LOSS

repetitive miscarriages

PREGNANCY OF UNKNOWN LOCATION

a pregnancy defined by hCG testing but without a
confirmed sonographic location
Technological Developments
● serum hCG concentrations

● transvaginal sonography
(1) early conceptions in which no products are seen
sonographically;
(2) pregnancies that display a gestational sac without an
embryo;
(3) dead embryo is seen
FIRST TRIMESTER SPONTANEOUS ABORTION
Pathogenesis
Incidence
Fetal Factors
Maternal Factors
Paternal Factors
PATHOGENESIS
more than 80% occur within the first 12 weeks AOG

fetal death is usually accompanied by hemorrhage into the

decidua basalis, followed by adjacent tissue necrosis that
stimulates uterine contractions and expulsion
fetal death is usually accompanied by hemorrhage into the
decidua basalis, followed by adjacent tissue necrosis that
stimulates uterine contractions and expulsion

DECIDUA
INCIDENCE
About 25 million of Filipino citizens are women of
reproductive age

In 2008, there were 1.9 million unintended

pregnancies in the Philippines, resulting in two
main outcomes—unplanned births and unsafe
abortions.

Abortion Rate
● 2000 - 27 abortions per 1,000 women
● 2008 - 560,000 abortions
● 2012 - 610,000 abortions
FETAL FACTORS
of all miscarriages, approx. half are euploid abortions

both abortion and anomaly rates decline with advancing

gestational age

75% - 8 weeks AOG

95% - maternal gametogenesis errors
5% - paternal errors

TRISOMY (50%-60%)
isolated nondisjunction (13, 16, 18, 21, 22)

MONOSOMY (9%-13%)
monosomy X (45,X) Turner syndrome

TRIPLOIDY (11%-12%)
hydropic or molar placental degeneration
MATERNAL FACTORS
INFECTIONS - via bloodborne transmission, GUT infection / colonization

MEDICAL DISORDERS - DM, obesity, thyroid disease, SLE

CANCERS - chemotherapy or radiotherapy may be abortificants

SURGICAL PROCEDURES - major trauma

NUTRITION - dietary quality may play a role

SOCIAL AND BEHAVIORAL FACTORS - alcohol, cigarette smoking, illicit drugs,

caffeine consumption

OCCUPATIONAL AND ENVIRONMENTAL FACTORS - environmental toxins

PATERNAL FACTORS
increasing paternal age due to spermatozoa chromosomal abnormalities
SPONTANEOUS ABORTION
It can present at any of its evolutionary stages

● Threatened abortion
● Inevitable abortion
● Incomplete abortion
● Complete abortion
● Missed Abortion
Threatened Abortion
Unprovoked vaginal bleeding, with or without lower abdominal pain, occurs
in a pregnancy of <20 weeks’ gestation.

With these cases, pregnancy may continue.

-WHO
Threatened Abortion
HISTORY PHYSICAL
EXAMINATION
● Vaginal spotting ● Bloody vaginal discharge or
● Bloody vaginal discharge bleeding appears through a
● Suprapubic discomfort closed cervical os
● Mild cramps
● Pelvic pressure
● Persistent low backache
Threatened Abortion

IMAGING

● Transvaginal sonography:

-locate the pregnancy

-determine viability

-gestational sac

Intradecidual sign
Threatened Abortion
IMAGING LAB RESULTS

● Transvaginal sonography: ● Serial quantitative B-hCG

○ used to locate the levels: should rise at least 35 to
pregnancy and determine 66% every 48 hours
viability
○ gestational sac - an
anechoic fluid collection
● Serum progesterone
that represents the
concentration: <5 ng/mL
exocoelomic cavity - 4-5
suggest a dying pregnancy
weeks
Threatened Abortion
MANAGEMENT PROGNOSIS

● Observation is the norm ● Perinatal mortality - not

● Acetaminophen-based increased in full term
analgesia children
● Hematocrit - evacuation ● Preterm mortality - very
● Blood type - transfusion high
● Progesterone
Inevitable Abortion

Pregnancy is in the process of physiologic expulsion

from within the uterine cavity will not continue will
proceed to incomplete or complete abortion.

-WHO
 Inevitable Abortion
HISTORY PHYSICAL EXAMINATION

● Vaginal bleeding ● A gush of fluid that is seen pooling

● Cramping during the sterile speculum exam -
● No passage of tissues confirms the diagnosis
Inevitable Abortion
IMAGING LAB RESULTS

● Transvaginal Sonography ● Amnionic fluid will fern on a

○ Oligohydramnios microscope slide or will have a
○ products of pH >7
conception in the ● Placental alpha
lower uterine microglobulin-1 assay
segment or cervical ● Insulin growth factor binding
canal protein-1 assay
Inevitable Abortion
MANAGEMENT PROGNOSIS

● Uterine evacuation ● PPROM at <24weeks aog, approx 20%

○ Manual vacuum of fetuses survive until hospital
evacuation discharge
○ Sharp curettage ○ Of surviving infants, 50-80% suffer
● Expectant management, from long-term sequelae

medical management, and ● Prognosis is improved if

○ Previable PPROM occurred later
surgical evacuation are all
○ Latency is longer
acceptable treatment options ○ Oligohydramnios is absent
Incomplete Abortion

Early pregnancy tissue is partially expelled.

It is possible that many incomplete
abortions are unrecognized missed
abortions.

-WHO
Incomplete Abortion
HISTORY PHYSICAL EXAMINATION
● Profuse vaginal bleeding with passing of
● Speculum Exam:
meaty tissues
● Abdominal pain
○ Products of conception may be
partially present in the uterus, may
protrude from the external os, or
may be present in the vagina
○ Cervical os may appear dilated or
effaced
● Bimanual Exam:
○ Uterus may be soft and enlarged.
Incomplete Abortion
IMAGING LAB RESULTS

● Transvaginal sonography ● CBC and blood typing

○ retained products of conception ● B-hCG level
○ no fetal heart tones ● PT/APTT
● Urinalysis
● Erythrocyte sedimentation rate
● Endocervical cultures
● Blood cultures
Incomplete Abortion
MANAGEMENT
● Expectant management, medical
management, and surgical
evacuation
● Products lying loosely within the
cervical canal can be easily
extracted with ring forceps
● Dilatation and curettage
PROGNOSIS
● Incomplete abortions cause many
complications and deaths of tens of
thousands of women each year.
● Expectant management of
spontaneous incomplete abortion
has failure rates of approx 25%
● Curettage has a success rate of 95
to 100%
Complete Abortion
Occurs when there is complete expulsion of early

pregnancy tissue.

-WHO
Complete Abortion
HISTORY

Bleeding, abdominal pain and/or

cramping, and tissue passage

Differentiate from blood clots

or decidual cast.
Complete Abortion
PHYSICAL EXAMINATION
● No abdominal distention
● Normal bowel sounds
● No rebound tenderness
● No hepatosplenomegaly
● No suprapubic tenderness
● Pelvic exam
○ Limited active bleeding
○ No cervical motion tenderness
○ Closed cervical os
○ Uterus small for dates and
nontender
○ Adnexa non to mildly tender
○ No adnexal mass
Complete Abortion
IMAGING
LAB RESULTS

● Transvaginal sonography ● Serial quantitative B-hCG levels

○ Minimally thickened endometrium
without a gestational sac -hCG levels drop quickly
Complete Abortion
Laboratory Results

● B-hCG levels should rise at least

35-66% every 48 hours in a healthy
pregnancy
● These levels drops quickly.
Complete Abortion
MANAGEMENT

● No surgical management is usually necessary.

● Ergot alkaloid and derivatives
● Antibiotics
● Analgesics
● Rho(D) immune globulin, if needed
Missed Abortion
It is miscarriage with ultrasound features
consistent with a nonviable noncontinuing
pregnancy retained in-utero, even in the absence
of clinical features.
Missed Abortion
HISTORY PHYSICAL EXAMINATION

● Lack of pregnancy symptoms ● Abdominal exam: palpable or

○ No nausea nonpalpable uterus, if palpable,
○ No vomiting small for dates
○ No breast soreness ● Closed cervical os
Missed Abortion
LAB RESULTS
-Serial quantitative B-hCG levels:
should rise at least 35 to 66% every 48
hours
-rapidly dropping serum hCG levels
Missed Abortion
IMAGING

● Transvaginal sonography
○ Mean gestation sac diameter is
≥25mm with no obvious yolk
sac
○ Fetal pole with a crown rump msd=37.5mm
length of ≥7mm without
evidence of fetal cardiac
activity
Missed Abortion
MANAGEMENT PROGNOSIS

● Surgical or medical evacuation ● If left untreated, tissue will pass

● Expectant observation is an option naturally
○ Successful in >65% of women
● If this is the patient’s first
miscarriage,
○ Second miscarriage - 14%
RECURRENT MISCARRIAGE
RECURRENT MISCARRIAGE
DEFINITION

Classical
>3 consecutive pregnancy losses <20
weeks’ gestation or with fetal weight <500g

American Society for Reproductive Medicine

> 2 failed pregnancies confirmed by
sonographic or histopathologic exam.
RECURRENT MISCARRIAGE
TYPES

Primary RPL
Multiple losses in a woman who has never
delivered a liveborn

Secondary RPL
Multiple pregnancy losses in a patient with
a prior live birth
RECURRENT MISCARRIAGE
ETIOLOGY

1. PARENTERAL CHROMOSOMAL ABN.

2. IMMUNOLOGIC (APAS)
3. ANATOMICAL FACTORS (STRUCTURAL
UTERINE ABN.)

*ENDOCRINE FACTORS
RECURRENT MISCARRIAGE
PARENTERAL CHROM. ABNORMALITIES

1. Reciprocal translocation
2. Robertsonian translocation

● Management:
IVF followed by preimplantation genetic
diagnosis
RECURRENT MISCARRIAGE
ANATOMICAL FACTORS

● Acquired
1. Asherman Syndrome/ Uterine Synchiae
- Result from destruction of large areas of
endometrium that results to adhesion
- Tx: hysteroscopic adhesiolysis
2. Uterine Leiomyoma
- Common; may cause miscarriage if near
implantation site
- Tx: excision of submucous leiomyoma
RECURRENT MISCARRIAGE
ANATOMICAL FACTORS

● Congenital Genital Tract Anomalies

- Originate from abnormal mullerian
duct formation
- Result: early miscarriage, midtrimester
abortion or preterm delivery
- Types:
➢ Unicornuate
➢ Bicornuate
➢ Septate uteri
RECURRENT MISCARRIAGE
ANATOMICAL FACTORS

● Congenital Genital Tract Anomalies

RECURRENT MISCARRIAGE
IMMUNOLOGIC FACTORS

● SLE- high risk for miscarriages

○ Antiphospholipid Antibodies
- autoAB to phospholipid binding
plasma protein
● APAS- APA + reproductive loss +
increased risk for venous
thromboembilism
● Tx: Blocking factors
RECURRENT MISCARRIAGE
IMMUNOLOGIC FACTORS
RECURRENT MISCARRIAGE
ENDOCRINE FACTORS

● Progesterone Deficiency
a. Luteal-Phase Defect
b. PCOS
● Uncontrolled DM
● Overt Hypothyroidism and Severe
Iodine Deficiency
MIDTRIMESTER ABORTION
MIDTRIMESTER ABORTION
DEFINITION

fetal loss that extends from the end

of the first trimester until the fetus
weighs <500 g or gestational age
reaches 20 weeks
MIDTRIMESTER ABORTION
CAUSES

Fetal Anomalies Placental Causes

Chromosomal Abruption, previa
Structural Defective spiral artery
Uterine Defects transformation
Congenital Chorioamnionitis
Leiomyomas Maternal Disorders
Incompetent cervix Autoimmune
Infections
Metabolic
MIDTRIMESTER ABORTION
MANAGEMENT

classified similarly to first-trimester

miscarriage;
Managed similar in many regards to
that used for 2nd trimester induced
abortion.

cervical cerclage - may be employed

for cervical insufficiency.
CERVICAL INSUFFICIENCY
What is Cervical Insufficiency?
● aka Incompetent Cervix
● Painless cervical dilation in the 2nd Trimester
○ Followed by prolapse and ballooning of membrane into
the vagina
○ Ultimately result into the expulsion of an immature
fetus
Causes?
● Previous Cervical Trauma
● Abnormal cervical development
○ Including that following in utero diethylstilbestrol
(DES) exposure
● Cervical ripening changes
○ Altered Hyaluronan or Collagen content

TX = CERCLAGE
Surgical Indications
-Unequivocal history of 2nd trimester Painless Delivery

-Physical findings of Early dilation of internal os

-Cervical length of <25mm and presence of Funneling in TVS

Cervical Funneling
Presurgical preparation
● Screening for aneuploidy and obvious malformation is
completed before the procedure.
● Cervical Secretions must be tested for gonorrhea and
chlamydia infection.

*Contraindications to cerclage: bleeding, contractions, or

ruptured membranes
Vaginal Cerclage
McDonald Cerclage
Procedure

● Simpler
● More widely used
Vaginal Cerclage
Modified Shirodkar Cerclage
Procedure

● Analgesia helps ensure

patient comfort and
adequate visualization
Vaginal Cerclage Removal
● For uncomplicated pregnancies without labor, cerclage is cut and
removed at 37 weeks’ gestation
○ This balances the risk of preterm birth against cervical laceration
from a cerclage in place with labor contraction.
● They are typically removed even with cesarean delivery to avoid rare
long-term foreign-body complications.
○ With scheduled cesarean delivery, cerclage may be removed at 37
weeks or deferred until the time of regional analgesia and
delivery.
Rescue Cerclage
● If cervix is found to be dilated, effaced, or both
● Replacement of the prolapsed amniotic sac back into the uterus will
usually aid suturing
○ Trendelenburg
○ Filling the bladder with 600 mL of saline through an indwelling Foley
catheter
○ Membrane reduction:
■ By pressure from a wide moist swab
■ By placing a Foley catheter and inflating the 30 mL balloon
○ *Transabdominal amnionic fluid aspiration
Transabdominal Cerclage
● Aka Transabdominal cervicoisthmic cerclage
● Reserved for selected instances of severe cervical anatomical defects
or prior transvaginal cerclage failure
Complications
● Membrane rupture
● Preterm labor
● Hemorrhage
● Infection- mandates immediate removal of the suture with labor induced or
augmented.

**With Imminent Abortion or delivery, the suture should be removed at once

because uterine contractions can tear through the uterus or cervix.

**if subsequent cervical thinning is detected, consider a renforcement cerclage

**Membrane rupture during suture placement or within 48 hours is considered an

indication for Cerclage removal
Induced Abortion
Definition of Terms
Induced Abortion - the medical or surgical termination of pregnancy
before the time of fetal viability.

Abortion ratio - the number of abortions per 1000 live births

Abortion rate - the number of abortions per 1000 women aged 15 - 44 y.o.
Classification
● Therapeutic abortion
○ termination of pregnancy for medical indications.
○ In the US, the most frequent indication is to prevent birth of a fetus
with a significant anatomical, metabolic, or mental deformity.
● Elective or Voluntary abortion
○ Interruption of pregnancy before viability at the request of a woman
but not for medical reasons
○ One of the most frequently performed medical procedure, in the US
Induced abortion in the Philippines
● Criminalized by the Revised Penal Code of the Philippines
○ Articles 256, 258, and 259 - mandate imprissonment for women
who undergoes abortion, as well as for any person who assists in
the procedure, even if they be the women’s parents, a physician or
midwife.
○ However, there is no law in the philippines that expressly
authorizes abortions in order to save the woman’s life.
○ Pleading for justifying circumstances has yet to be adjudicated by
the Philippine Supreme Court
Septic abortion
● Is an abortion, whether spontaneous or induced, complicated by
infection ranging from focal involvement of the endometrial cavity or its
contents or both, with or without the involvement of the uterus and its
appendages.
● >95% of cases are synonymous with illegal, criminal or non-medical
abortions.
● It is often complicated by fever, endometritis, and parametritis.
Septic abortion
● Characterized by
○ Temperature >100.4 F or 38 C
○ Offensive or purulent vaginal discharge
○ Lower abdominal pain and tenderness
○ History of unsafe intervention

**The presence of two or more criteria is considered as case definition

Septic abortion
● Signs and Symptoms
○ Elevated temperature, tachycardia, tachypnea, lower abdominal tenderness, signs of
severe sepsis
○ Fever, chills, malaise, vaginal bleeding, abdominal pain, and passage of placental
tissue
● Abdominopelvic exam
○ Most often, an open cervix with bleeding and foul smelling products of conception or
drainage
○ Cervical or vaginal lacerations
○ Open cervix with or without a catheter
○ Bimanual exam: uterine tenderness
○ Direct and rebound abdominal tenderness
○ Abdominal muscle guarding
 First trimester
Abortion Methods
SURGICAL ABORTION
Preoperative Preparation

Hygroscopic dilators Medications

MISOPROSTOL
400ug administered sublingually, buccally
or placed into the posterior vaginal fornix
L
for 3-4 hours prior to surgery.
LAMINARIA (algae): 12-24 HOURS
Disadvantage:
Introduces fever, bleeding and
Gastrointestinal effects

L MIFEPRISTONE
200mg given orally 24-48 hours before
DILAPAN-S (acrylic based gel): 4-6 HOURS surgery
Disadvantage: extend procedure time and
uncomfortable
SURGICAL ABORTION
Preoperative Preparation
 SURGICAL ABORTION
Preoperative Preparation

● Hemoglobin level and Rh status are assessed

● Screen for: gonorrhea, syphilis, HIV, hepatitis B, and
chlamydial infections.
● Cervical infections are treated and resolved before elective
procedures.
● Postabortal infection: Doxycycline, 100 mg oral 1 hour
before and then 200 mg oral after.
● Prophylaxis specifically for infective endocarditis prevention
in those with valvular heart disease is not required in the
absence of active infection.
Vacuum aspiration

o Vacuum aspiration, the

most common form of
suction curettage, requires a
rigid cannula attached to an
electric‐powered vacuum
source

o Manual vacuum aspiration‐

used for early pregnancy
failures as well as elective
termination up to 12 weeks
Dilatation and curettage (D&C)

o Dilating the cervix and then evacuating the pregnancy by mechanically

scraping out the contents (sharp curettage) or by suctioning out the contents
(suction curettage) or both.
Dilation of cervix with hegar dilator. Note that the fourth
and fifth fingers rest against the perineum and buttocks,
lateral to the vagina.

This maneuver is an important safety measure because if

the cervix release abruptly, these fingers prevent a
sudden and uncontrolled thrust of the dilator, a
common cause of uterine perforation.
Small cannula Large cannula

● Risk of leaving retained intrauterine tissue ● Risk of cervical injury and more discomfort
postoperatively

Suction curettage Sharp curettage

● ≤6 weeks’ gestation
● Small pregnancy
● Missed by curette

● To identify placenta
○ aspirated contents are rinsed in a
strainer to remove blood
○ then placed in a clear plastic
container with saline and examined
with back lighting
○ Macroscopically appears so, fluffy,
and feathery. A magnifying lens,
colposcope, or microscope can
augment visualization.
● ≤7 weeks gestations,
○ failed abortion rate ~2%
○ Measure serum hCG levels if
products are not clearly identified.
Abortion Complications
● Rise with gestational age ● Perforation Risk factors:
● Uterine perforation and lower genital tract ○ Operator inexperience
laceration is uncommon but serious. ○ Prior cervical surgery or anomaly
○ Adolescence
● Uterine perforation, cervical, and vaginal
○ Multiparity
laceration <1% ○ Advanced gestational age
● Intraabdominal damage ● Incomplete abortion may require
● Uterine synechia reevacuation
● Hemorrhage ● Efficacy rates
○ >500ml bleeding prompts clinical response ○ Surgical 96-100%
○ first-trimester surgical abortions, hemorrhage ○ Medical 83-98%
complicates ≤1 %
○ Atony, abnormal placentation, and
coagulopathy are frequent sources
○ surgical trauma is a rare cause
● Incomplete removal of products
● Postoperative infections <0.3%
 Medical Abortion
MIFEPRISTONE MISOPROSTOL METHOTREXATE
(antiprogestin) (prostaglandin) (antimetabolite)

Augments uterine directly stimulates the acts on trophoblast and

contractility by reversing myometrium and ripens the halts implantation
progesterone induced cervix
myometrial quiescence and
ripens the cervix.

Williams Obstetrics 25th Edition p361-362

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 Medical abortion
CAUTIONS
● Current intrauterine device
● severe anemia
● coagulopathy, or anticoagulant use;
● long-term systemic corticosteroid therapy;
● chronic adrenal failure; inherited porphyria;
● Severe liver, renal, pulmonary, or cardiovascular disease;
● Uncontrolled hypertension
● misoprostol is suitable for early pregnancy
failure in those with prior uterine surgery.

● Methotrexate and Misoprostol are both

teratogens. Thus there must be a
commitment to completing the abortion
once these drugs are given
 Gestation up to 63 days

Side effects of Misoprostol: vomiting, diarrhea, fever and chills. Bleeding

and cramping with medical termination typically is significantly worse than
menses. Adequate analgesia is advised
AT follow up appointment:
● routine postabortal sonographic examination is unnecessary
● Assessment of clinical course along with bimanual pelvic examination is
recommended.
● Specifically, if no gestational sac is seen and there is no heavy bleeding,
then intervention is unnecessary.
SECOND
SecondTRIMESTER
Trimester
ABORTION METHODS
Abortion Methods
Indications for uterine evacuation
● fetal anomaly or death
● maternal health complications
● inevitable abortion
● desired termination

Dilatation and evacuation is dictated

because of the fetal size and bony
structure.
Dilation and Evacuation
Hygroscopic dilators
●The cervix is prepared for dilatation using
hygroscopic dilators or misoprostol. To be
able to evacuate the fetal parts.
● The degree needed rises with fetal gestational age,
and inadequate dilatation risks cervical trauma,
uterine perforation, or tissue retention.

●With complete removal of fetus, a

LAMINARIA
large-bore vacuum curette is used to
remove the placenta and remaining
tissue.

●This is better accomplished using

intraoperative sonographic imaging.
DILAPAN-S
 Dilation and Evacuation
Elective abortion
- Induce fetal demise prior to D and E to
avert a live birth or to avoid the partial
birth abortion ban act.
- For this an intracardiac potassium chloride
injection or 1mg intra amniotic or intrafetal
digoxin injection is frequently used prior to
cervical ripening.
 Dilation and Evacuation
Technique
● Sonography can be used as an adjunct
● Post procedure bleeding reduction: Vasopressin, 2 to 4 units in 20 mL of saline/anesthetic, intracervically or
as part of a paracervical block.
● Once adequate cervical dilation is achieved
● Initial surgical step: drains amnionic fluid with an 11- to 16-mm suction cannula or with amniotomy and
gravity.
● For pregnancies beyond 16 weeks, the fetus is extracted, usually in parts, using Sopher forceps or other
destructive instruments.
● With complete removal of the fetus, a large-bore vacuum curette is used to remove the placenta and
remaining tissue.

Major complications (0.2-2%) Rare complications

● uterine perforation ● disseminated intravascular coagulopathy
● cervical laceration ● amnionic fluid embolism
● uterine bleeding
● postabortal infection
 Dilation and Evacuation
Abnormal Placentation
● Placenta previa or the accrete syndromes can raise D ● Uterine rupture during medical abortion
& E risks. ○ 0.4% with one prior cesarean delivery
● Once diagnosed, placenta accreta typically prompts ○ 2.5% with two or more prior cesarean
hysterectomy. deliveries
● For placenta previa, D & E is preferred to quickly ○ PGE 2 (dinoprostone) appears to pose similar
evacuate the placenta. risk.
● Prior cesarean delivery is not a contraindication for D
& E and may be preferred over prostaglandins for
those with multiple prior hysterectomies
Dilation and Extraction (D&X)
o This is similar to dilatation 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.

o Termed as intact D and E or partial birth abortion

Medical Abortion
Hygroscopic dilators

LAMINARIA

Shorter termination duration

Vaginal or Sublingual route > Oral route

DILAPAN-S
Medical Abortion
● Infection surveillance during labor is applied

PGE2 - Dinoprostone

● Simultaneous administration of the following:

○ Antiemetic - Metoclopramide (Reglan)
○ Antipyretic - Acetaminophen
○ Antidiarrheal - Diphenoxylate/atropine

Concentrated oxytocin

Ethacridine lactate
● organic antiseptic that activates myometrial mast cells to release
prostaglandins
Fetal and Placental Evaluation
● Second-trimester: D & E or medical induction is
suitable
● Once delivered, viewing and holding the fetus
may or may not be desired by the patient .
● Evaluation of a stillborn fetus can be assessed
by different means one example of which is
autopsy.
● 95 percent of placentas in midtrimester
miscarriages are abnormal other abnormalities
are vascular thromboses and infarctions.
 Consequences of Elective Abortion
● Mortality rate: for first 2 months of pregnancy < 1 per 100,000
● No evidence of excessive mental disorders
● Subsequent ectopic pregnancies are not increased
● 1.5 fold greater incidence of preterm delivery following surgical
evacuation.
● Subsequent pregnancy outcomes are similar following medical and
surgical methods of induced abortions
 Postabortal Contraception
• Ovulation may resume as early as 8 days but the
average is 3 weeks after an early pregnancy is terminated .

• If pregnancy is to be prevented, effective contraception

should be initiated soon after abortion with the use of (IUD)
or any forms of various hormonal contraception.
Thank you for listening!