OBSTETRICS 2

1S-1 | CEU-SOM A & B

ABORTION

DR. ELEYNETH I. VALENCIA, FPOGS, FPSUOG

OUTLINE b) GS with embryo/fetus with no FHT
! Certain measurements in ultrasound can
I. OVERVIEW indicate demise of the embryo:
II. TYPES OF ABORTION Embryo: cut-off is 7mm
☝
III. FIRST-TRIMESTER SPONTANEOUS ABORTION GS: cut-off is 25mm
IV. RECURRENT MISCARRIAGE
☝
! Kapag ganyan na agad yung result ng first
V. MIDTRIMESTER ABORTION
scan mo tapos wala pa ring heart rate,sa mga
VI. MANAGEMENT expectant moms lalo na yung mga
VII. CASES nagpapa-infertility work-up di mo agad sya
VIII. REFERENCES
ia-out as demised, at least in my practice,
IX. APPENDIX allow ample time to repeat the scan just to
confirm.

OVERVIEW B. SPONTANEOUS ABORTION

1. Threatened
! In the medical practice, miscarriage and abortion are 2. Inevitable
used interchangeably. 3. Incomplete
! abortion is an umbrella diagnosis of induced abortion and 4. Complete
spontaneous abortion 5. Missed

SPONTANEOUS or INDUCED ABORTION C. RECURRENT PREGNANCY LOSS (RPL) or HABITUAL

● Termination of pregnancy before fetal viability (Wiliam’s 24th)
! Period of fetal viability is usually by the 24th week
● Termination or loss of pregnancy from whatever cause before
the fetus is capable of extra-uterine life (CPG on Abortion)
ABORTION (laypersons)
● implies intended pregnancy termination
MISCARRIAGE
● implies spontaneous pregnancy loss
INDUCED
● surgical or medical termination of a live fetus before viability
ABORTION
1. with repetitive miscarriage
2. > 2 failed clinical pregnancies confirmed by either
sonographic or histopathological examination
3. > 3 consecutive pregnancy losses prior to 20 weeks from LMP
(ACOG)
4. > 2 consecutive pregnancy losses prior to 20 weeks from LMP
5. risk of miscarriage after 3 pregnancy losses (33%) doesn’t
differ greatly from 2 (30%) (ASRM)
6. must be clinically-recognized pregnancy loss
7. visualized by US or pregnancy tissue identified
8. biochemical pregnancy or (+) PT
a) NOT COUNTED in RPL

PREGNANCY TERMINATION or LOSS D. PREGNANCY OF UNKNOWN LOCATION (PUL)

● Before 20 weeks AOG
● Fetus delivered weighing <500g
! Halimbawa, kahit na more than 20 weeks AOG pero nung
lumabas yung conceptus is <500g it is called an abortus.
Pag >500g tapos wala nang buhay yung baby,it is
considered as stillborn.
CURRENT ABORTION TERMINOLOGY
● Early conceptions with no products seen sonographically
● Pregnancies with GS but (-) embryo
● Dead embryo seen by Ultrasound (US)
! with the advent of β-hCG level determination as well as
ARTs, mas maagang nakakapagpawork-up yung mga
nanay at napeprevent yung possible complications like
hemoperitoneum or acute blood loss due to ruptured
ectopic pregnancy or abortion, most commonly yung
! induced abortion.
Induced abortion is illegal and is considered a criminal
!
case here in the Philippines.
In other countries, legal ang therapeutic/ medical/
induced abortion, the most common indication is due to
the early detection of aneuploidies during first trimester
scan, especially kung supported by laboratory work-up
findings.
1. Pregnancy identified by βhCG testing but without confirmed
sonographic location
! ! Earliest time for Positive Pregnancy Test (PPT): 3 weeks
Time of embryo implantation in the endometrium: 21
! days from LMP or 1 week after fertilization
Pag positive ang PT mo tapos symptomatic merong
hypogastric pain, konting spotting puwedeng normal pa
rin due to implantation bleeding, but you need to rule out if
it is intrauterine or extrauterine pregnancy and if
the pregnancy is viable to confirm: request for
transvaginal ultrasound and if you’re suspecting that
the patient has ectopic pregnancy, request for serum
β-hCG titer.
FIRST TRIMESTER SPONTANEOUS ABORTION
● > 80% of spontaneous abortion: within 12 weeks of gestation
● Demise of embryo/fetus usually precedes spontaneous
expulsion
● Incidence: 11-22%
! Death is usually accompanied by hemorrhage into the
decidua basalis. Followed by adjacent tissue necrosis
that stimulates uterine contractions and expulsion of the
products of conception.

TYPES OF ABORTION ANEMBRYONIC MISCARRIAGE

● Demise of embryo/fetus usually precedes spontaneous
A. EARLY PREGNANCY LOSS expulsion
1. Intrauterine pregnancy (IUP) loss within the first 12 6/7 weeks ! Contains no identifiable embryonic elements.
AOG EMBRYONIC MISCARRIAGE
a) Empty GS
1S-1 ABORTION ESTUYE • HO • JAVIER • RAMOS • ROCHA
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 ● With abnormality of the embryo, fetus, yolk sac and at times, ○ X-rays
placenta ○ Antineoplastic drugs
○ >3 hours of exposure to nitric oxide (dental
CAUSES OF FIRST TRIMESTER SPONTANEOUS ABORTION assistants)
CLINICAL CLASSIFICATION OF ABORTION
FETAL MATERNAL PATERNAL

50% euploid Infections

50% chromosomal Medical Disorders
abnormality Cancer
75% of chromosomal Surgical Procedure Increasing paternal
abnormality (6wks Nutrition age
AOG) Social/Behavioral
95% maternal Occupational/
gametogenesis error Environmental

Figure 1. Spontaneous Abortion Figure 2. Midtrimester Abortion
Table 1. Factors of Spontaneous Abortion.

FETAL FACTORS
● 50% euploid
● 50% chromosomal abnormality
● 75% of chromosomal abnormality (6 weeks AOG)
● 95% maternal gametogenesis error
! /# Most common abnormalities are trisomy, found in 50 to
60 percent; monosomy X, in 9 to 13 percent; and triploidy, in
11 to 12 percent

MATERNAL FACTORS

INFECTIONS
Figure 3. Induced Abortion Figure 4. Recurrent Abortion
● Common viruses, bacteria and parasites
!
like TORCH: Toxoplasmosis, Other agents (including HIV,
syphilis, varicella, and fifth disease), Rubella,
Cytomegalovirus, Herpes simplex
● Infect the fetoplacental unit by blood-borne transmission e.g.
UTI
MEDICAL DISORDERS
● Poorly controlled DM
● Obesity
● Thyroid disease ! most commonly yung hypothyroidism
● Systemic Lupus Erythematosus
Underlying inflammatory mediators
CANCER:
! Therapeutic doses of radiation are undeniably abortifacient.
SURGICAL PROCEDURES
! Uncomplicated surgical procedures performed during early Figure 5. Clinical Classification of Spontaneous Abortion
pregnancy is unlikely to increase the abortion risk
● Only if ovaries are removed before 10 weeks AOG (must be
given supplemental progesterone)
● Major trauma (abdominal) can cause fetal loss
NUTRITION
● Sole deficiency/moderate deficiency - ✗ increase risk of
abortion
● Miscarriage risk ↓ diet-rich in fruits, vegetables, whole grains,
vegetable oils, fish
● Risk of miscarriage

SOCIAL and BEHAVIORAL FACTORS

● Chronic and heavy-use of illicit drugs/
● Alcohol - potent teratogenic effects
● Excessive caffeine consumption
○ 5 cups of coffee/day = 500 mg caffeine
OCCUPATIONAL /ENVIRONMENTAL FACTORS
● Environmental toxins
○ Possible link bisphenol A
○ Phthalates
○ Polychlorinated biphenyls
○ DDT
● Slightly increased
○ Sterilizing agents
1S-1 ABORTION ESTUYE • HO • JAVIER • RAMOS • ROCHA
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 ! In threatened abortion, at par yung size ng uterus sa
estimated AOG, tapos confirmed by ultrasound, intrauterine may
viable fetus. In Missed Abortion, the uterine size is
smaller than the computed AOG and sa ultrasound the embryo
does not have cardiac activity or yung GS does not have an
embryo inside.

ULTRASOUND MANAGEMENT
FINDINGS

CRL <7mm with no Perform a second

visible heartbeat scan a minimum of 7
days after the first

CRL ³7mm with no Seek a second

visible heartbeat opinion on a viability
and/or perform a
Transvaginal Scan
second scan a
minimum of 7 days
after the first

MSD <25mm with Perform a second

no visible foetal pole scan a minimum of 7
days after the first

Figure 6 Intrauterine Pregnancy in Threatened Abortion MSD ³25mm with Seek a second
no visible foetal pole opinion on a viability
and/or perform a
second scan a
minimum of 7 days
after the first

Visible foetal pole Record the size of

with no visible the CRL, perform a
heartbeat second scan a
minimum of 14 days
after the first
Transabdominal
Scan Visible intrauterine Record the size of
with no visible foetal the MSD, and
pole perform a second
Figure 7 Ectopic Pregnancy scan a minimum of
14 days after the
first
Table 2 Diagnostic Criteria for Silent Miscarriage.

! ABORTION
EPTIC
Anything with history of instrumentation is septic abortion
● Complicated by infection
● Any abortion associated with clinical evidences of infection of
uterus and its contents is called as septic abortion
● Clinical evidence of infection
○ Fever 38 C or more for at least 24 hrs
○ Offensive or Purulent vaginal discharge
Figure 8 Early Pregnancy Failure
○ Lower abdominal pain, tenderness or mass
! ○ Tachycardia of more than 100 per min.
Management includes prompt administration of
broad-spectrum antibiotics

RECURRENT MISCARRIAGE
● ACOG: > 3 consecutive pregnancy losses < 20 weeks AOG
or fetal weight of < 500
● ASRM (2013): > 2 confirmed by sonographic or
histopathological examination

PRIMARY RPL
● Multiple losses in a woman who has never delivered a live
born
SECONDARY RPL
● Multiple pregnancy losses in a patient with prior live birth
Figure 1 Types of Sponataneous Abortion

THREE WIDELY ACCEPTED CAUSES OF RPL

1S-1 ABORTION ESTUYE • HO • JAVIER • RAMOS • ROCHA

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 1. Parental Chromosomal Abnormalities ● Also known as incompetent cervix
2. Anti-Phospholipid Antibody Syndrome (APAS)
3. Structural Uterine Abnormalities Painless cervical dilatation in the 2nd trimester (CYCLE)
↓
IMMUNOLOGICAL FACTORS: SLE & APAS
Prolapse and ballooning of membranes
Updated Sapporo classification criteria for antiphospholipid syndrome ↓
(APS) Expulsion of immature fetus
Clinical criteria
1) Vascular thrombosis: ³1 arterial, venous, or small vessel Indicators of Cervical Insufficiency:
thrombosis ● PE early dilatation of the cervix
2) Pregnancy morbidity ● TVS: funneling sought - dilatation of the internal cervical os
a) ³1 fetal death (at or beyond the 10th week of gestation) ! Normal measurement of a non-pregnant cervix: 3-4 cm
b) ³1 premature birth before the 34th week of gestation
because of eclampsia, severe preeclampsia, or placental
insuffieciency
c) ³3 consecutive (pre) embryonic losses (before the 10th
week of gestation)
Laboratory criteria
1) Lupus anticoagulant positivity on ³2 occasions at least 12
weeks apart.
2) Anticardiolipin antibody (IgG and/or IgM) in medium or high titer
(i.e.>4o or above the 99th percentile), on two or more occasions
at least 12 weeks apart.
3) Anti-b2-glycoprotein-I antibody (IgG and/or IgM) in medium or
high titer (i.e. above the 99th percentile) on two or more
occasions at least 12 weeks apart.

Definite APS is present if at least one of the clinical criteria and one
of the laboratory criteria are met.

ANATOMICAL FACTORS
● Congenital Genital Tract Anomalies (! most common:
septate uterus)
● Acquired Uterine Abnormality (! most common: Asherman
syndrome)

ACQUIRED UTERINE ANOMALY

Asherman Syndrome
● Destruction of large areas of the endometrium (e.g. uterine
curettage, hysteroscopic surgeries or uterine compression
sutures
Uterine Leiomyomas
● Submucous type

ENDOCRINE FACTORS

PROGESTERONE DEFICIENCY
! Luteal phase defect
●
corpus luteum: main source of progesterone in early
pregnancy (10w) Figure 9. Cervical Funneling
● Polycystic ovarian syndrome
● Uncontrolled diabetes mellitus
● Overt hypothyroidism ! shape of cervical funneling is associated with increasing morbidity
● Severe iodine deficiency ! T shaped- no funneling, normal
! Y shaped
MIDTRIMESTER ABORTION ! V shaped
● Midtrimester fetal loss from end of first trimester
! U shaped - internal os is bulging
○ Fetus weighs < 500g
○ Gestational age reaches 20 weeks
CERVICAL TRAUMA
INCIDENCE
● Conization
● 1.5-3%
● > 16 weeks: 1% ● Dilatation and Curettage
● Abnormal Cervical Development
EARLY MISCARRIAGE
● Chromosomal aneuploidies CERCLAGE
● Reinforces a weak cervix by an encircling suture
MIDTRIMESTER MISCARRIAGE
● Due to multiple factors/causes
● Medically-induced: (+) fetal anomalies detected in prenatal
screening

CERVICAL INSUFFICIENCY
1S-1 ABORTION ESTUYE • HO • JAVIER • RAMOS • ROCHA
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 Figure 11. Mc Donald Figure 12. Shirodkar

WHEN TO REMOVE CERCLAGE

For Uncomplicated Pregnancies: cut and removed at 37 weeks AOG

Transabdominal Cerclage
● Placement at the cervicoisthmic area by laparotomy or
laparoscopy

Cervical Length Screening at 16-24 weeks

● Recommended by both ACOG (2016)
● Society of Maternal Fetal Medicine (2015)
For High-risk patients (History of prior pre-term birth)

Figure 10. Cervical Cerclage Procedure
For High-Risk Patients:
Cervical measurement (CL) every 2 weeks
Multicenter randomized trial of 302 high-risk patients with cervical length If CL is 25-29mm - weekly interval
of <25mm: If CL is <25mm - may offer cerclage
● Cerclage can prevent birth before viability BUT not birth
before 34 weeks For Patients with NO History of Preterm birth but with a short cervix
<25mm
CONTRAINDICATIONS: Offer progesterone therapy instead of cerclage
● Bleeding
● Contractions Twin Gestations CL <25mm
● Ruptured membranes ACOG does not recommend cerclage

Pre-op Assessment: MANAGEMENT

● Aneuploidy
● Congenital malformation 1. Cervical Priming
● Infection ● Hegars, Hank or Pratt dilators
● Hygroscopic/Osmotic dilators
TYPES OF CERCLAGE ! Devices that draw water from surrounding
tissues and expand to gradually dilate the
PROPHYLACTIC endocervical canal.
● Cerclage before dilatation at 12-14 weeks ! One type is derived from various species
RESCUE of Laminaria algae that are harvested from the
● Cerclage done in a dilated, effaced or both ocean floor.
● Emergent: not done beyond fetal viability (24 weeks) ● Misoprostol
! Put the patient in trendelenburg position para umangat yung ● Antiprogestin Mifepristone
cervix, saka mo tahiin. 2. Basic Labs and Standard Screening
3. Prophylactic Doxycycline
Types of Vaginal Cerclage Operations:
** no 1 or 2 nylon or polypropylene monofilament suture of Mersilene
tape
● Mc Donald A B
● Shirodkar

Figure 13. (A) Hegars Dilator (B) Laminaria Tent

1S-1 ABORTION ESTUYE • HO • JAVIER • RAMOS • ROCHA

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 Few hours prior to admission, she had hypogastric pain radiating
SURGICAL to the back associated with vaginal bleeding. Few minutes prior to
● Dilatation and curettage consult she had passage of meaty tissues prompting consult at the
● Vacuum aspiration (EVA, MVA) ER.
PPE showed stable VS
MEDICAL IE: cervix:soft, admits 1 finger with palpable tissues per os
● Prostaglandins E2, E1, F2α and analogues corpus: enlarged to 2 months size
● Antiprogesterones RU-486 (mifepristone) ad: no mass/tenderness
● Methotrexate Diagnosis: 38 y/o, G3P2 (2002), abortion incomplete, 12 weeks

1 AOG, non-septic, non-induced.

REFERENCES
● Williams Obstetrics, 25th Ed
● ACOG
● Dr. Valencia’s PPT lecture

Figure 14. Manual Vacuum Aspiration

● Uterine
! perforation - < 1%
● Cervical or vaginal laceration
common in septic abortion
● Hemorrhage - incomplete removal of products of conception
● Post-operative infection
● Uterine synechiae

CASES

E. CASE 1
E.V. 28 y/o, G1P0 from Sampaloc, Manila, came at the ER due to
vaginal bleeding.
She had 6 weeks amenorrhea and self PT done 1 week ago (+).
Few hours prior to admission, she had hypogastric pain radiating
to the back and vaginal spotting which increased to vaginal
bleeding few minutes prior to consult
PPE showed stable VS
IE: cervix:soft closed
corpus: slightly-enlarged
ad: no mass/tenderness
Diagnosis: 28 y/o, G1P0, Pregnancy Uterine, 6 weeks AOG in
threatened abortion.
Request for: Transvaginal Ultrasound, CBC, Urinalysis

F. CASE 2
C.K. 38 y/o, G3P2 (2002) from Tondo, Manila, came at the ER due
to passage of meaty tissues.
She had 12 weeks amenorrhea and self PT done 2 wks ago (+).

1S-1 ABORTION ESTUYE • HO • JAVIER • RAMOS • ROCHA

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 APPENDIX

Figure 15. Regimens for Medical Termination of Early Pregnancy (Williams, 24th Ed.)

Figure 16. Regimens for Medical Termination of Early Pregnancy (Williams, 25th Ed.)

1S-1 ABORTION ESTUYE • HO • JAVIER • RAMOS • ROCHA

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