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hi this is dr. Jane Lamar gonna be
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talking about abortion the learning
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objectives for this talk are as follows
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to understand the difference between
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their appearing and spontaneous abortion
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to note the different types of
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spontaneous abortions
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trivita risk factors for spontaneous
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abortion to understand how should
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spontaneous abortions be managed and how
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therapeutic abortions are performed and
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to know the possible complications of
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both types of abortion
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the talk will proceed as follows we will
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review the types etiology and management
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of spontaneous abortion the types of
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induced abortion and the complications
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of both spontaneous abortion is more
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commonly known as miscarriage it is
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defined as pregnancy loss prior to 20
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weeks gestation such pregnancy loss
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occurs far more frequently than most
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people think and it is estimated that 50
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to 70 percent of all pregnancies end in
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miscarriage the majority of these losses
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occur before women even realize they are
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pregnant approximately 20% of clinically
01:07
recognized pregnancies end in
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spontaneous abortion it is estimated
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that 80% of spontaneous abortions occur
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in the first trimester of pregnancy
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prior to 12 weeks gestation spontaneous
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abortion is further categorized into
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subtypes based on whether the cervix is
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open or closed and whether or not the
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fetus is alive moreover there are some
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fertilization events that will lead to
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growth of pregnancy tissue but never
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develop a fetal pole known as an
01:36
embryonic gist stations or blighted ovum
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‘z these pregnancies also fall under the
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category of spontaneous abortion if a
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woman experiences vaginal bleeding but
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has a live fetus for potentially viable
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early first trimester pregnancy the
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speculum exam should be performed if the
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cervix is closed the patient is having a
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threatened abortion if the service is
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open the abortion is considered
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inevitable and the patient should be
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offered some type of intervention to
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complete the abortion we will discuss
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this further later in the presentation
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in comparison if a patient experiences
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fetal demise the type of spontaneous
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abortion depends on whether or not the
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fetal tissue remains in the uterus if
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all fetal and placental tissue remains
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the patient has a missed abortion
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some tissue has passed but still remains
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the patient has an incomplete abortion
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finally if the patient has had a fetal
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demise and has passed all the pregnancy
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tissue the abortion is categorized as
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complete some patients will develop
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intrauterine or even systemic infections
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associated with a spontaneous abortion
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often characterized by fevers and
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abdominal pain
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these patients are described as having
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septic abortion finally women who
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undergo three spontaneous abortions in a
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row with no intervening normal pregnancy
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are described as having recurrent
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abortions these women should be worked
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up for causes of recurrent miscarriage
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although the etiology of many
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spontaneous abortions is never known
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there are certain conditions that
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commonly end in pregnancy loss these
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conditions may be specific to the fetus
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or the mother or the mother’s
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environment certain conditions are more
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likely to cause pregnancy loss at
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certain gestational ages for example
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losses at less than 10 weeks gestation
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are usually related to a chromosomal
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anomaly in the fetus in contrast uterine
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anomalies and cervical insufficiency
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typically result in fetal loss in the
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mid second trimester after 18 weeks
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within chromosomal anomalies
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specifically which caused the majority
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of spontaneous pregnancy losses
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autosomal trisomy or 3 copies of a
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chromosome is the most common
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abnormality trisomy 16 and trisomy 22
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occur most frequently it is postulated
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that single gene mutations may also be
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responsible for the loss of chromosomal
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a normal pregnancies several maternal
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conditions place women at risk for
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pregnancy loss first structural
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anomalies in the uterus both congenital
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and acquired can create an inhospitable
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environment for fetal growth and
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development for example septate uterus
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is the most common uterine anomaly
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associated with spontaneous abortion
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other such anomalies include bicornuate
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uterus uterine fibroids and intricate
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arias Aniki eye or scar tissue from
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prior surgeries cervical insufficiency
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is painless cervical dilation leading to
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delivery of a non-viable fetus in the
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second trimester
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in addition there are multiple medical
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conditions such as hypothyroidism and
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poorly controlled diabetes mellitus that
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may predispose a woman to spontaneous
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abortion it is important to note that
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many women with these conditions carry
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successful pregnancies maternal
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thrombophilia is in which women have an
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increased tendency to form blood clots
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such as antiphospholipid antibody
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syndrome can lead to pregnancy loss
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likely by damaging the placental
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vasculature
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moreover certain infections in the
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cervix uterus and or semen have been
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associated with spontaneous abortion
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these include chlamydia gonorrhea urea
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plasma mycoplasma Staphylococcus and
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streptococcus
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in addition maternal infection with
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Listeria toxoplasmosis parvovirus b19
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varicella cytomegalovirus rubella and
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primary herpes simplex can cause
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pregnancy loss
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there are also modifiable factors in the
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maternal environment that may lead to an
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increased risk of miscarriage
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these include maternal tobacco and
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alcohol use and radiation exposure
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finally some women are carriers of
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balanced translocations such that they
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may have a normal number of chromosomes
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but their offspring often will not
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if a spontaneous abortion is not
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complete at the time of diagnosis
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sometimes intervention is required the
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need for active management of a
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pregnancy loss depends upon the presence
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or absence of heavy bleeding the
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presence or absence of infection the
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gestational age of the pregnancy the
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patient’s medical history and the
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patient’s wishes in the setting of
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infection and/or heavy vaginal bleeding
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with hemodynamic instability surgical
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intervention to empty the uterus is
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always indicated this can be
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accomplished with manual or surgical
06:37
vacuum aspiration pregnancies that later
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than nine weeks gestation are more
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likely to require surgical intervention
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in order to complete the passage of all
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pregnancy tissue simply because of the
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amount of tissue present it is estimated
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that a missed or incomplete abortion who
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will pass between 52 to 84 percent of
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the time with no intervention depending
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on how long the patient waits for the
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tissue to pass
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if a patient elects for medical
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management of pregnancy loss most
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commonly misoprostol a prostaglandin e1
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analog is prescribed
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this causes both cervical softening and
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dilation as well as uterine contractions
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to expel the pregnancy tissue women with
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pregnancies less than 12 weeks gestation
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can complete a spontaneous abortion at
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home using music rosto if they elect to
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do so in contrast medical management of
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a spontaneous abortion greater than 12
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weeks should be performing or close
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monitoring in the hospital due to an
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increased risk of heavy bleeding
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with all patients who undergo
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spontaneous abortion it is crucial to
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check a blood type and administer rhogam
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if the mother is Rh negative in order to
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prevent ISO immunization in future
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pregnancies in contrast to spontaneous
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abortion induced abortion is the medical
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or surgical termination of a live
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pregnancy induced abortions are
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sometimes also referred to as
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therapeutic abortions when they are
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performed because of risk to a woman’s
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health or lethal fetal anomalies when
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asked why they are choosing to terminate
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a pregnancy
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the most common response that women give
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is either responsibility to other family
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members or economic constraints it is
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estimated that 50% of pregnancies in the
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United States are unplanned and four out
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of ten of these pregnancies end in
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abortion
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it is important that women who have an
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unplanned pregnancy are counseled on all
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possible options which would include
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continuing the pregnancy terminating the
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pregnancy or giving the infant up for
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adoption
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methods for pregnancy termination are
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similar to those for managing a
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spontaneous abortion though there are
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some key differences medication
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terminations can be performed up to 63
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days or nine weeks gestation depending
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on the regimen that is used most
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commonly these are performed with a
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combination of mythic Prestone which is
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given first and music crustle which is
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taken at home 24 to 72 hours later with
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a Chris stone a competitive progesterone
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receptor antagonist interrupts the
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endometrial lining that is supporting a
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growing pregnancy and sensitizes the
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myometrium to prostaglandins thereby
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making these apostille more effective
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pregnancies in the first trimester that
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are past nine weeks gestation are
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terminated by uterine evacuation either
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manual or electrical uterine aspiration
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or D&C in the second trimester pregnancy
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terminations are completed either by
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dilation and evacuation or labor
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induction dilation and evacuation or D&E
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is similar to D and C except that the
09:38
cervix is dilated further and forceps
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are used to extract fetal tissue rather
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than ice suction cannula cervical
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dilation is often initiated the day
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prior to the procedure using laminaria
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laminaria are osmotic dilators that
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mechanically open the cervix as they
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absorb fluid and expand
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second and third trimester abortions can
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also be performed as labor inductions
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prior to D&E or labor induction fetal
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demise can be caused by injections of
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intracardiac potassium chloride or intra
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amniotic versus intra fetal digoxin or
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by trans section of the umbilical cord
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after membrane rupture there are
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multiple options for carrying out
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abortion as a labor induction first the
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cervix can be dilated and ripened
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mechanically with a Foley catheter
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balloon placed through the cervix
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alternatively even if oppressed own and
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misoprostol can be used by the same
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mechanism as previously discussed in
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addition music rustle alone can be used
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as can several prostaglandins including
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Emma Frost and denna Pro stone
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ethic right and lactate can be given as
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an intramuscular extra amniotic or intra
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amniotic injection urea can also be
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given as an intra amniotic injection
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finally high-dose oxytocin can be given
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intravenously to cause uterine
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contractions
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intra amniotic injections are rarely
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used anymore in the United States the
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potential complications of abortion are
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the same for both management of
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spontaneous abortion and induced
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abortion these include bleeding that may
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require a blood transfusion infection
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that may require antibiotics perforation
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of the uterus that may lead to injury of
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other intra-abdominal organs cervical
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laceration from either tearing of a
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tenaculum or excessively forceful
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dilation retain products of conception
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that may require another procedure in
11:37
formation of intrauterine scar tissue
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that can cause infertility otherwise
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known as a Sherman syndrome acute hamato
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Mitra is also known as post abortive
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syndrome in which women develop heavy
11:49
cramping and an enlarged tender uterus
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but have minimal bleeding it is treated
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by immediate uterine evacuation the
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numbers listed on this slide for
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complication rates are for suction
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curettage abortions
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according to tillens operative
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gynecology complications are more likely
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to occur at later gestational ages it is
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important to note that induced abortion
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is very safe less than 0.3 percent of
12:15
all patients who undergo abortion need
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to be hospitalized for complication if
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performed at less than 8 weeks gestation
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the risk of death from induced abortion
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is less than 1 in 1 million whereas the
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risk of death is one in 29 thousand at
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16 to 20 weeks gestation
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risk are minimized when procedures are
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performed by experienced providers it is
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also important to note that abortion is
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much safer than childbirth for women
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finally multiple studies have
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demonstrated that induced abortion
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causes no harm to a woman’s mental or
12:47
emotional health and in fact may improve
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her emotional well-being by providing a
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sense of relief
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in summary abortion is a term that
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refers to loss of a pregnancy whether
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spontaneous or induced there are many
13:02
types of spontaneous abortions as well
13:04
as multiple fetal and maternal
13:05
conditions that increase the risk of
13:07
spontaneous abortion the options for
13:10
managing a spontaneous abortion are
13:11
similar to the options for induced
13:13
abortion and these vary depending on the
13:15
gestational age of the pregnancy the
13:18
incidence of spontaneous abortion and
13:19
induced abortion is high and it is thus
13:22
important to know how to care for these
13:23
patients
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you

Following a pregnancy loss prior to the 20th week, patients are naturally concerned for their future prognosis.

And we reassure these patients that early pregnancy loss occurs in about one out of every six pregnancies, it is usually caused by isolated chromosome abnormalities or placental malformations, it is not preventable, and that the next time the patient becomes pregnant, she will again have a one out of six chance of having a miscarriage.

While all of that is true, it is also true that with increasing numbers of consecutive miscarriages, the likelihood of another miscarriage does go up, and the causes of these miscarriages change. And that’s because while in general, the vast majority of early pregnancy losses are caused by isolated, non-recurring events, a few of them are related to ongoing problems. So if these women continue to have pregnancies and pregnancy losses, they ultimately will make up a much larger proportion of the miscarriage population.

Understand that I’m not talking about large numbers of women. Only 2 percent of pregnant women will experience two miscarriages in a row, and only 0.4% will experience three miscarriages in a row.

Independently, as women age, their risk of a miscarriage increases, from around 13% between age 20 to 30, up to 40% at age 40.

Recurrent pregnancy loss is usually defined as 3 or more consecutive pregnancy losses prior to the 20th week.

There are a number of identifiable causes for these recurrences, although for about 40% of patients, no cause can be determined with our current knowledge. But we can identify one or more causes in 60% of these patients, and the causes include:

Anatomic genital malformations
Endocrine abnormalities
Immunologic problems
Microbiologic causes
Genetic abnormalities

Because of the significant rise in risk of another miscarriage after three in a row, we usually initiate an evaluation to identify causes for recurrent pregnancy loss at that time, although some physicians in specific settings might begin the evaluation after two losses. The evaluation addresses each of the categories of causes for repetitive early pregnancy loss.

Chromosome evaluation

I obtain a blood karyotype from each partner, looking for such abnormalities as translocations, either balanced or Robertsonian, and mosaicism that might contribute to a lethal fetal defect. The yield on these tests is small, with about 4% of couples being positive for some significant structural abnormality. With some abnormalities, simply trying again for pregnancy may be the best option. With others, it may be wiser to pursue a course of donor insemination or donor eggs to avoid the chromosomal problem.

Anatomic Genital Malformations

Anything that distorts the normal uterine cavity shape and size can adversely affect conception and maintaining an early pregnancy. These abnormalities would include:

Uterine fibroids
Uterine didelphyc deformities such as a bicornuate or septate uterus
Endometrial polyps

The best way to evaluate the patient for these problems will vary with their history, physical exam, and available resources, but some commonly-used techniques include:

Sonohysterogram
Hysterosalpingogram
Transvaginal ultrasound
Hysteroscopy
Laparoscopy

Whenever a significant abnormality is identified, it usually can be surgically corrected.

Endocrine Abnormalities

Thyroid disorders, notably hypothyroidism, is associated with pregnancy loss, so a TSH and free T4 can rule out this problem. It may also prove useful to check the thyroid peroxidase antibody levels, since elevated TPO levels in euthyroid women have also been associated with pregnancy loss.

Diabetes, particularly poorly controlled diabetes has a significant association with early pregnancy loss, so it is valuable to rule out diabetes.

Polycystic ovary syndrome is associated with an increased risk of early loss. Screening for this may be helpful in identifying a cause for loss, but it is unclear whether such insulin-resistance modifiers as metformin will lead to improved outcome.

In contrast, hyperprolactinemia, also associated with early pregnancy loss, has been shown to be effectively reduced with bromcriptine, with an accompanying reduction in subsequent pregnancy loss rates.

Microbiologic Problems

Although infectious organisms can be associated with recurrent pregnancy loss in about 5% of cases, routine screening for Chlamydia, mycoplasma, bacterial vaginosis and toxoplasmosis has not been shown to be effective in lowering the recurrent loss rates.

For that reason, some physicians screen for these conditions while others do not. Whenever infectious agents are identified, specific antibiotics or antivirals can be prescribed. If no infectious organisms are identified, some physicians will provide a course of antibiotics to both partners empirically.

Immunologic issues

Both anticardiolipin antibodies and lupus anticoagulant are associated with recurring early pregnancy loss.

When identified, antiphospholipid syndrome can be treated with heparin or aspirin with an anticipated reduction in risk to future pregnancies.

Immunotherapy, in contrast, has not consistently demonstrated beneficial effects and its use in this setting would be considered experimental.

Progesterone Deficiency

For many years, patients with recurring early pregnancy loss were tested for the presence of a progesterone, or luteal phase deficiency. This was based on the observation that many miscarriages were preceded by a significant drop in serum progesterone. What is not clear is whether this drop is the cause of the miscarriage, or an effect of an abnormal pregnancy, destined to miscarry. Large, randomized, prospective studies are not available.

While some physicians continue to test for progesterone deficiency with luteal phase serum progesterones and endometrial biopsies and to prescribe progesterone to treat presumed deficiencies, others have abandoned this practice.