Abortion: Medical Overview PDF

Abortion Jason Ryan, MD, MPH Spontaneous Abortion Miscarriage, SAB Loss of viable uterine pregnancy prior to 20 weeks Occurs most commonly in first trimester (before 12 weeks) Often identified by falling serial hCG levels or ultrasound findings Presents clinically as vaginal bleedin...

Abortion Jason Ryan, MD, MPH Spontaneous Abortion Miscarriage, SAB Loss of viable uterine pregnancy prior to 20 weeks Occurs most commonly in first trimester (before 12 weeks) Often identified by falling serial hCG levels or ultrasound findings Presents clinically as vaginal bleeding and pelvic cramping Shutterstock Spontaneous Abortion Etiology Fetal chromosomal anomalies Found in ~ 70% pregnancy losses Maternal anatomic anomalies Uterine fibroids Uterine polyps or septa Abnormal implantation Corpus luteum failure TORCH infections Trauma Spontaneous Abortion Risk Factors Maternal age > 35 years Prior pregnancy loss Smoking and alcohol consumption Maternal disease Infection Diabetes Obesity Thyroid Thrombophilias Pixabay/Public Domain Spontaneous Abortion Workup Pelvic exam Confirm bleeding from cervix Assess cervical os Open os = loss of pregnancy likely Transvaginal Ultrasound Transvaginal ultrasound Assess for products of conception Assess fetal heartbeat Serial hCG and progesterone level HCG should ↑ at least 60% over 48 hrs ↓ progesterone associated with failed gestation or ectopic Shutterstock Complete Spontaneous Abortion Documented intrauterine pregnancy Bleeding and cramping Closed cervical OS No products of conception (POC) evident No evidence of ectopic pregnancy Management: supportive Antibiotics in some cases Methylergonovine may be used: ↓ retained tissue and infection risk Other Abortion Types Type Findings Bleeding and cramping Supportive care Threatened Closed os May stop or progress Fetal heartbeat if older than 6 weeks Bleeding and cramping Inevitable Open os Fetal heartbeat present Bleeding and cramping Surgery Incomplete Open os Medical No fetal heartbeat; POC partially expelled Expectant Bleeding and Cramping Missed Closed os No fetal heart beat; POC retained Threatened Abortion Bleeding in early pregnancy (< 20 weeks) Cervical os closed Pregnancy still viable May resolve or progress to spontaneous abortion Weekly ultrasounds and serial hCGs until bleeding resolves Increased risk of preterm labor or IUGR Common causes of bleeding that resolves: Implantation at time menses Cervical trauma during intercourse Subchorionic hemorrhage Spontaneous Abortion Inevitable, Incomplete, Missed Surgical evacuation: dilation and suction curettage Medical evacuation: mifepristone and misoprostol Mifepristone: progesterone antagonist Causes endometrial degeneration Only dispensed to limited facilities that perform terminations Misoprostol: prostaglandin E1 analog Causes uterine contractions Must be hemodynamically stable Must have no evidence of hemorrhage or infection Expectant management: allow natural passage of POC Septic Abortion Spontaneous abortion with intrauterine infection May occur with attempted self-abortion Vaginal bleeding and pelvic cramping Fever and foul-smelling discharge Treated with broad-spectrum antibiotics Surgical evacuation with suction curettage Increased risk of uterine perforation Suction less traumatic than sharp curettage Shutterstock Spontaneous Abortion Alloimmunization prevention Rh negative mothers administered Rh (D) immune globulin Intrauterine Fetal Demise Stillbirth or Fetal Death Pregnancy loss after 20 weeks Death before delivery During delivery: intrapartum demise Mother may note lack of movement Uterus may be small for gestational age Suspected by absence of fetal heart sounds Diagnosis: ultrasound Will show absence of fetal heartbeat Intrauterine Fetal Demise Selected Risk Factors Most cases have no identifiable etiology Congenital anomalies Fetal growth restriction Maternal infection – systemic or in utero Placental abruption Maternal chronic disease Cord accidents Drugs, especially crack cocaine Intrauterine Fetal Demise Management Before 24 weeks: dilation and evacuation (D&E) After 24 weeks: induction of labor Preferred route even if baby is breech Traumatic for families May allow delay until patient is ready Prolonged retention of fetus over weeks may cause DIC Intrauterine Fetal Demise Further Workup Fetal autopsy Placental examination Drug screen Fetal chromosome testing Testing for antiphospholipid syndrome Testing for fetomaternal hemorrhage Fetomaternal Hemorrhage Bleeding without trauma or abruption Large hemorrhage can present as fetal death Diagnosis: Kleihauer-Betke acid elution assay Test of red cells in maternal circulation Detects hemoglobin F in fetal red cells Reports percentage fetal red cells in circulation Alternative: flow cytometry Uses monoclonal antibody to hemoglobin F Recurrent Pregnancy Loss Three or more consecutive pregnancy losses Many potential causes Recurrent Pregnancy Loss Selected Common Testing Uterine hysterosalpingography or sonohysterography Hysterosalpingography: fluoroscopy of uterus and fallopian tubes Sonohysterography: ultrasound of uterus filled with saline contrast Karyotype of parents Anticardiolipin antibodies and lupus anticoagulant TSH Cervical Insufficiency Inability of cervix to retain pregnancy in second trimester Recurrent second-trimester pregnancy losses Mild symptoms with pregnancy loss Absence of significant bleeding, cramping or contractions Contrast with spontaneous abortion Often < 20 weeks Often associated with cramping and contractions Cancer Research UK Cervical Insufficiency Diagnostic Criteria Method Criteria ≥2 consecutive second-trimester losses Obstetric History No or mild symptoms Second-trimester cervical length < 25mm Ultrasound Plus prior loss or preterm delivery Physical Exam Dilated and effaced cervix in early pregnancy Cervical Insufficiency Cervical Cerclage Treatments: cerclage and vaginal progesterone Cerclage: cervical stabilization with stitching Avoid exercise during pregnancy Shutterstock Elective Abortion Legalized in the U.S. in 1973 case Roe v. Wade Performed before 24 weeks (fetal viability) Extra-uterine survival before 24 weeks less likely After 24 weeks survival more likely “Late-term” abortions occur 21 to 24 weeks Medical and surgical options Medical abortion (less than 10 weeks): mifepristone/misoprostol