Abortion


Abortion is defined as loss of pregnancy at less than 20 weeks of gestation. Bleeding is often the identifying symptom.
Abortion may be classified as spontaneous or induced. Spontaneous abortions include missed, threatened, complete, incomplete, inevitable, habitual/recurrent, and tubal abortions. An example of an induced abortion is that of septic.
The above categories of abortion occur via several different mechanisms:
  • A missed abortion is when a diagnosis was not made immediately due to lack of symptoms
  • Incomplete abortion is when some parts of the fetus are retained
  • Complete abortion is when all parts of the fetus are eliminated
  • Threatened abortion refers to fetus being viable and is the most common form of abortion
  • Habitual/recurrent abortion refers to more than 3 consecutive losses of fetuses in their first trimester. This is rare as probability of continuous losses decreases (probability of a first miscarriage is that of approximately 25%)
  • Inevitable abortion occurs when the internal os is open upon vaginal examination. In first trimester, the internal os should always be closed

Causes



Factors associated with abortions include:
Thrombophilia (often the most common cause, including antiPL, LA, Factor V Leiden)
Antiphospholipids
Infective causes such as Toxoplasmosis, other (syphilis), Rubella, HepC (ToRCH)
Endocrinological causes e.g. TSH, DM (Hb1AC)
Genetic- balanced translation, parental chromosomes
Structural- uterine abnormalities e.g. Asherman’s syndrome (adhesions post repeated curettage surgeries)

History



LMP
Cycle length!!
Contraception, pap smear, PV discharge
Pain, febrile?

Examination


Vitals: HR, temp, BP
Abdominal Examination
Vaginal Examination
+/- Speculum Exam
+/- Bimanual Exam

Bimanual Examination:
  • Os open/closed
  • Adnexal tenderness (Ovaries, tubes etc) suggestive of PID, endometriosis
  • Adnexal masses
  • Cervical excitation
  • Uterus size (using descriptions below)
abortion_3.jpg

Investigation


Beta HCG (peaks around week 4, then goes down; > 1,500-2,000 can pick up intrauterine pregnancy)
Blood group and hold + antibody screen (IMPORTANT) For all women who bleed. Rh+ve (90%) ie if mother is Rh-ve, presume baby is Rh+ve (ie need to infuse AntiD to prevent antibodies from crossing the placenta.
U/S (transvaginal better than transabdominal at earlier stages- better resolution; picks up pregnancy in 5-6 weeks’ gestation)
FBE

DDx:
  • threatened abortion
  • Incomplete abortion
N.B. blood in POD (pouch of Douglas) means ruptured ectopion, ovarian cyst or endometriosis


Critical Management




Resucitate- fluid iv, O2 sat
FBE, Group and hold
Coagulation status
Beta HCG

O/E: abdomen soft, not distended, no rebound (ie no peritonitis)
DDx: ruptured ovarian cyst; Incomplete abortion
Ie O/E continued: speculum exam





Termination Pregnancy

The Law



Termination decriminalised in 2008 (Vic)
1. Allowed up to 24 weeks
2. > 24 weeks: 2 doctors consent,
if appropriate in all circumstances, including physical, psychological, social

Epidemiology


1 abortion: 3 live births (Victoria)
Perhaps role for education re: contraception here
Incidence of TOP is low in UK, Switzerlands, possibly associated with distribution of contraceptives

2/5 illegal abortions worldwide. Esp parts of S. America, Africa, parts of China, herbs/sticks/disinfectants in utero
Cx: sepsis, bowel problems, fistula

Medical (malignancy, foetal abnormalities, ingestion of teratogenic material)
Psychiatric, psychosocial (mostly economic)

Mortality


Risk of childbirth: 1st trim abortion = 11 : 1
90% abortions performed in first trimester
98% vacuum aspiration (Wu & Wu)
anaesthetics- general or local, paracervical block

Counselling:


Determine the reason/s
Discuss the implications
Offer emotional support
Discuss future contraceptive options

Typical Management Timeline


Monday: Hx, Ex [+/-] (U/S, Ix, psychologist)
Friday: TASC (therapeutic abortion suction curettage- pseudonym for TOP)

Surgical Termination Procedure



  • Cervical dilatation
Cervical preparation: misoprostol 400microgram (inserted vaginally) by woman 3hrs beforehand
Misoprostol is a Pg, cheap, 2 hexagonal tablets
The cervix should be dilated as atraumatically as possible, and as little as necessary.
  • Oxytocic drug
0.25mg Ergometrine IV
or
Syntocin (O/U IV)
  • Suction currettage perfored under vacuum pressure of 800mmHg
Equipments: Sim's speculum, dilators (go up to stage of gestation), currettes, Rampley's forceps (swab in Betadine/antiseptics)
  • Doxycyclin- 100mg 1hr prior, 200mg 2hrs after
N.B. for 2nd trimester termination, apply D&E with misoprostol 400microgram (vaginally 3 hours before); gameprostat 0.5-1mg (vaginally, 3-6 h before)

Medical Termination


Safe, effective, accessible.
95% rate success, 5% curretage required, 1% failure
  • 1st line Mifiprostone RU486 (anti-progestogen) 200mg
  • with 800microgram misoprostol (applied vaginally 48h later)
  • 2nd line Methotrexate 50mg/m2
  • with misoprostol 800microgram misoprostol (applied vaginally 7days later)
N.B. for 2nd trimester termination, vaginal PGE, or PGE2; intra-amniotic PGs, intramuscular PGs; then woman enters labour for 12-24 hours

Complications


1:100,000 mortality, with increased mortality with increased gestation and anaesthetic risks

4 major reasons:
  • infection
  • thromboembolism
  • haemorrhage
  • anaesthesia
Early complications:
  • uterine perforation (esp at cervical-uterine junction)
  • haemorrhage
  • cervical laceration
  • retained products (misoprostol Mx)
Late complicataions:
  • retained products
  • pelvic infection
  • anaemia
  • thromboembolism
  • cervical stenosis
No association with: later infertility, ectopic, non-viable pregnancy, breast CA
Children born as result of failed abortion experience problems in early education etc.