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1. SECTION III: ANTEPARTUM
Surgical Block
2012
1 Williams OBSTETRICS 23rd
Edition
CHAPTER 9
Abortion
Dr. Aida San Jose
INTRODUCTION
Abortion
termination of pregnancy, either spontaneously or
intentionally by any means before the fetus is sufficiently
developed to survive; premature birth before a live birth
is possible
On or before 20 weeks of gestation
 if over 20 weeks it will be called PRETERM not
abortion
Birth weight: < 500 grams
Crown rump length: <160 mm (16cm)
3 types:
 Spontaneous Abortion
 Induced Abortion
 Septic Abortion
SPONTANEOUS ABORTION
Spontaneous Abortion
Aka: MISCARRIAGE:
Abortion occurring without medical or mechanical means
to empty the uterus
Pathology:
 hemorrhage into the decidua basalis  necrotic
changes in the tissues adjacent to the bleeding
 Early Abortion
 ovum detaches, stimulating uterine contractions
that results in its expulsion
 death of the product of conception
 BLIGHTED OVUM
 When a gestational sac is opened, fluid is
commonly found surrounding a small
macerated fetus or alternatively no fetus is
visible
 Associated with missed abortion
 diagnosis by ULTRASOUND
 Late Abortions
 possible outcomes:
 MACERATION:
 Skull bone collapse, abdomen distends
with blood stained fluid and internal
organs degenerate, skin softens and
peels off in utero or at the slightest
touch
 Seen in late fetal death or when there is
death of product conception, even after
20 AOG
 FETUS COMPRESSUS:
 When amnionic fluid is absorbed, the
fetus may become compressed and
desiccated
 FETUS PAPYRACEOUS:
 Fetus may become so dry and
compressed that it resembles
parchment paper or calcified fetus
Etiology:
 > 80% occur in the 1
st
12 weeks of pregnancy
 ABNORMALITIES IN CHROMOSOMAL NUMBER
 About 50% to 60% of early ABORTIONS
 MOST COMMON CAUSE OF EARLY
SPONTANEOUS ABORTIONS (1
st
Trimester)
 After the first trimester both the abortion rate
and the incidence of chromosomal anomalies
decrease
 Significant chromosomal anomalies usually get
aborted in first trimester; hence less
chromosomal anomalies goes past 1
st
trimester
 Risk INCREASE with increased:
 Parity
 Paternal age
 Maternal age
Mechanisms
 not entirely clear
 Very early abortion
 embryonic death PRECEDES expulsion of ovum
 Dead embryo will act like a foreign body
and will subsequently be detached from
uterine wall and is expelled
 Late abortion
 fetus does not die in utero before expulsion, it is
ALIVE DURING EXPULSION
Factors That Causes
Spontaneous Abortion
Fetal factors
 ABNORMAL ZYGOTE/ EMBRYO DEVELOPMENT
 Cause EARLY SPONTANEOUS ABORTION
 Commonly display a developmental abnormality of
the zygote, embryo, early fetus, or at times the
placenta
 Of 1000 spontaneous abortions, half (500)
demonstrated degenerated or absent embryos 
BLIGHTED OVUM
 Morphological disorganization of growth in 40% of
abortuses
 50-60% Can be due to chromosomal abnormality
 CLASSIFICATIONS
 ANEUPLOIDY ABORTION (abnormal number of
chromosomes)
 50 to 60% of embryos and early fetuses that are
spontaneously aborted contain chromosomal
abnormalities
 95% of chromosomal abnormalities were due to
MATERNAL GAMETOGENESIS ERRORS
 5% due to PATERNAL ERRORS.
 Tend to expelled in early pregnancy:
 8 to 10 week AOG

2. SECTION III: ANTEPARTUM
Surgical Block
2012
2 Williams OBSTETRICS 23rd
Edition
 Can cause EARLY ABORTION
 AUTOSOMAL TRISOMY
 Most frequent chromosomal anomaly in 1
st
trimester abortion
 PATHOPHYSIOLOGY
 Isolated Non-Dysjunction
 most common cause of trisomies
 Balanced structural chromosomal
rearrangements
 present in one partner in 2% to 4%
of couples with a history of
recurrent abortions
 require work up
 Karyotyping
 chromosomal inversion
 For all autosomes except chromosome
number 1, have been identified in abortuses
 Autosomes 13, 16, 18 (Edwards
Syndrome), 21 (Downs Syndrome) And 22
are found most commonly.
 SEX CHROMOSOME MONOSOMY X (45, X)
 Single most common specific chromosomal
abnormalities
 Usually results in abortion and much less
frequently in live born females
 Turner Syndrome
 can be compatible with life
 AUTOSOMAL MONOSOMY
 rare and incompatible with life
 TRIPLOIDY
 Seen in gestational trophoblastic disease
like
 partial H-mole
 hydropic placental (molar)
degeneration
 Incomplete (partial) hydatidiform:
 69XXY
 moles may contain triploidy for only
chromosome 16
 can be born alive
 Advanced maternal and paternal age does
not increase the incidence
 complete H-mole is common among
advanced maternal & paternal age
 TETRAPLOID
 Rarely liveborn
 most often aborted early in gestation
 CHROMOSOMAL STRUCTURAL ABNORMALITY
 Identified only since the development of
banding techniques
 infrequently cause abortion.
 Some infants who are live born with a
balanced translocation may appear normal
 SEX CHROMOSOME TRISOME
 (47, XXY): Klinefelter’s Syndrome
 (47, XXX): Super Female
 EUPLOID ABORTION (abnormal development with a
normal chromosomal complement)
 Tend to abort later in pregnancy
 expulsion 13 weeks AOG: LATE ABORTION
 Incidence  dramatically after maternal age
exceeds 35 years
Maternal factors:
 Infections:
 Uncommon cause of early abortion
 associated with Recurrent Pregnancy Loss (3 or
more consecutive pregnancy losses)
 chromosomal abnormality is only 5% of the
cause of recurrent abortion
 Associated with BACTERIAL VAGINOSIS:
 occur in the 2
nd
trimester abortion
 Not with 1
st
trimester abortion
 Associated with spontaneous abortion in
humans
 Abortion may also be associated with serological
evidence of:
 Syphilis
 HIV1
 vaginal colonization with group B streptococci
 Infections that DOES NOT INCREASE INCIDENCE of
spontaneous abortion
 Brucella abortus, campylobacter fetus
 Cause chronic abortion in CATTLE not in
human
 Listeria monocytogenes & Chlamydia
trachomatis
 Herpes simplex virus
 mycoplasma hominis, ureaplasma urealyticum
 Chlamydia trachomatis
 Chronic debilitating illness
 TUBERCULOSIS AND CARCINOMATOSIS
 seldom abort, more on fetal death not abortion
 CELIAC SPRUE
 Cause male and female infertility and recurrent
abortion
 Endocrine Abnormalities
 Hypothyroidism
 Thyroid hormone deficiency
 common in women
 caused by an autoimmune disorder
 1
st
problem: problems with ovulation or getting
pregnant
 Severe iodine deficiency
 associated with miscarriages
 Any effects of hypothyroidism on early
pregnancy loss: not adequately studied
 thyroid auto-antibodies
  incidence of miscarriage
 Data less convincing that women with recurrent
miscarriage have increased incidence of
antithyroid antibodies than normal controls
 It can cause abnormal uterine bleeding
 once become pregnant usually they are
euthyroid
 Work up: TSH, T3 & T4
 Diabetes Mellitus
 Insulin-dependent diabetes
  rate of spontaneous abortion and major
congenital malformations

3. SECTION III: ANTEPARTUM
Surgical Block
2012
3 Williams OBSTETRICS 23rd
Edition
 Related to the degree of metabolic control in
the 1st trimester
 If the is excellent glucose control within 21
days of conception  spontaneous
abortion rate similar to that in nondiabetic
controls
 Poor glycemic control can lead to:
 spontaneous abortion in 1
st
trimester
 congenital malformation
 Large Baby
 Progesterone deficiency
 LUTEAL PHASE DEFECT
 Aka: corpus luteum defect, luteal phase
inadequacy
 insufficient progesterone secretion by the
corpus luteum or placenta
 Progesterone is supposed to sustain the
early pregnancy
 Corpus luteum produce progesterone till 6
to 7 weeks then placenta takes over around
7
th
to 8
th
week
 < 8 to 10 weeks AOG
 If corpus luteum is removed,
progesterone replacement is indicated
 Later in pregnancy, placenta will take over
producing progesterone and corpus luteum
degenerates
 CLINICAL CASE: OVARIAN CYST
 if contains corpus luteum of pregnancy,
delay intervention.
 Do not remove until the placenta take
over for the secretion of progesterone
because CL is the one that sustains in
the early pregnancy
 if cyst is remove with CL, it can cause
early abortion
 unless there is a life threatening
situation/emergency (6-7 wk AOG) then
remove ovarian cyst.
  Progesterone whether a problem in
delivery or utilization, can lead to recurrent
pregnancy loss
 Nutrition
 Dietary deficiency of any one nutrient or moderate
deficiency of all nutrients DO NOT appear important
causes of abortion
 Early pregnancy nausea and vomiting rarely followed
by spontaneous abortion
 Example: women underwent starvation during WWII
or hyperemesis gravidarum
 reduced risk in women who ate fresh fruit and
vegetables daily.
 Drug Use & Environmental Factors
 Tobacco
 Increase risk of Euploid abortion (>14
sticks/day)
 10 sticks/ day can even cause abortion
 Risk is 1.2 for each 10 cigarettes smoke per day
(1992)
 Failed to support association (2003)
 Still advised to pregnant women to stop
smoking
 Alcohol
 First 8 weeks AOG: frequent alcohol use causes
both spontaneous abortion and fetal anomalies
 Risk seems to be related to both the frequency
and dose
 Low level of consumption: no significant risk
of abortion
 no safe dose specified for young women)
 Fetal alcohol syndrome:
 facial deformity
 long philtrum, no cupids bow
 mental retardation
 growth restriction
 Drug classification: TERATOGEN
 Caffeine
  risk of abortion if:
 > 4 cups/day
 > 500 mg of caffeine a day
 PARAXANTHINE
 caffeine metabolite
 extreme  levels a/w twofold risk of
abortion
 Radiation
 Abortifacient in therapeutic doses (CA tx)
 Human dose to effect abortion is NOT precisely
known
 <5 rads
 no increased risk
 5 rads is the MINIMUM LETHAL DOSE (MLD)
 Avoid radiation as much as possible
 PREVENTIVE MEASURE
 Pregnant woman with pneumonia and
needed to have chest X-ray:
 put lead shield/apron shield on the
abdomen
 Contraception
 OCs or spermicidal agents
 NOT a/w  incidence of abortion
 NOT an abortifacient but can be teratogenic
or cause adverse sequelae:
 Continuous intake of high doses of
estrogen & progestin can lead to
developmental anomalies of fetus
 Hypospadias in male fetus due to
diesterolesterase
 When IUD fails to prevent pregnancy
 the risk of abortion, and especially septic
abortion, increases substantially
 IUD can cause ectopic implantation of
blastocyst
 The main action is to prevent
intrauterine pregnancy and not an
ectopic pregnancy
 what do we do? Pull out the IUD.
 Ectopic pregnancy Normal abortion
rate: 20% to 25%
 if you don’t pull out the IUD still
can cause abortion.
 Environmental toxins
 Possible abortifacient:

4. SECTION III: ANTEPARTUM
Surgical Block
2012
4 Williams OBSTETRICS 23rd
Edition
 Arsenic, lead, formaldehyde, benzene,
ethylene oxide, nitrous oxide
 especially in rooms without GAS-
SCAVENGING SYSTEM
 all operating rooms should have
gas scavenging system to prevent
accumulation of nitrous oxide in
room
 If a women is exposed to nitric
oxide without a gas scavenging
system, it can cause abortion.
 NO effects of abortion on any AOG
 video display terminals, ultrasound,
computers
 Autoimmune factors
 Recurrent abortion before 12 weeks along with
laboratory criteria for cardiolipin antibodies or lupus
anticoagulant satisfy the diagnosis
 ANTI-PHOSPHOLIPID ANTIBODIES:
 IgG, IgA or IgM
 Involves placental thrombosis and infarction and
recurrent pregnancy loss
 Autoimmune factors are responsible for 25 to 40% of
recurrent pregnancy lost.
 ANTIPHOSPHOLIPID ANTIBODY SYNDROME (APAS
SYNDROME):
 (+) anticardiolipin or lupus anticoagulant
 contribute to a major percentage of the risk for
recurrent pregnancy lost
 autoimmune mechanism
 Postulated mechanism
 Antiphospholid Antibodies may inhibit the
release of prostacyclin, a potent vasodilator
and inhibitor of platelet aggregation & will
lead to more synthesis of thromboxane
 Platelets produce thromboxane A2: potent
vasoconstrictor, enhance platelet
aggregation
 Leads to thrombosis, infarction & fetal
loss
 Inhibit protein C activation resulting to
fibrin activation & coagulation
 MANAGEMENT
 low dose aspirin and heparin
 thoughout pregnancy
 stopped 2 weeks prior to labor and
delivery to avoid bleeding.
 Stopped by 36 weeks coz 38 weeks is
considered the average time that
women go into labor
 Increased SECOND-TRIMESTER pregnancy losses
 TESTS:
 Activated PTT
 Characterized by
 moderate to high levels of phospholipid IgG
antibodies
 variable incidence of thrombosis,
thrombocytopenia and fetal loss
 Women who are Dx with APAS have higher risk
of secondary pregnancy complications:
 Preeclampsia
 fetal death
 Alloimmune factor:
 Causes recurrent abortion
 Maternal rejection of foreign fetal antigens that are
paternally derived
 Treatment modalities
 Paternal cell immunization
 3
rd
party donor leukocytes
 Trophoblast membranes
 IV Immunoglobin
 Inherited thrombophilias:
  risk of thrombosis & cardiovascular accident
 Proper treatment trials have not been conducted to
determine whether abortion might be prevented
 Caused by mutations of genes for:
 factor V leiden
 prothrombin, antithrombin
 proteins C & S
 methylene tetrahydrofolate reductase (hyper-
homocysteinemia)
 Mx: Folic acid supplemetation
 Laparotomy:
 Uncomplicated abdominal or pelvic surgery done in
early pregnancy does NOT appear to increase risk of
abortion
 Important exception:
 early removal of corpus luteum in an ovarian
cyst in < 10 weeks AOG
 if removed b/w 8-10 weeks, give 1 dose IM
17-hydroxyprogesterone caproate 150 mg
after surgery
 if removed b/w 6-8 weeks: give 3 doses IM
17-hydroxyprogesterone caproate 150 mg
given 1 & 2 weeks after 1
st
dose
 Physical trauma
 Major abdominal trauma can precipitate abortion
 Vehicular accidents: involving a direct blow to
the abdomen
 Minor trauma
 risk of abortion is not known
 slipping do not contribute to incidence of
abortion
 In general, trauma contributes minimally to the
incidence of abortion
 Uterine defects:
 ACQUIRED UTERINE DEFECTS
 Large and multiple leiomyomas
 Most Common benign tumor of the uterus
 May cause miscarriage but location is more
important than their size
 Intramural
 within the uterine wall
 Subserous
 located in the serosa outside the
mymetrium
 Submucous
 within uterine cavity which is the
most common
 More clinically significant
 Located w/in endometrial cavity
 Protrudes into uterine cavity

5. SECTION III: ANTEPARTUM
Surgical Block
2012
5 Williams OBSTETRICS 23rd
Edition
 If large and especially if blastocyst
implants on submucous myoma 
increased incidence of abortion
 ASHERMANN SYNDROME:
 Aka: Uterine Synechiae
 d/t destruction of large areas of the
endometrium by curettage where amount
of remaining endometrium may be
insufficient to support pregnancy 
abortion
 Intrauterine adhesions develop possibly d/t
intrauterine procedures
 Imaging Test
 Hysterosalpingogram
 Show characteristic multiple filling
defects
 Hysteroscopy
 Give more accurate dx
 DEVELOPMENTAL UTERINE DEFECTS
 Anormal Mullerian Duct Formation or Fusion
 may develop spontaneously or may follow
in utero exposure to diethylstilbestrol (DES)
 Uterus Didelphys, Cornate, Unicornate And
Septate Uterus, Uterine Septum
 congenital uterine defects. Acquired
 SEPTATE UTERUS
 most common defect of the uterus that
causes abortion
 DOUBLE HORN OR BICONUATE UTERUS
 One blastocyst can implant on one horn
 No incidence of increased abortion
 MANAGEMENT
 Corrective surgery is done as a last resort
 can improve success in pregnancy:
 Uterus Didelphys
 can do metroplasty to connect the
tube, so it will be big enough for
the pregnancy
 Incompetent cervix:
 weakening of cervical os, product of conception can
pass thru before reaching term
 Cervix is partially dilated already leading to painless
dilatation of the cervix in the 2
nd
or early 3
rd
trimester with prolapsed and ballooning of
membranes into the vagina and expulsion of
immature fetus
 IMAGING
 Transvaginal ultrasound:
 Shows funneling but with a closed external
os.
 Expulsion of conceptus usually occurs in 2
nd
or 3
rd
trimester, NOT on 1
st
trimester
 In 1
st
trimester: cervix is still strong enough to
hold product of conception since fetus is still
small
 As product becomes bigger after the 1
st
trimester; this cervix now progressively dilates
and the product of conception is expelled
 When is the BEST TIME TO DIAGNOSE INCOMPETENT
CERVIX?
 Test patient when she is not pregnant to fully
assess the cervix
 Use Transvaginal Ultrasound
 ETIOLOGY
 incompetent cervix, can be acquired and
developmental.
 DEVELOPMENTAL:
 Can arise d/t exposure of female offspring
to high doses of diethyldestriol (DES).
 ACQUIRED
 Develop after repeated trauma to the
cervix.
 D & C
 conisation (cone biopsy)
 done w/ suspicion of intraepithelial
neoplasia that is already CIN3,
 excising a cone shaped area on the
cervix
 purpose: to RULE OUT or confirm
diagnosis of a non invasive
carcinoma of a cervix (CIN3)
 cauterization
 amputation
 history and diagnosis of incompetent cervix
 presumptive
 suspect the diagnosis when you see repeated
history of painless effacement and dilatation of
the cervix with subsequent rupture of bag of
waters and expulsion of premature product of
conception.
 Treatment:
 CERCLAGE:
 Done usually on the 15
th
to 18
th
week AOG
and NOT done beyond 24
th
to 26
th
week
 McDonald’s Cerclage
 application of a series of first trimester
sutures applied all around the body of
cervix at the level of internal os and tie
it up to  the diameter of the cervix t0
5-10 mm
 most popular type of cerclage
procedure
 Shirodkar Cerclage
 Used when the McDonald’s approach
failed
 Contraindications:
 Bleeding
 uterine contractions
 rupture membranes
 Complications:
 membrane rupture
 chorioamnionitis
 intrauterine infection.
Paternal factors
 little is known
 Chromosomal abnormalities in sperm
 Certain spermatozoa can carry this
 chromosomal translocations within the genes of the
father can cause chromosomal abnormalities

6. SECTION III: ANTEPARTUM
Surgical Block
2012
6 Williams OBSTETRICS 23rd
Edition
Clinical Classification of
Spontaneous Abortion
Clinical Classifications
Threatened abortion
Inevitable abortion
Incomplete abortion
Complete abortion
Missed Abortion
Threatened abortion
Clinical diagnosis:
 Bloody vaginal discharge or bleeding appears through
a closed cervical os during the first half of pregnancy
Fetuses are at increased risk for:
 preterm delivery
 low birthweight
 perinatal death
Pain of abortion may manifest:
 Anterior and clearly rhythmic cramps
 Persistent low back ache
Associated with pelvic pressure
PRESENTAION
 (+) pregnancy test
 minimal or sometimes moderate vaginal bleeding that
may persist for days or week
 pelvic examination
 cervix is close w/ uterus compatible with the
gestational age
 brownish spotting or discharge
 hypogastric pain/abdominal cramps w/c follows a few
hours to several days after bleeding
MANAGEMENT
 no effective therapies
 observation and conservative Mx
 Bed rest, although often prescribed, does not
alter its course
 Acetaminophen-based analgesia may be given
for discomfort
 transvaginal sonography, serial serum
quantitative human chorionic gonadotropin
(hCG), and serum progesterone levels, used
alone or in combination, are analyzed to
ascertain if the fetus is alive and within the
uterus.
 With persistent or heavy bleeding, a hematocrit is
performed, and if there is significant anemia or
hypovolemia, then pregnancy evacuation is usually
indicated.
Risk for Miscarriage
 bleeding usually begins first, and cramping abdominal
pain follows a few hours to several days later.
 pain may present as anterior and clearly rhythmic
cramps; as a persistent low backache, associated with
a feeling of pelvic pressure; or as a dull, midline,
suprapubic discomfort.
 Whichever form the pain takes, the COMBINATION
OF BLEEDING AND PAIN PREDICTS A POOR
PROGNOSIS for pregnancy continuation.
DDx
 ectopic pregnancy
 should always be considered in the differential
diagnosis of threatened abortion
 ovarian torsion
Diagnosis:
 vaginal ultrasound, serums beta-HCG (especially to
r/o molar pregnancy), serum progesterone
 I/E
 Cervix is closed
 Uterus size is as expected w/ AOG
Inevitable abortion
unavoidable abortion
clinical features:
 gross rupture of membranes in presence of cervical
dilatation
 passage of amniotic fluid from the cervix
 uterine contractions begin or infection develops
diagnosis:
 speculum exam:
 passage of amniotic fluid and protein in the
cervix
 fetus is small for gestational age
treatment/management:
 without pain or bleeding:
 complete bed rest and observed
 with gush or fluid, pain bleeding and fever:
 abortion inevitable
 I/E
 Cervix is open
 Uterus initially as expected w/ AOG but size
then decrease
 Tx:
 uterus emptied (D & C)
Complete abortion
clinical features:
 complete detachment and expulsion of the fetus 
bleeding eventually stops, internal cervical os closes,
and the cramps stop.
 This is more common in the early cases of abortion <8
wks AOG
diagnosis:
 UTZ: will show an empty uterus
 PREGNANCY TEST: if several days have passed,
pregnancy test which will be negative
 I/E: uterus small
treatment/management:
 just do a plain observation. Just tell her to rest for 2
weeks from work.
 No need for D&C
Incomplete Abortion
most commonly seen in the hospital
MOST COMMON CAUSE OF PROFUSE BLEEDING
 Placental parts act as splints preventing closure of
blood vessels causing profuse bleeding
clinical features:
 placenta in whole or in part, detaches from the
uterus, bleeding ensues
 internal cervical os remains open and allows passage
of blood, presence of profuse or moderate bleeding
 uterus is smaller the AOG

7. SECTION III: ANTEPARTUM
Surgical Block
2012
7 Williams OBSTETRICS 23rd
Edition
diagnosis:
 internal exam
 ultrasound
 shows retained products of conception
treatment/management:
 expectant management
 completion curettage
 extraction by ring forceps
 used if placental tissue lies loosely in the cervical
canal
 Antibiotic
 Given before curettage if mom has fever
Missed Abortion
Early Pregnancy Failure
clinical features:
 uterus retains dead product of conception behind a
closed cervical os for days or even weeks
 early pregnancy
 appears normal, with amenorrhea, nausea and
vomiting, breast tenderness, and growth of the
uterus
 later on when fetus has died
 signs & symptoms of pregnancy will stop
 breasts starts to sag & women lose a few
pounds
 abdomen does not grow any bigger
 cervix still closed
 uterus smaller than AOG
 there maybe no bleeding at all since cervix is
closed
diagnosis: ULTRASOUND
 (+) blighted ovum or dead products of conception or
abnormal gestational sac
Treatment:
 Sometimes we wait for 1 week before doing any
intervention
 Repeat UTZ after 1 week if no fetal heart sound,
remove fetus due to risk of consumption
coagulopathy or DIC
 medical
 medication to ripen and dilate cervix
 surgical
 completion curettage
OTHER TYPES OF ABORTION
Recurrent miscarriage
Definition:
 AKA: Recurrent Spontaneous Abortion & Recurrent
Pregnancy Loss
 Refers to three or more consecutive pregnancy losses
at 20 weeks or less w/ fetal weights less than 500 g
Causes:
 Genetic (2 to 4%)
 Anatomical (7 to 15%)
 Uterus didelphys
 Bicornuate uterus
 Asherman Syndrome
 Leiomyomas
 Immunological (15-40%)
 Autoimmune theory:
 immunity against self
 APAS
 Found in women w/ SLE and in normal
women
 Causes midpregnancy fetal death
 One of the criterion for APAS
 Tx
 Low dose aspirin w/ or w/o heparin
 Alloimmune theory:
 immunity against another person
 Inherited Thrombophilias
 Endocrine (8 to 12%)
 Polycystic Ovarian Syndrome
 2 mechanisms
  LH
 Direct effects of hyperinsulinemia on
ovarian function
 Tx: Metformin before & during
pregnancy
 Also  gestational DM & fetal
growth restriction
 DM
 Hypothyroidism
 Infection (<10%)
Workup:
 parental karyotyping
 chromosomal abnormalities account for 2-4 % of
recurrent losses
 ♀:♂ratio 2:1
 parental cytogenic analysis
 Lupus anticoagulant anticardiolipin antibodies assay
 hCG
 serum progesterone
 HSG
 HSSG
 r/o anatomic defects
 aPTT
 dDVVT
 TSH, T3, T4
 r/o infections
Induced abortion
Clinical features:
 Medical or surgical termination of pregnancy before
the time of fetal viability
 Illegal in the Philippines
 abortion ratio 238/1000 live birth
 abortion rate: 16 /1000 women aged 15 – 44 y.o.
 60% performed first 8 wks, 88% first 12 wks
Classification
 Therapeutic abortion
 Termination of pregnancy before the period of
fetal viability for the purpose of saving the life of
the mother
 To prevent serious or permanent bodily injury to
the mother
 To preserve the life of the mother
 Indications:

8. SECTION III: ANTEPARTUM
Surgical Block
2012
8 Williams OBSTETRICS 23rd
Edition
 Persistent heart disease after cardiac
decompensation
 Advanced hypertensive vascular
disease or diabetes
 Invasive CA of the cervix
 Pregnancy resulting from rape or incest
 Birth of a child with possible
deformities and mental retardation
 Elective (VOLUNTARY) Abortion
 Interruption of pregnancy before viability at the
request of the woman but not for reason of
impaired maternal health or fetal disease
 Counselling:
 Continued pregnancy with its risks and
parental responsibilities
 Continued pregnancy with its risks and
responsibilities of arranged adoption
 Choice of abortion with its risks
 American College of Obstetricians &
Gynecologists (ACOG) support legal right of
women to obtain an abortion
EARLY ABORTION TECHNIQUES
 Surgical techniques
 Cervical Dilation
 Dilatation and curettage
 Dilating the cervix  evacuating the
pregnancy by:
 mechanically scraping out the
contents (sharp curettage)
 suctioning out the contents
(suction curettage)
 vacuum aspiration
 most common form of
suction curettage
 Dilators used: Hagar Dilator
 Complications:
 Uterine perforation
 Cervical laceration
 Hemorrhage
 Incomplete removal of fetus and
placenta: aka Incomplete
Curettage
 Infections
 Do antimicrobial prophylaxis
 indications
 H-mole
 Pregnancy before 14 -15 weeks
AOG
 Dilation & Evacualtion
 Done is pregnancy is at 16 weeks AOG
 Devices used:
 Hygroscopic Dilators
 Protaglandins: Misoprostol
 Menstrual aspiration
 menstrual induction or menstrual expulsion
 Devices used
 Karman Cannula
 Indication:
 H-mole
 involves the use of 20 mL syringe attached to a
foley ethylene tubing and is inserted into the
cervix & uterus and is more for early delays in
the menstrual period with a possible pregnancy
test.
 Done more by unscrupulous people
 Aka:
 Menstrual extraction
 Menstrual induction
 Instant period
 Mini abortion
 Traumatic abortion
 Manual Vacuum Aspiration
 similar to menstrual aspiration but is used
for early pregnancy failures as well as
elective termination up to 12 weeks
 Laparotomy
 Abdominal Hysterectomy
 especially for:
 septic abortion that does not respond
to antibiotics
 Significant uterine disease
 open up the patient scope out the product
of conception then if she’s multipara
bilateral tubal ligation maybe necessary
 Abdominal hysterotomy
 +/- Bilateral tubal ligation

9. SECTION III: ANTEPARTUM
Surgical Block
2012
9 Williams OBSTETRICS 23rd
Edition
Medical induction of abortion
 1st Trimester Abortion
 3 Widely used medications for EARLY MEDICAL
ABORTION
 Antiprogestin MIFEPRISTONE &
Antimetabolite METHOTREXATE:
 Both Increase uterine contractility by
reversing the progesterone-induced
inhibition of contraction
 Mifepristone
 Also causes cervical collagen
degradation, possibly because of
increased expression of matrix
metalloproteinase-2
 Prostaglandin MISOPROSTOL:
 increasing uterine contractility by
stimulating the myometrium directly
 CYTOTEC
 Contraindications:
 Specific allergies to medicine
 In situ IUD
 Severe anaemia
 Coagulopathy or anticoagulant use
 Significant medical conditions:
 active liver diseases
 CVD
 Uncontrolled seizure disorders
 adrenal disease
 those on glucocorticoid treatment
 2
nd
Trimester Abortion
 High dose IV Oxytocin:
 mixing with isotonic solution, normal saline.
 Preferred agent for induction
 Done when uterus is sufficiently large
already
 Vaginal Prostaglandin
 PGE 2
 PGE1
 Misoprostol pills
Consequences of abortion
 Maternal mortality:
 Legally induced abortion done during first 2
months
 Mortality rate is 0.7/100 000 procedures
 Rate double for each 2 weeks after 8 weeks
gestation
 Impact on future pregnancy:
 Fertility does not appear to  by an elective
abortion, except as a consequence of infection.
Septic abortion
Abortion with infection of the products of conception,
uterus or with presence of microorganisms or their
products in the systemic circulation
Associated with criminally induced abortion
 Using a hanger, wire, straight catheter (insert a piece
of wire inside straight catheter to dilate the cervix;
this procedure can lead to septic abortion
can affect myometrium, parametrium and can cause
peritonitis.
Complications:
 sever hemorrhage
 sepsis
 bacterial shock and acute renal failure  DEATH
 uterine perforation and peritonitis
Clinical Presentation
 abdominal pain
 tenderness
 septic temp
 Speculum Exam
 foul smelling vaginal discharge
 cervix can be open or closed
 Uterus can be enlarged
Management
 admit patient right away
 start broad spectrum antibiotics
 Cefoxitin
 IV fluid
 blood transfusion
 evacuation and curretage after initial doses of
antibiotics
 total pelvic clean out if w/ uterine perforation &
peritonitis
 TAHBSO if curretage and antibiotics do not improve
pt’s condition and condition deteriorate
Etiologic agents:
 anaerobic bacteria
 coliforms

10. SECTION III: ANTEPARTUM
Surgical Block
2012
10 Williams OBSTETRICS 23rd
Edition
 H. influenza
 clostridium jejuni
 group A streptococcus
Diagnostic criteria for Septic Abortion
 High fever, usually above 101 °F
 Chills
 Severe abdominal pain and/or cramping /or strong
perineal pressure
 Beginning miscarriage symptoms (heavy bleeding and
or cramping) that suddenly stops and does not
resume
 Prolonged or heavy vaginal bleeding
 Foul-smelling vaginal discharge
 Backache or heavy back pressure
CONTRACEPTION
Contraception Following Miscarriage or Abortion
Ovulation
 may resume as early as 2 weeks after completion of
abortion
LH surge
 Can be detected 16-22 days after abortion
SAMPLEX CORNER
ABORTION
True or False:
Define Blighted Ovum
 ANSWER: When a gestational sac is opened, fluid is
commonly found surrounding a small macerated
fetus or alternatively no fetus is visible
95% due to chromosomal errors in maternal
gametogenesis:
 ANSWER: True
Abortion CRL < 250 cm:
 ANSWER: False
 Correct CRL: <160 mm
Early abortion, baby does not die before extrusion:
 ANSWER: False
 Correct Answer: embryonic death precedes
expulsion of ovum
Cerclage is done after 12 weeks?
 ANSWER: False
 Correct Answer: Done usually between 15th
to
18th
week AOG
Define Missed abortion
 DEFINITION: uterus retains dead product of
conception behind a closed cervical os for days or
even weeks
Maternal death rate doubles every 2 weeks after 8
weeks gestation?
 ANSWER: True
OCP can be started after abortion to prevent
another fertilization?
 ANSWER: True
After undergoing voluntary (elective) abortion, you
will no longer be fertile?
 ANSWER: False
 Correct Answer: Ovulation may resume after 2
weeks of complete abortion
 GOOD LUCK! 