Abortion Chromosomal abnormalities are the most common reason for first-trimester losses, occurring at a 60% frequency.

Most chromosomal abnormalities are sporadic defects; in a small percentage of cases, one of the parents carries a balanced translocation. Autosomal trisomies are the most common anomaly, followed by 45X monosomy (the most common single anomaly seen in abortuses), triploidy, tetraploidy, translocations, and mosaicism. Spontaneous abortions are classified into five types. 1. Threatened abortion is a term traditionally used when bleeding occurs in the first / half of gestation without cervical dilation or passage of tissue. Twenty-five percent of pregnant women experience spotting or bleeding early in gestation; 50% of these proceed to lose the pregnancy. An ultrasound is obtained to document viability after 6 weeks' gestation. 2. Inevitable abortion is diagnosed when bleeding or rupture of the membranes occurs with cramping and dilation of the cervix. Suction curettage is performed to evacuate the uterus; Rh immune globulin is administered to the Rh-negative woman. 3. Incomplete abortion occurs when there has been partial but incomplete expulsion of the products of conception from the uterine cavity. Therapy is evacuation of remaining tissue by suction curettage. Rh immune globulin is administered to the Rh-negative woman.

4. Missed abortion is death of the fetus or embryo without the onset of labor or the passage of tissue for a prolonged period of time. Suction curettage is used to evacuate the first-trimester uterus. Dilation and evacuation (D and E) or prostaglandin induction of labor are methods used to evacuate the early second-trimester uterus. 5. Recurrent spontaneous abortion. In the past, this condition has been called habitual abortion and is defined as three or more spontaneous, consecutive firsttrimester losses. This affects 2% of couples. In women with previous liveborn infants who have had a loss, the risk of a subsequent abortion is 25% to 30% regardless of whether she has had one or more losses. In women with no previous liveborn infants, the recurrence risk is 40% to 45%. Evaluation is indicated after three losses, and after two losses depending on the age of those involved.

6. The workup for spontaneous abortion includes the following: a. Detailed history and physical examination

b. Chromosomal evaluation of the couple c. Endometrial biopsy to exclude luteal phase defect

d. Thyroid function test and screening for diabetes mellitus in the woman e. Cervical cultures for Ureaplasma urealyticum

i. Hysterosalpingogram or hysteroscopy to evaluate uterine cavity g. Screening test for lupus anticoagulant and anti-cardiolipin antibody Induced (elective) abortion. Abortion first became legal in 1973 and can be induced up to approximately 20 weeks' gestation, depending on state laws. Legal abortion is one of the most frequently performed surgical procedures in the United States. Therapeutic abortions are terminations of pregnancy that are done when there is maternal risk associated with continuation of the pregnancy or fetal abnormalities associated with genetic, chromosomal, or structural defects. Techniques of pregnancy termination. Techniques used effectively to empty the uterus of the products of conception fall under the categories of surgical evacuation or induction of labor. The preferred procedure depends on gestational age and, in some cases, operator training. Rh status is determined in each patient and Rh immune globulin is administered to Rh-negative mothers to prevent sensitization. a. Surgical evacuation (1) Suction curettage is the method of dilation of the cervix and vacuum aspiration of the uterine contents used for termination of pregnancy at 12 weeks' or less gestational age. Suction curettage is the most common method of pregnancy termination in this country. (a) Laminaria can be used when necessary to facilitate gentle dilation of the cervix. (b) The administration of prophylactic antibiotics just before or after the procedure significantly reduces the risk of infection associated with induced abortion. (2) D and E is the preferred method of termination at 13 or more weeks of gestation. (a) As the length of gestation increases, wider cervical dilation is required to accomplish the procedure successfully. Preoperative cervical Laminaria is used.

(b) Vacuum aspiration of uterine contents is usually an adequate method of evacuation from 13 to 16 weeks. After 16 weeks, uterine evacuation is accomplished with forceps extraction. Successful completion of this procedure depends largely on operator skill. Evaluation for major fetal parts is an important component of this procedure. (c) The routine use of prophylactic antibiotics is recommended. (3) Other mechanical methods, which are now obsolete, include: (a) Sharp curettage (b) Hysterotomy (c) Hysterectomy (used only when there is another indication for this procedure) (4) Anesthesia. Anesthesia for induced abortion is usually sedation with a local paracervical block. General anesthesia can be used but is accompanied by a higher incidence of hemorrhage, cervical injury, and perforation because general anesthetics render the uterine musculature more relaxed and, thus, easier to penetrate. b. Induction of labor. Medical means of inducing abortion include extrauterine and intrauterine administration of abortifacients, such as prostaglandins, urea, hypertonic saline, and oxytocin. These methods are used for second-trimester terminations; the frequency of use of these methods increases with increasing gestational age. (1) Hypertonic solutions of saline or urea are injected directly into the amniotic cavity. This procedure requires amniocentesis and care to avoid intravascular injection. (2) Prostaglandins are most commonly administered as vaginal suppositories of prostaglandin E2; 90% of abortions are accomplished within 24 hours. Common side effects include fever, nausea and vomiting, and diarrhea; prophylactic medications are administered before initiation to control side effects. (3) Complication rates are lowest when the uterus is successfully evacuated within 13 to 24 hours. Laminaria to facilitate cervical dilation is useful to shorten the length of induction. c. Progesterone antagonists are not available in this country for pregnancy termination but are an effective method used in Europe and other countries. (1) Mifepristone (RU 486), taken orally, is highly effective in pregnancies with up to 49 days of amenorrhea. (2) Effectiveness can be increased with the addition of prostaglandin E. (3) Side effects arc minimal and complication rates, including hemorrhage and retained tissue, are low. Complications. Complications after induced abortion are categorized into immediate, delayed, and late complications. The incidence of complications is largely determined by the method of termination and gestational age; incidence varies directly with increasing gestational age. a. Immediate complications. These complications develop during the procedure or within 3 hours after

completion. (1) Hemorrhage. The incidence of hemorrhage is most accurately determined by the rate of transfusion. Rates vary with method of termination and are reported to be within 0.06% to 1.72%. The lowest rates are seen with suction curettage, and the highest with saline instillation. (2) Cervical injury. The rates of cervical injury associated with suction curettage are within the range of 0.01% to 1.6%. Factors that decrease the risk of this complication include the use of local anesthetics instead of general anesthesia, use of Laminaria, and an experienced operator. (3) Uterine perforation. Uterine perforation is a potentially serious complication of suction curettage abortions; the incidence is approximately 0.2%. (a) Factors that increase the risk of perforation include multiparity, advanced gestational age, and operator inexperience. The use of Laminaria to facilitate cervical dilation decreases the risk of uterine perforation. (b) The serious consequences of uterine perforation include hemorrhage and damage to intraabdominal organs. Because of the location of the uterine vessels, lateral perforations may be associated with hemorrhage. Perforation with a suction curette may be associated with bowel or other organ injury, and requires exploration. (c) Many perforations require only observation. Surgical exploration is indicated when there is evidence of hemorrhage or hematoma formation, or injury to abdominal organs is suspected. (4) Acute hematometra. This complication occurs in 0. at increase the risk of infection include the presence of cervical gonococcal or chlamydial infection, advanced gestational age, uterine instillation methods of termination, and the use of local anesthesia instead of general anesthesia.

(c) The uterine infection is usually polymicrobial in nature, similar to other gynecologic infections, and is treated with broad-spectrum antibiotics and prompt evacuation of retained tissue. (d) The use of prophylactic antibiotics significantly decreases the risk of infectious complications associated with induced abortions. (2) Retained tissue complicates less than 1% of suction curettage abortions. (a) Retained tissue may be associated with infection, hemorrhage, or both. (b) Treatment requires repeat curettage and antibiotic administration if infection is present. c. Late complications (1 ) Rh sensitization. The risk of sensitization increases with advanced gestational age. (a) The estimated risk of sensitization associated with suction curettage is 2.6% if Rh immune globulin is not appropriately administered. (b) The recommended dose for Rh immune globulin prophylaxis is 50 /xg up to 12 weeks' gestation, and 300 /u-g there after. (2) Future adverse pregnancy outcomes. The incidences of infertility, spontaneous abortion, and ectopic pregnancy are not increased after uncomplicated suction curettage procedures. d. Maternal mortality. The case mortality rate for induced abortion is less than 0.05 per 100,000 procedures. The risk varies with gestational age and method of termination. (1) The leading cause of death associated with induced abortion is anesthetic complications, followed in frequency by hemorrhage, embolism, and infection. (2) The risk of death is lowest for suction curettage procedures and highest for instillation procedures; risk increases with advancing gestational