Abortion

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nuha Al-Howthi, MD[2]

Synonyms and Keywords: Pregnancy loss, miscarriage, spontaneous abortion

Overview

Abortion is the termination of pregnancy before 20 weeks of gestation, which was first described by an ancient Egyptian medical text as the Ebers Papyrus in 1550 BCE. Abortion is classified as threatened, complete, incomplete, inevitable, septic or missed. Chromosomal abnormalities is the most common cause of sporadic abortion that occur as early as 4-8 weeks gestation, or it could be due to either infectious, immunologic, and environmental factors. Fetal causes of abortion are genetic or chromosomal abnormalities while maternal causes include age, antiphospholipid syndrome, severe hypertension, or systemic lupus erythematosus (SLE). Risk factors for abortion include non-modifiable risk factors like advanced age >35 years and previous pregnancy loss. Modifiable risk factors include obesity, infections, acute and chronic stress, medication and substance use, cocaine, alcohol, tobacco and caffeine. Complications of abortion include infection, post abortion traid, uterine perforation, septic abortion, cervical shock, cervical laceration, and disseminated intravascular coagulation (DIC). The prognosis of abortion depends on the gestational age. The younger the gestational age, the lower the risk of complications.

Historical Perspective

  • Abortion means termination of a pregnancy and it has been known since ancient times.
  • Abortion was first described by an ancient Egyptian medical text as the Ebers Papyrus in 1550 BCE, which suggested that an abortion can be induced with the use of a plant-fiber tampon coated with honey and crushed dates.[1]
  • During the ancient Egyptian, Persian, and Roman eras, abortion was practiced although it was never explicitly mentioned in any book of the Judeo-Christian Bible.[1]
  • In the fourth century BCE, Niddah 23a, a chapter of the Babylonian Talmud, reviews abortion as determining whether a woman is "unclean" and permitting abortion during early pregnancy.[1]

" A woman can only abort something in the shape of a stone, and that can only be described as a lump."

  • In 11th century BCE, the Code of Assura, '' a harsh set of laws restricting women in general'' was the earliest legal ban on abortion by forcing the death penalty on married women who obtain abortions without permission of their husbands.[2]
  • In the fifth century BCE, the Hippocratic Oath prohibited physicians from inducing elective abortions.[3]
  • In the 19th century, surgical abortions became common and Hegar dilator in 1879 invented dilation-and-curettage (D&C).[4]
  • On November 18, 1920, the Commissariats of Health and Justice legalized abortion in Soviet hospitals.[5][6]
  • In 1970, Hawaii, New York, Alaska and Washington declared their abortion laws. Hawaii was the first state to legalize abortions and New York allowed abortions up to the 24th week of pregnancy.[7]


Classification

Abortion can be classified into the following:[8] [9][10]

Abortion type Characteristics
Early Threatened Abortion before 12 weeks gestation

Symptoms: the variable amount of bleeding

Cervix: closed

Ultrasound: viable pregnancy

Late Inevitable Abortion between 12 and 20 weeks gestation

Symptoms: vaginal bleeding and abdominal pain

Cervix:dilated/ open

Ultrasound: product of conception seen at or above the cervix.

Spontaneous Non-induced abortion
Missed Undetected death of an embryo or a fetus that is not expelled and that causes no bleeding (also called a blighted ovum, anembryonic pregnancy, or intrauterine embryonic demise)

Symptoms: variable, asymptomatic, light vaginal bleeding

Cervix: closed

Ultrasound: Nonviable fetus

Inevitable Vaginal bleeding or rupture of the membranes accompanied by dilation of the cervix

Symptoms: Vaginal bleeding, uterine cramps,

Cervix: Open

Ultrasound: Intrauterine fetus with possible heartbeats, ruptured or collapsed gestational sac

Incomplete Expulsion of some products of conception

Symptoms: Vaginal bleeding with large clots or tissue, uterine cramps, some products of conception can be visualized in the dilated cervical os

Cervix: Open

Ultrasound: products of conception in the cervix

Threatened Vaginal bleeding occurring before 20 weeks gestation without cervical dilation and indicating that spontaneous abortion may occur

Symptoms: the variable amount of bleeding

Cervix: closed

Ultrasound: viable pregnancy

Septic Serious infection of the uterine contents during or shortly before or after an abortion. Usually after induced abortion and rarely after spontaneous abortion

Symptoms: fever, malaise, signs of sepsis, foul vaginal discharge, cervical motion tenderness, uterine tenderness, can be life-threatening

Cervix: open

Ultrasound: retained products of conception

Complete Expulsion of all products of conception

Symptoms: variable, asymptomatic

Cervix: closed, and the uterus should be contracted.

Ultrasound: uterus is empty

Recurrent or habitual ≥ 2 to 3 consecutive spontaneous abortions
Therapeutic Termination of pregnancy because the woman’s life or health is endangered or because the fetus is dead or has malformations incompatible with life.
Induced Termination of pregnancy for medical or elective reasons


Pathophysiology


Causes

Early Pregnancy Loss[19][20]

Fetal causes:

Maternal causes:

Differentiating abortion from other Diseases

Abortion should be differentiated from other causes of bleeding with cramping in early pregnancy:[21]

Epidemiology and Demographics

  • The incidence of abortion worldwide was estimated to be 35 per 1,000 women ages 15 to 44 from 2010 to 2014.[22]
  • The rate in resource-rich countries was 27 per 1,000 and in resource-limited countries was 37 per 1,000. The incidence was highest in the Caribbean (65 per 1,000), and the lowest in North America (17 per 1,000). [23]
  • In the United States, one in four women will have an abortion during their reproductive life.[23]
  • The incidence of abortion is approximately 31%, the true incidence of abortion is difficult to ascertain, as many losses are not recognized[24][25]
  • The rate of abortion is influenced by maternal age and history of prior pregnancy loss.[26] 15% of women experience sporadic abortion, 2% of pregnant women experience two consecutive abortion and only 0.4 to 1% have three consecutive abortion. [27]
  • The incidence of abortions in the United States were highest in women ages 20 to 24 (19.1 per 1,000 women) and 25 to 29 (18.5 per 1,000 women)[28]
  • Most abortions were done in women who were unmarried (85%) and had one or more children (59%).[28]
  • Abortion rates in individuals of non-Hispanic White were 38.7, 20.0 for Hispanic, and 7.7 for other races per 1,000 women. [28]
  • In the United States in 2018, 78% of abortions occur at 9 weeks or earlier, 92% at 13 weeks or earlier, and 8% at or after 14 weeks.[29]

Risk Factors

Non-modifiable risk factors include: [30]

Modifiable risk factors include:

Screening

There is insufficient evidence to recommend routine screening for abortion.

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

  • Vital signs

Depends on the amount of bleeding, if severe, the patient will be hemodynamically unstable.

Laboratory Findings

Electrocardiogram

There are no ECG findings associated with abortion.

X-ray

There are no x-ray findings associated with abortion.

Abdominal/ trans-vaginal Ultrasound [51][52]

CT scan

There are no CT scan findings associated with abortion. However, a CT scan may be helpful in the diagnosis of complications like uterine rupture.[53]

MRI

The use of a MRI in maternal emergency obstetric conditions is relatively limited, a MRI has a role where USG is indeterminate, particularly in ectopic pregnancy.[54]

Other Imaging Findings

There are no other imaging findings associated with abortion.

Other Diagnostic Studies

There are no other diagnostic studies associated with abortion.

Treatment

Expectant management

Medical Therapy

  • 13 to 20 weeks of gestation
Guideline for safe abortion according to WHO[57]
Recommended methods for medical abortion
The recommended method for medical abortion is mifepristone followed by misoprostol.
Gestational age up to 9 weeks the recommended method for medical abortion is mifepristone followed 1 to 2 days later by misoprostol
Dosages and recommendation
For pregnancies of gestational age between 9 and 12 weeks
For pregnancies of gestational age over 12 weeks

The recommended method for medical abortion is 200 mg mifepristone administered orally followed 36 to 48 hours later by repeated doses of misoprostol.

  • Gestations between 12 and 24 weeks, the initial misoprostol dose following oral mifepristone administration may be either 800 μg administered vaginally or 400 μg administered orally. Subsequent misoprostol doses should be 400 μg, administered either vaginally or sublingually, every 3 hours up to four further doses.


Surgery

Guideline for safe abortion according to WHO[59]
Recommended methods of abortion for pregnancies of gestational age over 12 to 14 weeks
Dilatation and evacuation (D&E) and medical methods (mifepristone and misoprostol; misoprostol alone) are both recommended methods for abortion for gestation over 12 to 14 weeks. Facilities should offer at least one, and preferably both methods, if possible, depending on provider experience and the availability of training.
Guidelines for antibiotic prophylaxis prior uterine evacuation with vacuum aspiration[60]
If there is no suspicion of infection and uterine size is less than 14 weeks
Antibiotic prophylaxis should be given before surgical evacuation

(NB. If antibiotics are not available, the procedure should not be delayed.)

If there is no suspicion of infection and uterine size is 14 weeks or larger

Primary Prevention

Effective measures for the primary prevention of unsafe abortion include :[61]

  • Use of contraception has been shown an effective decrease in the abortion rate.
  • Sexual education programs.
  • Easy access to contraception.
  • Social protection to reduce induced abortion among pregnant women who have been abandoned by their partners, rejected by their families.

Secondary Prevention

The only way to prevent an unsafe abortion is to provide safe services for termination of pregnancy.[61]

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