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.
• 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.
• 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.

" 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.
• In the fifth century BCE, the Hippocratic Oath prohibited physicians from inducing elective abortions.
• In the 19th century, surgical abortions became common and Hegar dilator in 1879 invented dilation-and-curettage (D&C).
• On November 18, 1920, the Commissariats of Health and Justice legalized abortion in Soviet hospitals.
• 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.

Classification

Abortion can be classified into the following:

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

• Chromosomal abnormalities is the most common cause of sporadic abortion that occurs as early as 4-8 weeks gestation, for instance aneuploidy, mosaicism, translocation, inversion, deletion, or fragile sites.
• First-trimester pregnancy loss could be due to either infectious, immunologic, and environmental factors.
• Immunologic factors is not well defined. Several theories suggest that early pregnancy loss could be due to:
  • Allogeneic factors.
  • Lack of the immunological protection of the embryos, such as complement regulatory proteins (eg, mannose-binding lectin, and HLA-DR, HLA-G or HLA-E)
  • Increased activity of uterine natural killer (uNK) cells.
  • Alloimmunization to blood group antigen P.
• Anatomic distortion of uterus may be associated with early or second trimester pregnancy loss, eg: fibroids, polyps, adhesions, or septa depending on the size and position.
• The mechanism of pregnancy loss due to septate uterus is not clearly understood, one theory suggests that poor blood supply to the septum leads to poor implantation.
• FXIII and fibrinogen play an essential role in placental implantation and maintenance of pregnancy, that is why a deficiency of factor XIII (FXIII) and fibrinogen are associated with pregnancy loss.
• It is thought that miscarriage risk is associated with low plasma levels of the hormone kisspeptin.
• The mechanism of abortion in cases of PCOS is unknown, however it could be related to elevated serum luteinizing hormone (LH) levels, high testosterone and androstenedione concentrations or insulin resistance

Causes

Early Pregnancy Loss

Fetal causes:

• Genetic or chromosomal abnormalities (45,X karyotype, Trisomies (Trisomy 16 is the most common), aneuploidy, mosaicism, translocation, inversion, deletion, fragile sites)
• Teratogenic and mutagenic factors.

Maternal causes:

• Genetic: Maternal age is directly related to the aneuploidy risk,
• Parental chromosomal anomaly balanced translocation

• Corpus luteum deficiency
• Active infection such as rubella virus, cytomegalovirus

• Antiphospholipid syndrome
• Severe hypertension
• Systemic lupus erythematosus (SLE)
• Renal disease
• Poorly controlled diabetes mellitus
• Polycystic ovary syndrome

Differentiating abortion from other Diseases

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

• Related to Pregnancy
  • Ectopic pregnancy
  • Subchorionic hematoma
  • Hydatidiform mole
• Unrelated to pregnancy
  • Infection (cervicitis)
  • Polyps
  • Fibroids

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.
• 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).
• In the United States, one in four women will have an abortion during their reproductive life.
• The incidence of abortion is approximately 31%, the true incidence of abortion is difficult to ascertain, as many losses are not recognized
• The rate of abortion is influenced by maternal age and history of prior pregnancy loss. 15% of women experience sporadic abortion, 2% of pregnant women experience two consecutive abortion and only 0.4 to 1% have three consecutive abortion.
• 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)
• Most abortions were done in women who were unmarried (85%) and had one or more children (59%).
• 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.
• 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.

Risk Factors

Non-modifiable risk factors include:

• Advanced age >35 years, the most significant risk factor because of the associated fetal chromosomal abnormalities.
• Extremes of age
• Advanced paternal age
• Previous pregnancy loss increases the risk of later pregnancy loss.

Modifiable risk factors include:

• Obesity
• Infection (eg: Parvovirus B19 infection,syphilis, cytomegalovirus (CMV) infection)
• Pre-gestational diabetes increases the risk of miscarriage two- to threefold.
• Hyper- and hypothyroidism
• Acute and chronic stress
• Medication and substance use, examples are NSAIDs (ibuprofen and diclofenac), cocaine, methamphetamines

• Alcohol, tobacco and caffeine

Screening

There is insufficient evidence to recommend routine screening for abortion.

Natural History, Complications, and Prognosis

• Complications of spontaneous abortion and therapeutic abortions include the following:
  • Complications of anesthesia
  • Post abortion triad (pain, bleeding, low-grade fever) caused by retained products of conception.
  • Retained products of conception
  • Uterine perforation
  • Septic abortion
  • Cervical shock
  • Cervical laceration
  • Disseminated intravascular coagulation (DIC)
• Prognosis of abortion depends on the gestational age. The younger the gestational age, the lower the risk of complications. The highest risk of death is from a septic abortion; the majority of these cases are a result of illegal abortions in developing countries.

Diagnosis

Diagnostic Study of Choice

• Ultrasound shows no intrauterine pregnancy or loss of previously seen cardiac activity is diagnostic if the intrauterine pregnancy is confirmed by ultrasound in a previous visit.

• The diagnosis of early pregnancy loss (EPL) occurs if the initial transvaginal ultrasound shows intrauterine pregnancy without fetal cardiac activity and is based on the criteria made by the Society of Radiologists in Ultrasound Multi-specialty Panel on Early First Trimester Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy, which include:
  • A gestational sac ≥25 mm in mean diameter that does not contain a yolk sac or embryo
  • An embryo with a crown-rump length (CRL) ≥7 mm that does not have cardiac activity
  • After a pelvic ultrasound shows a gestational sac without a yolk sac, absence of an embryo with a heartbeat in ≥2 weeks
  • After a pelvic ultrasound shows a gestational sac with a yolk sac, absence of an embryo with a heartbeat in ≥11 days
  • Findings that are suspicious for, but not diagnostic of, pregnancy loss include:
    • CRL <7 mm and no heartbeat.
    • Mean sac diameter of 16 to 24 mm and no embryo.
    • Absence of embryo with a heartbeat 7 to 13 days after a scan that showed a gestational sac without a yolk sac
    • Absence of embryo with a heartbeat 7 to 10 days after a scan that showed a gestational sac with a yolk sac
    • Absence of embryo ≥6 weeks after last menstrual period
    • Empty amnion (amnion seen adjacent to yolk sac with no visible embryo)
    • Enlarged yolk sac (>7 mm)
    • Small gestational sac in relation to the size of the embryo (<5 mm difference between mean sac diameter and CRL)

History and Symptoms

• Constitutional symptoms including fever or chills, suggesting septic abortion.
• The history should include when was the date of last menstrual period (LMP), estimated length of gestation, bleeding disorders, previous miscarriage.

• The symptoms that raise suspicion of abortion are:
  • Vaginal bleeding (the volume of bleeding varies) and suprapubic abdominal cramping (especially during passage of gestational tissue), passage of clot is an important sign.
  • Loss or reduction of pregnancy symptoms, such as decreased breast tenderness, nausea and vomiting.
• Asymptomatic discovered incidentally or on routine ultrasound in early pregnancy.

Physical Examination

• Vital signs

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

• Pelvic examination
  • Bimanual examination to determine the status of cervix and to estimate the gestational age, adnexal tenderness or masses or cervical motion tenderness to exclude ectopic pregnancy.
  • Speculum examination to see the source and quantity of bleeding and whether bleeding coming from the cervix and an open cervical os.
  • Common physical examination findings of threatened miscarriage include vital signs should be within reference ranges, soft and non-tender abdomen, and closed internal cervical os.
  • Common physical examination findings of incomplete miscarriage include enlarged and soft uterus, dilated and effaced cervix, and products of conception may be partially present in the uterus, at the external os, or may be present in the vagina.
  • Common physical examination findings of complete miscarriage include a closed cervix, and the uterus should be contracted.
  • Common physical examination findings of missed miscarriage include normal vital signs, the uterus is small for gestational age, absent fetal heart tones on sonogram and closed cervix.

Laboratory Findings

• Laboratory studies may include the following:
  • Urine pregnancy test.
  • Complete blood count with differential, hemoglobin and hematocrit.
  • Blood type and Rh factor.
• Serum hCG and progesterone have limited utility in the diagnostic evaluation of abortion. In general, the diagnosis of pregnancy loss is made by an ultrasound (U/S) once the presence of intrauterine gestational sac is confirmed.
• An intrauterine pregnancy may be seen with (transvaginal ultrasound) (TVUS) at a ß-hCG level of 1500-2000 IU/L. However, indeterminate pregnancy on TVUS should undergo ß-hCG level testing and if ß-hCG levels <1500 repeat hCG in 2 days, if ß-hCG levels >1500, do TVUS again.
• U/S is the most accurate diagnostic modality in the confirmation of a viable pregnancy during the first trimester.
• An empty uterus revealed by U/S in a pregnant woman with positive beta-hCG, suggests a very early pregnancy < 3 wk, a completed miscarriage, or an ectopic pregnancy.

Electrocardiogram

There are no ECG findings associated with abortion.

X-ray

There are no x-ray findings associated with abortion.

Abdominal/ trans-vaginal Ultrasound

• Findings on an ultrasound suggestive of nonviable pregnancy include gestational sac >25-mm mean sac diameter on transabdominal sonogram; >16-mm MSD on endovaginal sonogram without a detectable embryo, embryo without a heartbeat, hyperechoic material within the uterine cavity.
• An incomplete miscarriage on ultrasound shows gestational sac misshaped or collapsed, an irregular complex mass within the endometrial or cervical canal may be present or echogenic material in the endometrial canal.
• A complete miscarriage may demonstrate an empty uterus noted on transvaginal ultrasound.

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.

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.

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

• Waiting for pregnancy tissue to pass recommended only in the first trimester, after 13 weeks, medication management in a health facility or surgical management should be considered.
• Pain management in the first trimester is typically nonsteroidal anti-inflammatory drugs for pain.
• Follow-up to confirm complete passage of gestational tissue by ultrasound.
• Incomplete uterine emptying still require uterine aspiration.
• Administer RhoGAM to women with Rh-negative and is experiencing vaginal bleeding

Medical Therapy

• Up to 13 weeks of gestation:
  • mifepristone followed by misoprostol 24 hours later.
  • Dose: mifepristone 200 mg orally followed in 24 hours by misoprostol 800 mcg per vagina (typically given as four 200 mcg tablets).
  • Antibiotics are not recommended for routine medication management of abortion.
  • Pain management with nonsteroidal anti-inflammatory drug (NSAID) prior to using misoprostol.
  • Misoprostol alone regemin 800 mcg per vagina (typically four 200 mcg tablets). For patients who do not have complete expulsion after a single dose, a second dose can be given. Between 9 and 12 weeks, the World Health Organization (WHO) recommends an initial 800 mcg dose of misoprostol followed by 400 mcg every three hours until expulsion.

• 13 to 20 weeks of gestation
  • Regardless of the gestational age, medication management of pregnancy loss includes mifepristone and misoprostol. The difference is that the misoprostol dose is often reduced and repeated, and should be done in a health facility.

Guideline for safe abortion according to WHO

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 Mifepristone should always be administered orally. The recommended dose is 200 mg. Administration of misoprostol is recommended 1 to 2 days (24 to 48 hours) following ingestion of mifepristone. For vaginal, sublingual routes, the recommended dose of misoprostol is 800 μg. For oral administration, the recommended dose of misoprostol is 400 μg. With gestations up to 7 weeks misoprostol may be administered by vaginal, sublingual or oral routes. After 7 weeks of gestation, oral administration of misoprostol should not be used. With gestations up to 9 weeks misoprostol can be administered by vaginal, sublingual routes.
For pregnancies of gestational age between 9 and 12 weeks The recommended method for medical abortion is 200 mg mifepristone administered orally followed 36 to 48 hours later by 800 μg misoprostol administered vaginally. Subsequent misoprostol doses should be 400 μg, administered either vaginally or sublingually, every 3 hours up to four further doses, until expulsion of the products of conception.
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. For pregnancies beyond 24 weeks, the dose of misoprostol should be reduced, due to the greater sensitivity of the uterus to prostaglandins, but the lack of clinical studies precludes specific dosing recommendations.

Surgery

• Surgery evacuation with sharp curettage or suction curettage is not the first-line treatment option for patients with early pregnancy loss.
• Surgery is usually reserved for patients with either hemorrhage, hemodynamic instability, or signs of infection.
• This is also the preferred method of treatment for women with comorbid conditions such as cardiovascular disease, infection, severe anemia, or bleeding disorders.

Guideline for safe abortion according to WHO

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.

• Antibiotic prophylaxis should be given before surgical evacuation

Guidelines for antibiotic prophylaxis prior uterine evacuation with vacuum aspiration
If there is no suspicion of infection and uterine size is less than 14 weeks
Antibiotic prophylaxis should be given before surgical evacuation 200 mg doxycycline within 2 hours before the procedure or A single dose of 500 mg azithromycin within 2 hours before the procedure (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 Antibiotic prophylaxis should be given before surgical evacuation 200 mg doxycycline within 2 hours before the procedure (with or without 200 mg doxycycline after the abortion) or A single dose of 500 mg azithromycin within 2 hours before the procedure

Primary Prevention

Effective measures for the primary prevention of unsafe abortion include :

• 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.