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===History and Symptoms===
===History and Symptoms===


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


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**[[Vaginal bleeding]] (the volume of bleeding varies) and [[Abdominal cramping|suprapubic abdominal cramping]] (especially during passage of gestational tissue), passage of clot is an important sign.
**[[Vaginal bleeding]] (the volume of bleeding varies) and [[Abdominal cramping|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 [[Mastalgia|breast tenderness]], [[nausea and vomiting]].
**Loss or reduction of [[pregnancy]] symptoms, such as decreased [[Mastalgia|breast tenderness]], [[nausea and vomiting]].
*[[Asymptomatic]] discovered incidentally or on routine [[ultrasound]] in early [[pregnancy]].
*Asymptomatic discovered incidentally or on routine ultrasound in early pregnancy.


===Physical Examination===
===Physical Examination===
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*'''Vital signs'''
*'''Vital signs'''


Depends on the amount of [[bleeding]], if severe the patient will [[hemodynamically unstable]].
Depends on the amount of bleeding, if severe the patient will hemodenamically unstable.


*'''Pelvic examination'''  
*'''Pelvic examination'''  
**Bimanual examination to determine the status of [[cervix]] and to estimate the [[gestational age]], [[adnexal]] [[tenderness]] or masses or [[Cervical motion tenderness|cervical motion]] [[tenderness]] to exclude [[ectopic pregnancy]].
**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]], a [[cervix]] that appears closed and has no active [[bleeding]] does not rule out EPL.
**Speculum examination to see the source and quantity of bleeding and whether bleeding coming from the cervix and an open cervical os, a cervix that appears closed and has no active bleeding does not rule out EPL.
**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 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 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 closed [[cervix]], and the [[uterus]] should be contracted.
**Common physical examination findings of complete miscarriage include 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]].
**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 Findings===


*[[Laboratory]] studies may include the following:<ref name="pmid16217116">{{cite journal| author=Murray H, Baakdah H, Bardell T, Tulandi T| title=Diagnosis and treatment of ectopic pregnancy. | journal=CMAJ | year= 2005 | volume= 173 | issue= 8 | pages= 905-12 | pmid=16217116 | doi=10.1503/cmaj.050222 | pmc=1247706 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16217116  }}</ref>
*Laboratory studies may include the following:<ref name="pmid16217116">{{cite journal| author=Murray H, Baakdah H, Bardell T, Tulandi T| title=Diagnosis and treatment of ectopic pregnancy. | journal=CMAJ | year= 2005 | volume= 173 | issue= 8 | pages= 905-12 | pmid=16217116 | doi=10.1503/cmaj.050222 | pmc=1247706 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16217116  }}</ref>
**[[Pregnancy test|Urine pregnancy test]].
**Urine pregnancy test.
**[[Complete blood count]] with differential, [[hemoglobin]] and [[hematocrit]].
**Complete blood count with differential, hemoglobin and hematocrit.
**[[Blood type]] and [[Rh factor]].
**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 made by U/S once the presence of intrauterine [[gestational sac]] is confirmed.<ref name="pmid16217116" />
*Serum hCG and progesterone have limited utility in the diagnostic evaluation of abortion. In general, the diagnosis of pregnancy loss made by U/S once the presence of intrauterine gestational sac is confirmed.<ref name="pmid16217116" />
*An intrauterine [[pregnancy]] may be seen with 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 while If ß-hCG levels >1500 do TVUS again.<ref name="pmid16217116" />
*An intrauterine pregnancy may be seen with 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 while If ß-hCG levels >1500 do TVUS again.<ref name="pmid16217116" />
*U/S is the most accurate diagnostic modality in the confirmation of a viable [[pregnancy]] during the first [[trimester]].
*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]].<ref name="pmid16217116" />
*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.<ref name="pmid16217116" />


===Electrocardiogram===
===Electrocardiogram===
There are no [[ECG]] findings associated with abortion.
There are no ECG findings associated with abortion.


===X-ray===
===X-ray===
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===Expectant management===
===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 consider.
*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 consider.
*Pain management in the first trimester are typically offered nonsteroidal anti-inflammatory drugs for pain.
*[[Pain management]] in the [[first trimester]] are typically offered [[Non-steroidal anti-inflammatory drug|nonsteroidal anti-inflammatory drugs]] for [[pain]].
*Follow-up to  confirm complete passage of gestational tissue by ultrasound.
*Follow-up to  confirm complete passage of gestational tissue by [[ultrasound]].
*Incomplete uterine emptying still require uterine aspiration.
*Incomplete [[uterine]] emptying still require [[uterine]] aspiration.
*Administer RhoGAM to a women with Rh-negative and is experiencing vaginal bleeding
*Administer [[Rho(D) Immune Globulin|RhoGAM]] to a women with [[Rh incompatibility (patient information)|Rh-negative]] and is experiencing [[vaginal bleeding]]


===Medical Therapy===
===Medical Therapy===


*'''Up to 13 weeks of gestation''':<ref name="pmid29874535">{{cite journal| author=Schreiber CA, Creinin MD, Atrio J, Sonalkar S, Ratcliffe SJ, Barnhart KT| title=Mifepristone Pretreatment for the Medical Management of Early Pregnancy Loss. | journal=N Engl J Med | year= 2018 | volume= 378 | issue= 23 | pages= 2161-2170 | pmid=29874535 | doi=10.1056/NEJMoa1715726 | pmc=6437668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29874535  }}</ref><ref name="urlMiscarriage - StatPearls - NCBI Bookshelf4">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK532992/#!po=5.55556 |title=Miscarriage - StatPearls - NCBI Bookshelf |format= |work= |accessdate=}}</ref>
*'''Up to 13 weeks of gestation''':<ref name="pmid29874535">{{cite journal| author=Schreiber CA, Creinin MD, Atrio J, Sonalkar S, Ratcliffe SJ, Barnhart KT| title=Mifepristone Pretreatment for the Medical Management of Early Pregnancy Loss. | journal=N Engl J Med | year= 2018 | volume= 378 | issue= 23 | pages= 2161-2170 | pmid=29874535 | doi=10.1056/NEJMoa1715726 | pmc=6437668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29874535  }}</ref><ref name="urlMiscarriage - StatPearls - NCBI Bookshelf4">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK532992/#!po=5.55556 |title=Miscarriage - StatPearls - NCBI Bookshelf |format= |work= |accessdate=}}</ref>
**mifepristone followed by misoprostol 24 hours later.
**[[mifepristone]] followed by [[misoprostol]] 24 hours later.
**'''Dose:''' the protocol for medication management of pregnancy loss is mifepristone 200 mg orally followed in 24 hours by misoprostol 800 mcg per vagina (typically given as four 200 mcg tablets). above 13 weeks of gestation no data looking at mifepristone and misoprostol treatment for pregnancy loss, however mifepristone continues to improve outcomes.
**'''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.<ref name="urlapps.who.int">{{cite web |url=https://apps.who.int/iris/bitstream/handle/10665/70914/9789241548434_eng.pdf?sequence=1 |title=apps.who.int |format= |work= |accessdate=}}</ref>
**[[Antibiotics]] are not recommended for routine medication management of abortion.<ref name="urlapps.who.int">{{cite web |url=https://apps.who.int/iris/bitstream/handle/10665/70914/9789241548434_eng.pdf?sequence=1 |title=apps.who.int |format= |work= |accessdate=}}</ref>
**'''Pain management'''  with nonsteroidal anti-inflammatory drug (NSAID) prior to using misoprostol.<ref name="urlapps.who.int" />
**[[Pain]] management with [[Non-steroidal anti-inflammatory drug|nonsteroidal anti-inflammatory drug (NSAID)]] prior to using [[misoprostol]].<ref name="urlapps.who.int" />
**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.<ref name="urlapps.who.int" />
**[[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|World Health Organization (WHO)]] recommends an initial 800 mcg dose of [[misoprostol]] followed by 400 mcg every three hours until expulsion.<ref name="urlapps.who.int" />


*'''13 to 20 weeks of gestation'''
*'''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.
**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.


{| class="wikitable"
{| class="wikitable"
|+Guideline for safe abortion according to WHO<ref name="urlapps.who.int" />
|+Guideline for safe abortion according to [[WHO]]<ref name="urlapps.who.int" />
!Recommended methods for medical abortion
!Recommended methods for medical abortion
|-
|-
|'''The recommended method for medical abortion is mifepristone followed by misoprostol.'''
|'''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
|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  
|[[Dosage|Dosages]] and recommendation  


*Mifepristone should always be administered orally. The recommended dose is 200 mg.
*[[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.
*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 [[vaginal]], [[sublingual]] routes, the recommended dose of [[misoprostol]] is 800 μg.
**For oral administration, the recommended dose of misoprostol is 400 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 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.
**With [[Gestation|gestations]] up to 9 weeks [[misoprostol]] can be administered by [[vaginal]], [[sublingual]] routes.
|-
|-
|'''For pregnancies of gestational age between 9 and 12 weeks'''  
|'''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.
*The recommended method for medical abortion is 200 mg [[mifepristone]] administered orally followed 36 to 48 hours later by 800 μg [[misoprostol]] administered [[Vaginal|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.
*Subsequent [[misoprostol]] doses should be 400 μg, administered either [[Vaginal|vaginally]] or [[Sublingual|sublingually]], every 3 hours up to four further doses, until expulsion of the products of [[conception]].
|-
|-
|'''For pregnancies of gestational age over 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.  
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.
*[[Gestation|Gestations]] between 12 and 24 weeks, the initial [[misoprostol]] dose following oral [[mifepristone]] administration may be either 800 μg administered [[Vaginal|vaginally]] or 400 μg administered orally. Subsequent [[misoprostol]] doses should be 400 μg, administered either [[Vaginal|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.
*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.
|}
|}
<br />
<br />
===Surgery===
===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 because these conditions require urgent treatment.<ref name="pmid18053098">{{cite journal| author=Wen J, Cai QY, Deng F, Li YP| title=Manual versus electric vacuum aspiration for first-trimester abortion: a systematic review. | journal=BJOG | year= 2008 | volume= 115 | issue= 1 | pages= 5-13 | pmid=18053098 | doi=10.1111/j.1471-0528.2007.01572.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18053098  }}</ref>
*[[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]] because these conditions require urgent treatment.<ref name="pmid18053098">{{cite journal| author=Wen J, Cai QY, Deng F, Li YP| title=Manual versus electric vacuum aspiration for first-trimester abortion: a systematic review. | journal=BJOG | year= 2008 | volume= 115 | issue= 1 | pages= 5-13 | pmid=18053098 | doi=10.1111/j.1471-0528.2007.01572.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18053098  }}</ref>


*This is also the preferred method of treatment for women with comorbid conditions such as cardiovascular disease, infection, severe anemia, or bleeding disorders.
*This is also the preferred method of treatment for women with comorbid conditions such as [[cardiovascular disease]], [[infection]], [[Anemia|severe anemia]], or [[bleeding]] disorders.


{| class="wikitable"
{| class="wikitable"
|+guideline for safe abortion according to WHO<ref name="urlapps.who.int2">{{cite web |url=https://apps.who.int/iris/bitstream/handle/10665/70914/9789241548434_eng.pdf?sequence=1 |title=apps.who.int |format= |work= |accessdate=}}</ref>
|+guideline for safe abortion according to WHO<ref name="urlapps.who.int2">{{cite web |url=https://apps.who.int/iris/bitstream/handle/10665/70914/9789241548434_eng.pdf?sequence=1 |title=apps.who.int |format= |work= |accessdate=}}</ref>
!Recommended methods of abortion for pregnancies of gestational age over 12 to 14 weeks
!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 availabil-ity of training.
|[[Dilation and curettage|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
*[[Antibiotic|Antibiotic prophylaxis]] should be given before surgical [[Evacuation of retained products of conception|evacuation]]


{| class="wikitable"
{| class="wikitable"
Line 368: Line 368:
!Guidelines for antibiotic prophylaxis prior uterine evacuation with vacuum aspiration<ref name="urlwww.rcog.org.uk">{{cite web |url=https://www.rcog.org.uk/globalassets/documents/guidelines/best-practice-papers/best-practice-paper-2.pdf |title=www.rcog.org.uk |format= |work= |accessdate=}}</ref>
!Guidelines for antibiotic prophylaxis prior uterine evacuation with vacuum aspiration<ref name="urlwww.rcog.org.uk">{{cite web |url=https://www.rcog.org.uk/globalassets/documents/guidelines/best-practice-papers/best-practice-paper-2.pdf |title=www.rcog.org.uk |format= |work= |accessdate=}}</ref>
|-
|-
|'''If there is no suspicion of infection and uterine size is less than 14 weeks'''
|'''If there is no suspicion of [[infection]] and [[Uterine|uterine size]] is less than 14 weeks'''
|-
|-
|Antibiotic prophylaxis should be given before surgical evacuation  
|Antibiotic prophylaxis should be given before surgical evacuation  


*200 mg doxycycline within 2 hours before the procedure or
*200 mg [[doxycycline]] within 2 hours before the procedure or


*A single dose of 500 mg azithromycin within 2 hours before the procedure
*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.)
(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'''
|'''If there is no suspicion of [[infection]] and [[uterine]] size is 14 weeks or larger'''
*Antibiotic prophylaxis should be given before surgical evacuation  
*[[Antibiotic]] prophylaxis should be given before surgical [[Evacuation of retained products of conception|evacuation]]
**200 mg doxycycline within 2 hours before the procedure (with or without 200 mg doxycycline after the abortion) or
**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
**a single dose of 500 mg [[azithromycin]] within 2 hours before the [[procedure]]
|}
|}


===Primary Prevention===
===Primary Prevention===
Effective measures for the primary prevention of unsafe abortion include :<ref name="pmid22883917">{{cite journal| author=Faúndes A| title=Strategies for the prevention of unsafe abortion. | journal=Int J Gynaecol Obstet | year= 2012 | volume= 119 Suppl 1 | issue=  | pages= S68-71 | pmid=22883917 | doi=10.1016/j.ijgo.2012.03.021 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22883917  }}</ref>
Effective measures for the [[primary prevention]] of unsafe abortion include :<ref name="pmid22883917">{{cite journal| author=Faúndes A| title=Strategies for the prevention of unsafe abortion. | journal=Int J Gynaecol Obstet | year= 2012 | volume= 119 Suppl 1 | issue=  | pages= S68-71 | pmid=22883917 | doi=10.1016/j.ijgo.2012.03.021 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22883917  }}</ref>


*Use of contraception has been shown effective decrease in abortion rate.
*Use of [[contraception]] has been shown effective decrease in abortion rate.
*Sexual education programs.
*[[Sexual]] [[education]] programs.
*Easy access to contraception.
*Easy access to [[contraception]].
*social protection to reduce induced abortion among women already pregnant and they have been abandoned by their partners, rejected by their families.
*Social protection to reduce induced abortion among women already pregnant and they have been abandoned by their partners, rejected by their families.


<br />
<br />

Revision as of 02:58, 31 March 2021

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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 was first describe by 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 involves by either infectious, immunologic, and environmental factors. Causes of abortion include fetal causes are genetic or chromosomal abnormalities while maternal causes include age, Antiphospholipid syndrome, Severe hypertension, Systemic lupus erythematosus (SLE). risk factor for abortion include Non-modifiable risk factor like Advanced age >35 years Previous pregnancy loss increase the risk of later pregnancy loss. modifiable risk factor like obesity, Infection, Acute and chronic stress, Medication and substance use, Cocaine, Alcohol, tobacco and caffeine. complication of abortion include infection, post abortion traid, 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.

Historical Perspective

  • Abortion means termination of a pregnancy and it has been known since ancient times.
  • Abortion was first describe by ancient Egyptian medical text as the Ebers Papyrus in 1550 BCE, suggests that an abortion can be induced with the use of a plant-fiber tampon coated with honey and crushed dates.[1]
  • During the ancient Egyptians, Persians, and Romans eras, abortion was practiced although it was never explicitly mentioned in any book of the Judeo-Christian Bible.[2]
  • In the fourth century BCE, Niddah 23a, a chapter of the Babylonian Talmud, review about abortion as determining whether a woman is "unclean." and permitting abortion during early pregnancy.[3]

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

  • On 11th century BCE, 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.[4]
  • On the fifth century BCE Hippocratic Oath prohibit physicians from inducing elective abortions.[5]
  • On 19th century surgical abortion become common and Hegar dilator in 1879 who invent dilation-and-curettage (D&C).[6]
  • On November 18,1920, the Commissariats of Health and Justice legalized abortion in Soviet hospitals.[7][8]
  • 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.[9]


Classification

Abortion can be classified into the following:[10] [11][12]

Abortion type Characterestics
Early Threatened Abortion before 12 weeks gestation

Symptoms: 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 Noninduced abortion
Missed Undetected death of an embryo or a fetus that is not expelled and that causes no bleeding (also called 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: 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[21][22]

Fetal causes:

Maternal causes:

Differentiating abortion from other Diseases

Abortion should be differentiated from other causes of bleeding with cramping in early pregnancy:[23]

Epidemiology and Demographics

  • The incidence of abortion Worldwide, was estimated to be 35 per 1000 women ages 15 to 44 from 2010 to 2014.[24]
  • The rate in resource-rich countries was 27 per 1000 and in resource-limited countries was 37 per 1000. The incidence was highest in the Caribbean (65 per 1000), and the lowest in North America (17 per 1000). [25]
  • In the United States, one in four women will have an abortion during their reproductive life.[25]
  • The incidence of abortion is approximately 31%, the true incidence of abortion is difficult to ascertain, as many losses are not recognized[26][27]
  • The rate of abortion influenced by maternal age and history of prior pregnancy loss.[28] 15% of women experience sporadic abortion, 2% of pregnant women experience two consecutive abortion and only 0.4 to 1% have three consecutive abortion. [29]
  • The incidence of Abortions in the united state were highest in women ages 20 to 24 (19.1 per 1000 women) and 25 to 29 (18.5 per 1000 women)[30]
  • Most abortions were done in women who were unmarried (85%) and had one or more children (59%).[30]
  • Abortion rates in individuals of non-Hispanic White were 38.7 ,20.0 for Hispanic, and 7.7 for other races per 1000 women. [30]
  • 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.[31]

Risk Factors

Non-modifiable risk factor :[32]

modifiable risk factor:

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 hemodenamically 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, a cervix that appears closed and has no active bleeding does not rule out EPL.
    • 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 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:[52]
    • 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 made by U/S once the presence of intrauterine gestational sac is confirmed.[52]
  • An intrauterine pregnancy may be seen with 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 while If ß-hCG levels >1500 do TVUS again.[52]
  • 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.[52]

Electrocardiogram

There are no ECG findings associated with abortion.

X-ray

There are no x-ray findings associated with abortion.

Abdominal/ trans-vaginal Ultrasound[53][54]

  • Findings on an ultrasound suggestive of nonviable pregnancy include gestational sac >25-mm mean sac diameter [MSD] 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 U/S 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 trans-vaginal U/S.

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.[55]

MRI

The use of MRI in maternal emergency obstetric conditions is relatively limited, MRI has a role where USG is indeterminate, particularly in ectopic pregnancy.[56]

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[59]
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[61]
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[62]
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

Primary Prevention

Effective measures for the primary prevention of unsafe abortion include :[63]

  • Use of contraception has been shown effective decrease in abortion rate.
  • Sexual education programs.
  • Easy access to contraception.
  • Social protection to reduce induced abortion among women already pregnant and they 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.[63]

References

  1. ↑ "The Ancient History of Abortion and When it Began".
  2. ↑ "The Ancient History of Abortion and When it Began".
  3. ↑ "The Ancient History of Abortion and When it Began".
  4. ↑ "Internet History Sourcebooks".
  5. ↑ "The Hippocratic Oath in Roe v. Wade | by Tara Mulder | EIDOLON".
  6. ↑ "The Ancient History of Abortion and When it Began".
  7. ↑ "docshare03.docshare.tips" (PDF).
  8. ↑ Endres, Richard J. (1971). "Abortion in perspective". American Journal of Obstetrics and Gynecology. 111 (3): 436–439. doi:10.1016/0002-9378(71)90791-5. ISSN 0002-9378.
  9. ↑ "docshare03.docshare.tips" (PDF).
  10. ↑ Rushton DI (1978). "Simplified classification of spontaneous abortions". J Med Genet. 15 (1): 1–9. doi:10.1136/jmg.15.1.1. PMC 1012814. PMID 564967.
  11. ↑ Ganatra B, Gerdts C, Rossier C, Johnson BR, Tunçalp Ö, Assifi A; et al. (2017). "Global, regional, and subregional classification of abortions by safety, 2010-14: estimates from a Bayesian hierarchical model". Lancet. 390 (10110): 2372–2381. doi:10.1016/S0140-6736(17)31794-4. PMC 5711001. PMID 28964589.
  12. ↑ Fujikura T, Froehlich LA, Driscoll SG (1966). "A simplified anatomic classification of abortions". Am J Obstet Gynecol. 95 (7): 902–5. doi:10.1016/0002-9378(66)90537-0. PMID 5914126.
  13. ↑ Stephenson MD, Awartani KA, Robinson WP (2002). "Cytogenetic analysis of miscarriages from couples with recurrent miscarriage: a case-control study". Hum Reprod. 17 (2): 446–51. doi:10.1093/humrep/17.2.446. PMID 11821293.
  14. ↑ Kallen CB, Arici A (2003). "Immune testing in fertility practice: truth or deception?". Curr Opin Obstet Gynecol. 15 (3): 225–31. doi:10.1097/00001703-200306000-00003. PMID 12858110.
  15. ↑ Hill JA, Choi BC (2000). "Maternal immunological aspects of pregnancy success and failure". J Reprod Fertil Suppl. 55: 91–7. PMID 10889838.
  16. ↑ Hanafusa N, Noiri E, Yamashita T, Kondo Y, Suzuki M, Watanabe Y; et al. (2006). "Successful treatment by double filtrate plasmapheresis in a pregnant woman with the rare P blood group and a history of multiple early miscarriages". Ther Apher Dial. 10 (6): 498–503. doi:10.1111/j.1744-9987.2006.00393.x. PMID 17199881.
  17. ↑ Homer HA, Li TC, Cooke ID (2000). "The septate uterus: a review of management and reproductive outcome". Fertil Steril. 73 (1): 1–14. doi:10.1016/s0015-0282(99)00480-x. PMID 10632403.
  18. ↑ Inbal A, Muszbek L (2003). "Coagulation factor deficiencies and pregnancy loss". Semin Thromb Hemost. 29 (2): 171–4. doi:10.1055/s-2003-38832. PMID 12709920.
  19. ↑ Jayasena CN, Abbara A, Izzi-Engbeaya C, Comninos AN, Harvey RA, Gonzalez Maffe J; et al. (2014). "Reduced levels of plasma kisspeptin during the antenatal booking visit are associated with increased risk of miscarriage". J Clin Endocrinol Metab. 99 (12): E2652–60. doi:10.1210/jc.2014-1953. PMC 4255122. PMID 25127195.
  20. ↑ Craig LB, Ke RW, Kutteh WH (2002). "Increased prevalence of insulin resistance in women with a history of recurrent pregnancy loss". Fertil Steril. 78 (3): 487–90. doi:10.1016/s0015-0282(02)03247-8. PMID 12215322.
  21. ↑ Pereza N, Ostojić S, Kapović M, Peterlin B (2017). "Systematic review and meta-analysis of genetic association studies in idiopathic recurrent spontaneous abortion". Fertil Steril. 107 (1): 150–159.e2. doi:10.1016/j.fertnstert.2016.10.007. PMID 27842992.
  22. ↑ Barut MU, Bozkurt M, Kahraman M, Yıldırım E, Imirzalioğlu N, Kubar A; et al. (2018). "Thrombophilia and Recurrent Pregnancy Loss: The Enigma Continues". Med Sci Monit. 24: 4288–4294. doi:10.12659/MSM.908832. PMC 6045916. PMID 29932168.
  23. ↑ "Miscarriage - StatPearls - NCBI Bookshelf".
  24. ↑ Sedgh G, Bearak J, Singh S, Bankole A, Popinchalk A, Ganatra B; et al. (2016). "Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends". Lancet. 388 (10041): 258–67. doi:10.1016/S0140-6736(16)30380-4. PMC 5498988. PMID 27179755.
  25. ↑ 25.0 25.1 Jones RK, Jerman J (2017). "Abortion Incidence and Service Availability In the United States, 2014". Perspect Sex Reprod Health. 49 (1): 17–27. doi:10.1363/psrh.12015. PMC 5487028. PMID 28094905.
  26. ↑ Magnus MC, Wilcox AJ, Morken NH, Weinberg CR, Håberg SE (2019). "Role of maternal age and pregnancy history in risk of miscarriage: prospective register based study". BMJ. 364: l869. doi:10.1136/bmj.l869. PMC 6425455. PMID 30894356.
  27. ↑ Wilcox AJ, Weinberg CR, O'Connor JF, Baird DD, Schlatterer JP, Canfield RE; et al. (1988). "Incidence of early loss of pregnancy". N Engl J Med. 319 (4): 189–94. doi:10.1056/NEJM198807283190401. PMID 3393170.
  28. ↑ Magnus MC, Wilcox AJ, Morken NH, Weinberg CR, Håberg SE (2019). "Role of maternal age and pregnancy history in risk of miscarriage: prospective register based study". BMJ. 364: l869. doi:10.1136/bmj.l869. PMC 6425455. PMID 30894356.
  29. ↑ Salat-Baroux J (1988). "[Recurrent spontaneous abortions]". Reprod Nutr Dev. 28 (6B): 1555–68. PMID 3073445.
  30. ↑ 30.0 30.1 30.2 Kortsmit K, Jatlaoui TC, Mandel MG, Reeves JA, Oduyebo T, Petersen E; et al. (2020). "Abortion Surveillance - United States, 2018". MMWR Surveill Summ. 69 (7): 1–29. doi:10.15585/mmwr.ss6907a1. PMC 7713711 Check |pmc= value (help). PMID 33237897 Check |pmid= value (help).
  31. ↑ Kortsmit K, Jatlaoui TC, Mandel MG, Reeves JA, Oduyebo T, Petersen E; et al. (2020). "Abortion Surveillance - United States, 2018". MMWR Surveill Summ. 69 (7): 1–29. doi:10.15585/mmwr.ss6907a1. PMC 7713711 Check |pmc= value (help). PMID 33237897 Check |pmid= value (help).
  32. ↑ Hu X, Miao M, Bai Y, Cheng N, Ren X (2018). "Reproductive Factors and Risk of Spontaneous Abortion in the Jinchang Cohort". Int J Environ Res Public Health. 15 (11). doi:10.3390/ijerph15112444. PMC 6266092. PMID 30400160.
  33. ↑ Magnus MC, Wilcox AJ, Morken NH, Weinberg CR, Håberg SE (2019). "Role of maternal age and pregnancy history in risk of miscarriage: prospective register based study". BMJ. 364: l869. doi:10.1136/bmj.l869. PMC 6425455. PMID 30894356.
  34. ↑ Metwally M, Ong KJ, Ledger WL, Li TC (2008). "Does high body mass index increase the risk of miscarriage after spontaneous and assisted conception? A meta-analysis of the evidence". Fertil Steril. 90 (3): 714–26. doi:10.1016/j.fertnstert.2007.07.1290. PMID 18068166.
  35. ↑ Frazier T, Hogue CJR, Bonney EA, Yount KM, Pearce BD (2018). "Weathering the storm; a review of pre-pregnancy stress and risk of spontaneous abortion". Psychoneuroendocrinology. 92: 142–154. doi:10.1016/j.psyneuen.2018.03.001. PMID 29628283.
  36. ↑ Rasti S, Ghasemi FS, Abdoli A, Piroozmand A, Mousavi SG, Fakhrie-Kashan Z (2016). "ToRCH "co-infections" are associated with increased risk of abortion in pregnant women". Congenit Anom (Kyoto). 56 (2): 73–8. doi:10.1111/cga.12138. PMID 26499091.
  37. ↑ Gomez GB, Kamb ML, Newman LM, Mark J, Broutet N, Hawkes SJ (2013). "Untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and meta-analysis". Bull World Health Organ. 91 (3): 217–26. doi:10.2471/BLT.12.107623. PMC 3590617. PMID 23476094.
  38. ↑ Tennant PW, Glinianaia SV, Bilous RW, Rankin J, Bell R (2014). "Pre-existing diabetes, maternal glycated haemoglobin, and the risks of fetal and infant death: a population-based study". Diabetologia. 57 (2): 285–94. doi:10.1007/s00125-013-3108-5. PMID 24292565.
  39. ↑ Maraka S, Ospina NM, O'Keeffe DT, Espinosa De Ycaza AE, Gionfriddo MR, Erwin PJ; et al. (2016). "Subclinical Hypothyroidism in Pregnancy: A Systematic Review and Meta-Analysis". Thyroid. 26 (4): 580–90. doi:10.1089/thy.2015.0418. PMC 4827301. PMID 26837268.
  40. ↑ Li Y, Margerison-Zilko C, Strutz KL, Holzman C (2018). "Life Course Adversity and Prior Miscarriage in a Pregnancy Cohort". Womens Health Issues. 28 (3): 232–238. doi:10.1016/j.whi.2018.02.001. PMID 29530382.
  41. ↑ Nakhai-Pour HR, Broy P, Sheehy O, Bérard A (2011). "Use of nonaspirin nonsteroidal anti-inflammatory drugs during pregnancy and the risk of spontaneous abortion". CMAJ. 183 (15): 1713–20. doi:10.1503/cmaj.110454. PMC 3193112. PMID 21896698. Review in: Evid Based Nurs. 2012 Jul;15(3):76-7
  42. ↑ Avalos LA, Roberts SC, Kaskutas LA, Block G, Li DK (2014). "Volume and type of alcohol during early pregnancy and the risk of miscarriage". Subst Use Misuse. 49 (11): 1437–45. doi:10.3109/10826084.2014.912228. PMC 4183196. PMID 24810392.
  43. ↑ Ness RB, Grisso JA, Hirschinger N, Markovic N, Shaw LM, Day NL; et al. (1999). "Cocaine and tobacco use and the risk of spontaneous abortion". N Engl J Med. 340 (5): 333–9. doi:10.1056/NEJM199902043400501. PMID 9929522.
  44. ↑ Chen LW, Wu Y, Neelakantan N, Chong MF, Pan A, van Dam RM (2016). "Maternal caffeine intake during pregnancy and risk of pregnancy loss: a categorical and dose-response meta-analysis of prospective studies". Public Health Nutr. 19 (7): 1233–44. doi:10.1017/S1368980015002463. PMID 26329421.
  45. ↑ Lee SW, Han YJ, Cho DH, Kwak HS, Ko K, Park MH; et al. (2018). "Smoking Exposure in Early Pregnancy and Adverse Pregnancy Outcomes: Usefulness of Urinary Tobacco-Specific Nitrosamine Metabolite 4-(Methylnitrosamino)-1-(3-Pyridyl)-1-Butanol Levels". Gynecol Obstet Invest. 83 (4): 365–374. doi:10.1159/000485617. PMID 29739005.
  46. ↑ Lim LM, Singh K (2014). "Termination of pregnancy and unsafe abortion". Best Pract Res Clin Obstet Gynaecol. 28 (6): 859–69. doi:10.1016/j.bpobgyn.2014.05.005. PMID 24962349.
  47. ↑ Koshiba A, Koshiba H, Noguchi T, Iwasaku K, Kitawaki J (2012). "Uterine perforation with omentum incarceration after dilatation and evacuation/curettage: magnetic resonance imaging findings". Arch Gynecol Obstet. 285 (3): 887–90. doi:10.1007/s00404-011-2127-z. PMID 22048784.
  48. ↑ Saultes TA, Devita D, Heiner JD (2009). "The back alley revisited: sepsis after attempted self-induced abortion". West J Emerg Med. 10 (4): 278–80. PMC 2791734. PMID 20046250.
  49. ↑ "Miscarriage - StatPearls - NCBI Bookshelf".
  50. ↑ "UpToDate".
  51. ↑ Doubilet PM, Benson CB, Bourne T, Blaivas M, Society of Radiologists in Ultrasound Multispecialty Panel on Early First Trimester Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy. Barnhart KT; et al. (2013). "Diagnostic criteria for nonviable pregnancy early in the first trimester". N Engl J Med. 369 (15): 1443–51. doi:10.1056/NEJMra1302417. PMID 24106937.
  52. ↑ 52.0 52.1 52.2 52.3 Murray H, Baakdah H, Bardell T, Tulandi T (2005). "Diagnosis and treatment of ectopic pregnancy". CMAJ. 173 (8): 905–12. doi:10.1503/cmaj.050222. PMC 1247706. PMID 16217116.
  53. ↑ Helm TN, Wirth PB, Helm KF (2000). "Inexpensive digital photography in clinical dermatology and dermatologic surgery". Cutis. 65 (2): 103–6. PMID 10696563.
  54. ↑ Schmidt ML, Smith HE, Gamerman S, DiMichele D, Glazer S, Scott JP (1991). "Prolonged recombinant activated factor VII (rFVIIa) treatment for severe bleeding in a factor-IX-deficient patient with an inhibitor". Br J Haematol. 78 (3): 460–3. doi:10.1111/j.1365-2141.1991.tb04468.x. PMID 1873233X Check |pmid= value (help).
  55. ↑ Themistoklis SN, Chrysovalantis V, Stylianos A, Nikolaos KL, Efthymia A (2011). "CT Diagnosis of an Abortion-Related Retroperitoneal Space Abscess". J Clin Med Res. 3 (5): 268–9. doi:10.4021/jocmr509w. PMC 3279491. PMID 22383917.
  56. ↑ Gupta R, Bajaj SK, Kumar N, Chandra R, Misra RN, Malik A; et al. (2016). "Magnetic resonance imaging - A troubleshooter in obstetric emergencies: A pictorial review". Indian J Radiol Imaging. 26 (1): 44–51. doi:10.4103/0971-3026.178292. PMC 4813073. PMID 27081223.
  57. ↑ Schreiber CA, Creinin MD, Atrio J, Sonalkar S, Ratcliffe SJ, Barnhart KT (2018). "Mifepristone Pretreatment for the Medical Management of Early Pregnancy Loss". N Engl J Med. 378 (23): 2161–2170. doi:10.1056/NEJMoa1715726. PMC 6437668. PMID 29874535.
  58. ↑ "Miscarriage - StatPearls - NCBI Bookshelf".
  59. ↑ 59.0 59.1 59.2 59.3 "apps.who.int" (PDF).
  60. ↑ Wen J, Cai QY, Deng F, Li YP (2008). "Manual versus electric vacuum aspiration for first-trimester abortion: a systematic review". BJOG. 115 (1): 5–13. doi:10.1111/j.1471-0528.2007.01572.x. PMID 18053098.
  61. ↑ "apps.who.int" (PDF).
  62. ↑ "www.rcog.org.uk" (PDF).
  63. ↑ 63.0 63.1 Faúndes A (2012). "Strategies for the prevention of unsafe abortion". Int J Gynaecol Obstet. 119 Suppl 1: S68–71. doi:10.1016/j.ijgo.2012.03.021. PMID 22883917.


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