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 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
- Chromosomal abnormalities is the most common cause of sporadic abortion that occur as early as 4-8 weeks gestation, for instance aneuploidy, mosaicism, translocation, inversion, deletion, fragile sites.[13]
- First-trimester pregnancy loss could be involves by either infectious, immunologic, and environmental factors.
- Immunologic factors is not well defined. several theories suggest that early pregnancy loss could be due to: [14][15]
- Allogeneic factors.
- Lack the immunological protection of the embryos, such as complement regulatory proteins (eg, mannose-binding lectin, and HLA-DR, HLA-G or HLA-E)
- Increased the activity of uterine natural killer (uNK) cells.
- Alloimmunization to blood group antigen P.[16]
- 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 suggest that poor blood supply to the septum lead to poor implantation.[17]
- FXIII and fibrinogen play an essential role in placental implantation and maintenance of pregnancy, that is why deficiency of factor XIII (FXIII) and fibrinogen are associated with pregnancy loss.[18]
- It is thought that miscarriage risk is associated with low plasma levels of the hormone kisspeptin.[19]
- 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[20]
Causes
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:[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]
- 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 increase the risk of later pregnancy loss.[33]
modifiable risk factor:
- obesity[34]
- Infection (eg: Parvovirus B19 infection,syphilis, cytomegalovirus (CMV) infection)[35][36][37]
- Pregestational diabetes increase the risk of miscarriage two- to threefold.[38]
- hyper- and hypothyroidism[39]
- Acute and chronic stress[40]
- Medication and substance use, example are NSAIDs (ibuprofen and diclofenac), Cocaine, methamphetamines[41]
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:[46]
- Complications of anesthesia
- Post abortion triad (pain, bleeding, low-grade fever) caused by retained products of conception.
- Retained products of conception
- Uterine perforation[47]
- Septic abortion[48]
- 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.[49]
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.[50]
- The diagnosis of early pregnancy loss (EPL) if the initial transvaginal ultrasound shows intrauterine pregnancy without fetal cardiac activity is based on the creteria 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:[51]
- 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 showed a gestational sac without a yolk sac, absence of an embryo with a heartbeat in ≥2 weeks
- After a pelvic ultrasound showed 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 rise suspension 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 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, 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
- 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.
- Follow-up to confirm complete passage of gestational tissue by ultrasound.
- Incomplete uterine emptying still require uterine aspiration.
- Administer RhoGAM to a women with Rh-negative and is experiencing vaginal bleeding
Medical Therapy
- Up to 13 weeks of gestation:[57][58]
- 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.
- Antibiotics are not recommended for routine medication management of abortion.[59]
- Pain management with nonsteroidal anti-inflammatory drug (NSAID) prior to using misoprostol.[59]
- 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.[59]
- 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.
| 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.
|
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.[60]
- This is also the preferred method of treatment for women with comorbid conditions such as cardiovascular disease, infection, severe anemia, or bleeding disorders.
| 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. |
- Antibiotic prophylaxis should be given before surgical evacuation
| 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
|
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
- ↑ "The Ancient History of Abortion and When it Began".
- ↑ "The Ancient History of Abortion and When it Began".
- ↑ "The Ancient History of Abortion and When it Began".
- ↑ "Internet History Sourcebooks".
- ↑ "The Hippocratic Oath in Roe v. Wade | by Tara Mulder | EIDOLON".
- ↑ "The Ancient History of Abortion and When it Began".
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Hill JA, Choi BC (2000). "Maternal immunological aspects of pregnancy success and failure". J Reprod Fertil Suppl. 55: 91–7. PMID 10889838.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ "Miscarriage - StatPearls - NCBI Bookshelf".
- ↑ 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.
- ↑ 25.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Salat-Baroux J (1988). "[Recurrent spontaneous abortions]". Reprod Nutr Dev. 28 (6B): 1555–68. PMID 3073445.
- ↑ 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). - ↑ 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). - ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 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.
- ↑ 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.
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|pmid=value (help). - ↑ 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.
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