DIAGNOSIS OF SPONTANEOUS ABORTION

ULTRASOUND (TVS) FINDINGS

<35 days: Pregnancy of unknown location (PUL) or an intrauterine pregnancy of uncertain viability (IPUVI)

35 to 41 days: Early intrauterine pregnancy of uncertain viability

42 days: Viable intrauterine pregnancy *For early TVS, repeat TVS for at least a week to confirm pregnancy.

Suggestive of possible pregnancy failure or pregnancy of questionable viability:

Failure to visualize IUP by TVS if B-hCG level is between 1000-2000 mIU/ml (discriminatory level)

Failure to detect a yolk sac when the mean sac diameter (MSD) is ≥ 8mm

Failure to detect cardiac activity when MSD is ≥ 16mm

MSD fails to increase in size by at least 0.6 mm/day

Absent cardiac activity if crown-rump length (CRL) is ≥ 5mm

Surgical Techniques

Cervical dilatation followed by uterine evacuation Curettage Vacuum aspiration (suction curettage) Dilatation and evacuation (D&E) Dilatation and extraction (D&X) Menstrual aspiration Laparotomy Hysterotomy Hysterectomy

Medical TechniquesMedical Tachniques

Intravenous oxytocin Intra-amnionic hyperosmotic fluid 20-percent saline 30-percent urea Prostaglandins E2, F2, E1, and analogues Intra-amnionic injection Extraovular injection Vaginal insertion Parenteral injection Oral ingestion Antiprogesterones—RU 486 (mifepristone) and epostane Methotrexate—intramuscular and oral Various combinations of the above

Features of Medical and Surgical Abortion

TECHNIQUES:SURGICAL ABORTION

DILATATION AND CURETTAGE

First dilating the cervix and then evacuating the pregnancy by mechanically scraping out the contents—sharp curettage, by suctioning out the contents—suction curettage, or both.

Requires antimicrobial prophylaxis“gritty” feeling

To know if all products of conception have been removed (in mechanical evacuation)

If still “slimy” – not completely evacuated

Complications: likelihood increases after 1st trimesterUterine perforation

Mgt.: hysterectomy, esp if septic

Cervical lacerationHemorrhageIncomplete removal of the fetus and placentaInfections

C. Introduction of a sharp curette. The instrument is held with the thumb and forefinger. In the upward movement of the curette, only the strength of these two fingers should be used.

A. Dilatation of cervix with a Hegar dilator. Note that the fourth and fifth fingers rest against the perineum and buttocks, lateral to the vagina. This maneuver is an important safety measure because if the cervix relaxes abruptly, these fingers prevent a sudden and uncontrolled thrust of the dilator, a common cause of uterine perforation

B. A suction curette is advanced to the uterine fundus and then back to the internal os. During its insertion and retraction, the curette is simultaneously rotated 360° several times to remove tissue circumferentially from the uterine walls.

USE OF DILATORS

Mechanical (metal) dilators can cause trauma. Use devices that slowly dilate the cervix.

HYGROSCOPIC DILATORSOriginate from the stems of Laminaria digitata or Laminaria japonica, a

brown seaweedDraw water from cervical tissues and expand, gradually dilating the cervixAnother mechanism: draw water from proteoglycan complexes, causing the

complexes to dissociate, and thereby allowing the cervix to soften and dilate

Insertion of laminaria prior to dilatation and curettage. A. Laminaria immediately after being appropriately placed with its upper end just through the internal os. B. Several hours later the laminaria is now swollen, and the cervix is dilated and softened. C. Laminaria inserted too far through the internal os; the laminaria may rupture the membranes.

MEDICAL ABORTIONPROSTAGLANDINS

Misoprostol (Cytotec)Prostalandin E1Cause abortion by increasing uterine contractility by stimulating

the myometrium directlyMay be placed into the posterior vaginal fornix to aid

subsequent dilatationFor early medical abortion

Regimens for Medical Termination of Early Pregnancy

Mifepristone/Misoprostol aMifepristone, 100-600 mg orally followed by: bMisoprostol, 200-600 g orally or 800 g vaginally in multiple doses over 6-72 hours.Methotrexate/Misoprostol cMethotrexate, 50 mg/m2 intramuscularly or orally followed by: dMisoprostol, 800 g vaginally in 3-7 days. Repeat if needed 1 week after methotrexate initially given.Misoprostol alone 800 g vaginally, repeated for up to three doses.

Prostaglandin E2 Suppositories of 20 mg prostaglandin E2 placed in the posterior

vaginal fornix are a simple and effective means of effecting second-trimester abortion.

not more effective than high-dose oxytocin, and it causes more frequent side effects such as nausea, vomiting, fever, and diarrhea

OXYTOCIN

Given as a single agent in high doses, oxytocin will effect second-trimester abortion in 80 to 90 percent of cases.

Concentrated Oxytocin Protocol for Mid-Trimester Abortion