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Williams Obstetrics Chapter 9 Abortion

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Williams Obstetrics Chapter 9 Abortion OBGY R1 Lee Eun Suk Abortion Spontaneous abortion Pathology Etiology Fetal Factors Maternal Factors Paternal Factors Categories ... – PowerPoint PPT presentation

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Title: Williams Obstetrics Chapter 9 Abortion


1
Williams Obstetrics Chapter
9 Abortion
  • OBGY R1 Lee Eun Suk

2
Abortion
  • Spontaneous abortion
  • Pathology
  • Etiology
  • Fetal Factors
  • Maternal Factors
  • Paternal Factors
  • Categories of Spontaneous Abortion
  • Induced abortion
  • History of abortion
  • Indications
  • Elective (Voluntary) Abortion
  • Presumption of ovulation after abortion

3
Abortion
  • Termination of pregnancy, either spontaneously or
    intentionally
  • Pregnancy termination prior to 20 weeks
    gestation or less than 500-g birthweight
  • Definition vary according to state laws for
    reporting abortions, fetal deaths, and neonatal
    deaths

4
Spontaneous abortion
  • Abortion occurring without medical or mechanical
    means to empty the uterus is referred to as
    spontaneous
  • Another widely used term is miscarriage
  • Pathology
  • Hemorrhage into the decidua basinalis, followed
    by necrosis of tissues adjacent to the bleeding
  • If early, the ovum detaches, stimulating uterine
    contractions
  • that result in its ovulation
  • Gestational sac is opened , fluid surrounding a
    small macerated
  • fetus or alternatively no fetus is visible ?
    blighted ovum

5
Spontaneous abortion
  • Pathology
  • In later abortion, the retained fetus may undergo
    maceration
  • The skull bones collapse, the abdomen distends
    with blood-
  • stained fluid, and the internal organs
    degenerate
  • The skin softens and peels off in utero or at the
    slightest tough
  • When amnionic fluid is absorbed, the fetus may
    become compressed and desiccated ? fetal
    compressus
  • The fetus become so dry and compressed that it
    resembles parchment - a fetus papyraceous

6
Spontaneous abortion
  • Etiology
  • More than 80 percent of abortions occur in the
    first 12 weeks of pregnancy
  • At least half result from chromosomal anomalies
  • After the first trimester, both the abortion rate
    the incidence of chromosomal anomalies decrease

7
F9-1
8
Spontaneous abortion
  • Etiology
  • The risk of spontaneous abortion increases with
    parity as well as with maternal and paternal age
  • The frequency of abortion increases from 12
    percent in women younger than 20 years to 26
    percent in those older than 40 years
  • If a woman conceives within 3 months following a
    term birth
  • ? incidence of abortion ?

9
F9-2
10
Spontaneous abortion
  • Etiology
  • The exact mechanism responsible for abortion are
    not apparent
  • In the first 3 months of pregnancy
  • Death of the embryo or fetus nearly always
    precedes spontaneous expulsion of the ovum
  • Finding of the cause of early abortion involves
    ascertaining
  • the cause of fetal death
  • In subsequent months
  • The fetus frequently does not die before
    expulsion
  • Other explanations for its expulsion should be
    sought

11
Spontaneous abortion - Fetal factors
  • Abnormal zygotic development
  • Early spontaneous abortion commonly display a
    developmental abnormality of the zygote, embryo,
    early fetus, or placenta
  • 1000 spontaneous abortions analyzed by Hertig
    and Sheldon
  • Half demonstrated degenerated or absent embryos,
    that is,
  • blighted ova

12
F9-3
13
Spontaneous abortion - Fetal factors
  • Aneuploid abortion
  • Approximately 50 to 60 percent of embryos and
    early fetuses
  • that are spontaneously aborted contain
    chromosomal abnor-malities accounting for most of
    early pregnancy wastage
  • Jacobs and Hassold (1980)
  • 95 percent of chromosomal abnormalities
  • d/t maternal gametogenesis error
  • 5 percent ? d/t paternal error

14
T9-1
15
Spontaneous abortion - Fetal factors
  • Aneuploid abortion - Autosomal trisomy
  • The most frequently identified chromosomal
    anomaly associated with first-trimester abortions
  • Most trisomies result from isolated
    nondisjunction , balanced structural chromosomal
    rearrangements are present in one partner in 2 to
    4 percent of couples with a history of recurrent
    abortions
  • Autosomes 13, 16, 18, 21, and 22 most commom

16
Spontaneous abortion - Fetal factors
  • Monosomy X
  • The second frequent chromosomal abnormality
  • Usually results in abortion
  • Much less frequently in liveborn female infant
    (Turner syndrome)
  • Triploidy
  • Associated with hydropic placental (molar)
    degeneration
  • Incomplete (partial) hydatidiform moles may
    contain triploidy or trisomy for only chromosome
    16

17
Spontaneous abortion - Fetal factors
  • Tetraploid abortuses
  • Rarely are liveborn and most often are aborted
    early in gestation
  • Chromosomal structural abnormalities
  • Identified only since the development of banding
    techniques, infrequently cause abortion

18
Spontaneous abortion - Fetal factors
  • Euploid abortion
  • Abort later in gestational than aneuploid
  • Three fourths of aneuploid abortions occurred
    before8 weeks
  • Euploid abortions peak at about 13 weeks
  • The incidence of euploid abortions increased
    dramatically after maternal age exceeded 35 years

19
Spontaneous abortion Maternal factors
  • Infections
  • Uncommon causes of abortion in human
  • Listeria monocytogenes
  • Clamydia trachomatis
  • Mycoplasma hominis
  • Ureaplasma urealyticum
  • Toxoplasma gondii

20
Spontaneous abortion Maternal factors
  • Chronic debilitating diseases
  • In early pregnancy, fetuses seldom abort
    secondary to chronic wasting disease such as
    tuberculosis or carcinomatosis
  • Celiac sprue
  • Cause both male and female infertility and
    recurrent abortions

21
Spontaneous abortion Maternal factors
  • Endocrine abnormalities
  • Hypothyroidism
  • Iodine deficiency associated with excessive
    miscarriages
  • Thyroid autoantibodies ? incidence of abortion?
  • Diabetes mellitus
  • The rates of spontaneous abortion major
    congenital malformations
  • Poor glucose control ? incidence of abortion?
  • Progesterone deficiency
  • Luteal phase defect
  • Insufficient progesterone secretion by the corpus
    luteum or placenta
  • Poor glucose control ? incidence of abortion?

22
Spontaneous abortion Maternal factors
  • Nutrition
  • Dietary deficiency of any one nutrients ? not
    important cause
  • Drug use and environmental factor
  • Tobacco
  • ? Risk for euploid abortion
  • More than 14 cigarettes a day ? the risk twofold
    greater ?
  • Alcohol
  • Spontaneous abortion fetal anomalies ? result
    from frequent alcohol use during the first 8
    weeks of pregnancy
  • Drinking twice a week ? abortion rates doubled ?
  • Drinking daily ? abortion rates tripled ?
  • Caffeine
  • At least 5 cups of coffee per day ? slightly
    increased risk of abortion

23
Spontaneous abortion Maternal factors
  • Drug use and environmental factor
  • Radiation
  • In sufficient doses ? abortifacient
  • Contraceptives
  • When intrauterine devices fail to prevent
    pregnancy ? abortion?
  • Environmental toxins
  • Anesthetic gases exact fetal risk of chronic
    maternal exposure is unknown
  • Arsenic, lead, formaldehyde, benzene, ethylene
    oxide ? abortifacient
  • Video display terminal accompanying
    electromagnetic fields
  • short waves ultrasound do not increase the
    risk of abortion

24
Spontaneous abortion Maternal factors
  • Immunological factors autoimmune factors
  • Recurrent pregnancy loss patients 15
  • Antiphospholipid antibody most significant
  • LCA (lupus anticoagulant), ACA (anticardiolipin
    Ab)
  • Reduce prostacyclin production
  • ? facilitating thromboxane dominant milieu ?
    thrombosis
  • Prostacyclin produced by vascular endothelial
    cell
  • ? potent vasodilator inhibit platelet
    aggregation
  • Thromboxane A2 produced by platelets
  • ? vasoconstrictor platelet aggregator
  • Strong association with
  • Decidual vasculopathy , placental infarction,
    fetal growth restriction
  • Early-onset preeclampsia, recurrent abortion,
    fetal death

25
Spontaneous abortion Maternal factors
  • Immunological factors autoimmune factors
  • Therapy of antiphopholipid antibody syndrome
  • low dose aspirin, prednisone, heparin,
    intravenous Ig
  • ? affect both immune coagulation system
  • ? counteract the adverse action of
    antibodies

26
Spontaneous abortion Maternal factors
  • Immunological factors alloimmune factors
  • Allogeneity
  • Genetic dissimilarities between animals of the
    same species
  • Human fetus is allogenic transplant tolerated by
    mother
  • Several test for diagnosis of alloimmune factors
  • Maternal paternal HLA comparison
  • Maternal serum test for blocking antibodies
  • blocking antibodies to paternal antigens
  • ig G origin
  • Maternal serum test for antipaternal antibodies
  • cytotoxic antibodies to paternal leukocyte

27
Spontaneous abortion Maternal factors
  • Inherited thrombophilia
  • Many studies of aggregated thrombophilias
  • ? excessive recurrent abortions
  • Laparotomy
  • Surgery performed during early pregnancy
  • ? no evidence of tncreased abortion
  • Peritonitis increases the likelihood of abortion
  • Physical trauma
  • Major abdominal trauma ? abortion?

28
Spontaneous abortion Maternal factors
  • Uterine defects acquired uterine defects
  • Uterine leiomyoma usually do not cause abortion
  • Placental implantation over or in contact with
    myoma
  • ? placental abruption, abortion, preterm
    labor ?
  • ? location is more important than size
  • Uterine synechiae (Asherman syndrome)
  • Partial or complete obliteration of the uterine
    cavity by adherence of uterine wall
  • Cause destruction of large areas of endometrium
    by curettage
  • ? insufficient endometrium to support
    implantation menstruation
  • ? recurrent abortion, amenorrhea,
    hypomenorrhea

29
Spontaneous abortion Maternal factors
  • Uterine defects acquired uterine defects
  • Diagnosis of uterine synechiae
  • Hysterosalpingogram ? characteristic multiple
    filling defects
  • Hysteroscopy ? most accurate direct diagnosis
  • Treatment of uterine synechiae
  • Lysis of adhesions via hysteroscopy
  • Prevention of adherence IUD
  • Promotion of endometrial proliferation
  • Continuous high-dose estrogen (60-90 days)

30
Spontaneous abortion Maternal factors
  • Uterine defects developmental uterine defects
  • Consequence of abnormal mullerian duct formation
    or fusion
  • Spontaneously
  • Induced by in utero exposure to DES
    (diethylstilbestrol)

31
Spontaneous abortion Maternal factors
  • Incompetent cervix
  • Painless dilatation of cervix in the 2nd or early
    in the 3rd trimester
  • ? prolapse ballooning of membranes into
    vagina
  • ? rupture of membrane expulsion of immature
    fetus
  • Unless effectively treated, tends to repeat in
    each pregnancy
  • Diagnosis in nonpregnant women
  • Hysterography
  • Pull-through techniques of inflated Foley
    catheter balloons
  • Acceptance without resistance at the internal os
    of specifically sized cervical dilators
  • The use of transvaginal ultrasound in pregnant
    women
  • Cervical length - shortening
  • Funneling

32
Spontaneous abortion Maternal factors
  • Incompetent cervix Etiology
  • Previous trauma to the cervix
  • Dilatation curettage
  • Conization
  • Cauterization
  • Abnormal cervical development
  • Exposure to DES in utero

33
Spontaneous abortion Maternal factors
  • Incompetent cervix Treatment
  • The operation is performed to surgically
  • Reinforcement of weak cervix by some type of
    purse string suture
  • ( Cerclage )
  • Prophylactic surgery generally performed
    between 12 16weeks
  • Should be delayed until after 14 weeks gestation
  • ? Early abortion due to other factors will be
    completed
  • The more advanced the pregnancy, the more likely
    the risk that surgical intervention stimulate
    preterm labor or membrane rupture
  • Usually do not perform after about 23 weeks

34
Spontaneous abortion Maternal factors
  • Incompetent cervix Preoperative evaluation
  • Sonography
  • Confirm living fetus exclude major fetal
    anomalies
  • Cervical cytology
  • Cultures for gonorrhea, chlamydia, group B
    streptococci
  • Obvious cervical infections ? treatment is given
  • For at least a week before after surgery ?
    sexual intercourse should be restricted

35
Spontaneous abortion Maternal factors
  • Incompetent cervix Cerclage procedures
  • Types of operations commonly used
  • McDonald
  • Modified Shirodkar
  • ? 8590 success rate

36
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38
Spontaneous abortion Maternal factors
  • Incompetent cervix Transabdominal cerclage
  • Requries laparotomy for
  • Placement of cerclage at uterine isthmus level
  • Cerclage removal, delivery, or both
  • Indications
  • Anatomical defects of cervix
  • Failed transvaginal cerclage

39
Spontaneous abortion Maternal factors
  • Incompetent cervix Complications
  • High incidence when performed much after 20 weeks
  • Membranes ruptures
  • Chorioamnionitis
  • Intrauterine infection
  • Urgent removal of suture
  • Operation fails
  • Signs of imminent abortion or delivery

40
Spontaneous abortion Paternal factors
  • Little is known in the genesis of spontaneous
    abortion
  • Chromosomal translocations in sperm can lead to
    abortion

41
Categories of spontaneous abortion
  • Threatened abortion
  • Inevitable abortion
  • Complete or incomplete abortion
  • Missed abortion
  • Recurrent abortion

42
Threatened abortion
Categories of spontaneous abortion
  • Definition
  • Any bloody vaginal discharge or bleeding during
    1st half of pregnancy
  • Bleeding is frequently slight, but may persist
    for days or weeks
  • Frequency
  • Extremely common (one out of four or five
    pregnant women)
  • Prognosis
  • Approximately ½ will abort
  • Risk of preterm delivery, low birthweight,
    perinatal death?
  • Risk of malformed infant does not appear to be
    increased

43
Threatened abortion
Categories of spontaneous abortion
  • Symptoms
  • Usually bleeding begins first
  • Cramping abdominal pain follows a few hours to
    several days later
  • Presence of bleeding pain
  • ? Poor prognosis for pregnancy continuation
  • Treatment
  • Bed rest acetaminophen-based analgesia
  • Progesterone (IM) or synthetic progestational
    agent (PO or IM)
  • Lack of evidence of effectiveness
  • Often results in no more than a missed abortion
  • D-negative women with threatened abortion
  • Probably should receive anti-D immunoglobulin

44
Threatened abortion
Categories of spontaneous abortion
  • Treatment slight bleeding persists for weeks
  • Vaginal sonography
  • Serial serum quantitative hCG
  • Serum progesterone
  • ? can help ascertain if the fetus is alive its
    location
  • Vaginal sonography
  • Gestational sac() hCG lt 1000mIU/ml
  • ? gestation is not likely to survive
  • ? If any doubt(), check the serum hCG level at
    intervals of 48hrs
  • ? if not increase more than 65, almost
    always hopeless
  • Serum progesterone value lt 5 ng/ml
  • ? dead conceptus

45
Threatened abortion
Categories of spontaneous abortion
  • Treatment after death of conceptus
  • Uterus should be emptied
  • ? examination of all passed tissue whether
    the abortion is complete
  • Ectopic pregnancy should be considered if
    gestational sac or
  • fetus are not identified

46
Inevitable abortion
Categories of spontaneous abortion
  • Gross rupture of membrane,evidenced by leaking
    amnionic fluid, in the presence of cervical
    dilatation, but no tissue passed during 1st half
    of pregnancy
  • Placenta (in whole or in part) is retained in the
    uterus
  • ? Uterine contractions begin promptly or
    infection develops
  • The gush of fluid is accompanied by bleeding,
    pain, or fever, abortion should be considered
    inevitable

47
Complete or incomplete abortion
Categories of spontaneous abortion
  • Complete abortion
  • Following complete detachment expulsion of the
    conceptus
  • The internal cervical os closes
  • Incomplete abortion
  • Expulsion of some but not all of the products of
    conception during 1st half of pregnancy
  • The internal cervical os remains open allows
    passage of blood
  • The fetus placenta may remain entirely in utero
    or may partially extrude through the dilated os
  • ? Remove retained tissue without delay

48
Missed abortion
Categories of spontaneous abortion
  • Retention of dead products of conception in utero
    for several weeks
  • Many women have no symptoms except persistent
    amenorrhea
  • Uterus remain stationary in size, but mammary
    changes usually
  • regress ? uterus become smaller
  • Most terminates spontaneously
  • Serious coagulation defect occasionally develop
    after prolonged retention of fetus

49
Recurrent abortion
Categories of spontaneous abortion
  • Definition Three or more consecutive
    spontaneous abortions
  • Clinical investigation of recurrent miscarriage
  • Parental cytogenetic analysis
  • Lupus anticoagulant anticardiolipin antibodies
    assays
  • Postconceptional evaluation
  • Serial monitoring of ßhCG from missed mens
    period
  • ßhCGgt1500mIU/ml ? USG
  • Maternal serum a-fetoprotein assessment
    (GA16-18wks)
  • Amniocentesis ? fetal karyotype
  • Prognosis
  • Depends on potential underlying etiology number
    of prior losses

50
  • INDUCED ABORTION

51
Induced abortion
  • The medical or surgical termination of pregnancy
    before the time of fetal viability
  • Therapeutic abortion
  • Termination of pregnancy before of fetal
    viability for the purpose
  • of saving the life of the mother

52
Induced abortion
  • Indication
  • Continuation of pregnancy may threaten the life
    of women or seriously impair her health
  • Persistent heart disease after cardiac
    decompensation
  • Advanced hypertensive vascular disease
  • Invasive carcinoma of the cervix
  • Pregnancy resulted from rape or incest
  • Continuation of pregnancy is likely to result in
    the birth of child with severe physical
    deformities or mental retardation

53
Induced abortion
  • Elective (voluntary) abortion
  • Interruption of pregnancy before viability at the
    request of the women, but not for reasons of
    impaired maternal health or
  • fetal disease
  • Counseling before elective abortion
  • Continued pregnancy with its risks parental
    responsibilities
  • Continued pregnancy with its risks its
    responsibilities of arranged adoption
  • The choice of abortion with its risks

54
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56
Surgical techniques for abortion
  • Dilatation and curettage
  • Performed first by dilating the cervix
    evacuating the product of conception
  • Mechanically scraping out of the contents (sharp
    curettage)
  • Vacuum aspiration (suction curettage)
  • Both
  • Before 14 weeks, DC or vacuum aspiration should
    be performed
  • After 16 weeks, dilatation evacuation (DE) is
    performed
  • Wide cervical dilatation
  • Mechanical destruction evacuation of fetal
    parts

57
Surgical techniques for abortion
  • Dilatation and curettage
  • Hygroscopic dilators
  • swell slowly dilate cervix ? cervical
    trauma can be minimized
  • Laminaria tents
  • stem of brown seaweed ( Laminaria digitata
    or japonica)
  • ? drawing water from proteoglycan complexes
    of cervix
  • ? dissociation allow the cervix to soften
    dilate
  • Insertion technique tip rests just at the level
    of internal os
  • Usually after 4-6hours, laminaria dilate the
    cervix sufficiently to allow easier mechanical
    dilation curettage
  • May cause cramping pain
  • ? easily managed with 60 mg codeine every 3-4
    hours

58
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59
Surgical techniques for abortion
  • Technique for dilatation curettage
  • Remove laminaria ? Uterus is sounded carefully to
  • Identify the status of the internal os
  • Confirm uterus size position
  • Further dilation of cervix with Hegar dilator

60
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61
Surgical techniques for abortion
  • Complications uterine perforation
  • 2 important determinants
  • Skill of the physician
  • Position of the uterus (retroverted)
  • Small defects by uterine sound or narrow dilator
  • ? often heal without complication
  • Suction sharp curettage
  • ? Considerable intra-abdominal damage risk?
  • ? Laparotomy to examine abdominal content (safest
    action)
  • Other complications cervical incompetence or
    uterine synechiae

62
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63
Surgical techniques for abortion
  • Menstrual aspiration
  • Aspiration of endometrial cavity using a flexible
    cannula and syringe within 1-3 weeks after
    failure to menstruate
  • Several points at early stage of gestation
  • Woman not being pregnant
  • Implanted zygote may be missed by the curette
  • Failure to recognize an ectopic pregnancy
  • Infrequently, a uterus can be perforated

64
Surgical techniques for abortion
  • Laparotomy
  • Abdominal hysterotomy or hysterectomy
  • Indications
  • Significant uterine disease
  • Failure of medical induction during the 2nd
    trimester

65
Medical induction of abortion
  • Early abortion
  • Outpatient medical abortion is an acceptable
    alternative to surgical abortion in women with
    pregnancies of less than 49 days gestation
  • (ACOG, 2001b)
  • Three medications for early medical abortion
  • Antiprogestin mifeprostone
  • Antimetabolite methotrexate
  • Prostaglandin misoprostol

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67
Medical induction of abortion _ 2nd trimester
abortion
68
Medical induction of abortion
  • Oxytocin
  • Successful induction of 2nd trimester abortion is
    possible with high doses of oxytocin administered
    in small volumes of IV fluids
  • Satisfactory alternatives to PG E2 for
    midtrimester abortion
  • Laminaria tents inserted the night before
  • Chance of successful induction is greatly
    enhanced

69
Medical induction of abortion
  • Prostaglandins
  • Used extensively to terminate pregnancies,
    especially in the 2nd T
  • PG E1, E2, F2a
  • Technique
  • Can act effectively on the cervix uterus
    (8695 effectiveness)
  • Vaginal prostaglandin E2 suppository
    prostaglandin E1 (misoprostol)
  • As a gel through a catheter into the cervical
    canal lowermost uterus
  • Injection into the amnionic sac by amniocentesis
  • Parenteral injection
  • Oral ingestion

70
Medical induction of abortion
  • Intra-amnionic hyperosmotic solutions
  • 20-25 saline or 30-40 urea injected into
    amnionic sac
  • ? stimulate uterine contraction cervical
    dilatation
  • Action mechanism prostaglandin mediated ?
  • Complications of hypertonic saline
  • Death
  • Hyperosmolar crisis (early into maternal
    circulation)
  • Cardiac failure
  • Septic shock
  • Peritonitis
  • Hemorrhage
  • DIC
  • Water intoxication
  • Hyperosmotic urea less likely to be toxic

71
Medical induction of abortion
  • Antiprogesterone RU 486
  • Oral agent used alone in combination with oral PG
    to effect abortions in early gestation
  • High receptor affinity for progesterone binding
    site
  • ? Block progesterone action
  • Abortion rate
  • Single 600mg dose prior 6 weeks ? 85
  • Addition of oral, vaginal or injected PG ? over
    95
  • If given within 72 hours
  • Also highly effective as emergency postcoital
    contraception
  • Progressively less effective after 72 hours
  • Side effects
  • Nausea, vomiting, gastrointestinal cramping
  • Major risk ? hemorrhage is a risk if abortion is
    incomplete

72
Medical induction of abortion
  • Epostane
  • 3ß-hydroxysteroid dehydrogenase inhibitor
  • ? blocks the synthesis of endogenous
    progesterone
  • Frequent side effect nausea
  • Hemorrhage is a risk if abortion is incomplete

73
Consequences of elective abortion
  • Maternal mortality
  • Legally induced abortion
  • Relative safe during the first 2 months of
    pregnancy
  • ( 0.6/100,000 procedures)
  • Doubled for each 2 weeks of delay after 8 weeks
    gestation

74
Consequences of elective abortion
  • Impact on future pregnancies
  • Fertility not altered by an elective abortion
  • Vacuum aspiration for a first pregnancy
  • Do not increase the incidence of
  • 2nd trimester spontaneous abortions
  • Preterm delivery
  • Ectopic pregnancy
  • LBW infants

75
Consequences of elective abortion
  • Impact on future pregnancies
  • Dilatations curettage for a first pregnancy
  • Increased risks for
  • Ectopic pregnancy
  • 2nd trimester spontaneous abortions
  • LBW infants
  • Multiple elective abortion
  • Not increased the incidence of preterm delivery
    LBW infants
  • Placenta previa
  • ? increased following multiple sharp
    curettage abortion procedures

76
Consequences of elective abortion
  • Septic abortion
  • Most often associated with criminal abortion
  • Metritis is usual outcome, but parametritis,
    peritonitis, endocarditis, and septicemia may all
    occur
  • Management
  • Prompt evacuation of products of conception
  • Broad-spectrum IV antimicrobials

77
Resumption of ovulation after abortion
  • Ovulation may resume as early 2 weeks after an
    abortion
  • Therefore, if pregnancy is to be prevented,
  • effective contraception should be initiated
    soon after abortion
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