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Abortion

In spontaneous abortion (miscarriage) or induced (therapeutic) abortion, the products of conception are expelled from the uterus before fetal viability (fetal weight of less than 17½ oz [about 500 g] and gestation of less than 20 weeks). Up to 15% of all pregnancies and about 30% of first pregnancies end in miscarriage. At least 75% of miscarriages occur during the first trimester. The incidence of legal induced abortions is increasing in the United States.

Causes

Which are in the main the same as the causes of miscarriage and premature delivery. Abortion may be due to pathological changes in the ovum, the uterus, or its adnexa one or both -- to the physical or nervous condition of the woman, to diseases either inherited or acquired (syphilis, tuberculosis, rheumatism); to any infectious, contagious, or inflammatory disease; to shock, injury, or accident. It may be induced knowingly, willingly, and criminally by the pregnant person herself, or by someone else, with the aid of drugs, or instruments, or both.

Signs and Symptoms

A patient who has experienced a spontaneous abortion may report a pink discharge for several days or a scant brown discharge for several weeks before onset of cramps and increased vaginal bleeding. She may describe cramps that appear for a few hours, intensify, and occur frequently.

If the patient has expelled the entire contents of the uterus, the cramps and bleeding may subside. However, if any contents remain, cramps and bleeding continue.

Diagnostic tests

Human chorionic gonadotropin (HCG) in the blood or urine confirms pregnancy; decreased HCG levels suggest spontaneous abortion. Cytologic analysis indicates evidence of products of conception. Laboratory tests reflect decreased hematocrit and hemoglobin levels due to blood loss. Ultrasound examination confirms the presence or absence of fetal heart tones or an empty amniotic sac. The newer vaginal probe technique enables earlier visualization of the gestational sac. Differential diagnosis is done to distinguish spontaneous abortion from cervicitis, ectopic pregnancy, gestational thromboplastic disease, and malignancy.

Treatment

An accurate evaluation of uterine contents is necessary before planning treatment.

The progression of spontaneous abortion can't be prevented, except in those cases caused by an incompetent cervix. Hospitalization is necessary to control severe hemorrhage. Severe bleeding requires transfusion with packed red blood cells or whole blood. Initially, l.V. administration of oxytocin stimulates uterine contractions. If remnants remain in the uterus, dilatation and curettage or dilatation and evacuation (D&E) should be performed.

D&E is also used in first-trimester induced abortions. In second-trimester induced abortions, an injection of hypertonic saline solution or of prostaglandin into the amniotic sac or insertion of a prostaglandin vaginal suppository induces labor and expulsion of uterine contents.

After a spontaneous or induced abortion, an Rhnegative female with a negative indirect Coombs' test should receive Rhº(D) immune globulin (RhoGAM) to prevent future Rh isoimmunization.

In a habitual aborter, spontaneous abortion can result from an incompetent cervix. Treatment involves surgical reinforcement of the cervix (cerclage) about 14 to 16 weeks after the last menstrual period. A few weeks before the estimated delivery date, the sutures are removed and the patient waits for the onset of labor. An alternative procedure, especially for the woman who wants to have more children, is to leave the sutures in place and to deliver the infant by cesarean section.



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