Obstentrics_Williams

Obstentrics_Williams. Excessive cafeine consumption-not well defined-has been associated with a higher abortion risk. Reports link heavy intake of approximately ive cups of cofee per dayabout 500 mg of cafeine-with a slightly greater abortion risk (Cnattingius, 2000; Klebanof, 1999). Studies of "moderate" intake-less than 200 mg daily-did not indicate increased risk (Savitz, 2008; Weng, 2008). In contrast, in one prospective cohort of more than 5100 gravidas, cafeine was linked to miscarriage but not in a dose-response relationship (Hahn, 2015). Currently, the American College of Obstetricians and Gynecologists (2016e) has concluded that moderate consumption likely is not a major abortion risk and that any associated risk with higher intake is unsettled.


Obstentrics_Williams

Obstentrics_Williams. Environmental toxins suggested to have a possible link to miscarriage include bisphenol A, phthalates, polychlorinated biphenyls, and dichlorodiphenyltrichloroethane (DDT) (Krieg, 2016). Even fewer studies implicate occupational exposures. In a follow-up of the Nurses Health Study II, Lawson and associates (2012) reported slightly increased miscarriage risks in nurses exposed to sterilizing agents, x-rays, and antineoplastic drugs. Also, a higher miscarriage risk was found for dental assistants exposed to more than 3 hours of nitrous oxide daily if there was no gas-scavenging equipment (Boivin, 1997).


Obstentrics_Williams

Obstentrics_Williams. Increasing paternal age is signiicantly associated with an greater risk for abortion (de La Rochebrochard, 2003). In the Jerusalem Perinatal Study, this risk was lowest before age 25 years, after which it progressively increased at 5-year intervals (Kleinhaus, 2006). The etiology of this association is not well studied, but chromosomal abnormalities in spermatozoa likely play a role (Sartorius, 2010). his diagnosis is presumed when bloody vaginal discharge or bleeding appears through a closed cervical os during the first 20 weeks. This bleeding in early pregnancy must be diferentiated from that with implantation, which some women have at the time of their expected menses. Aside from this, almost one fourth of women develop bleeding during early gestation that may persist for days or weeks. It may be accompanied by suprapubic discomfort, mild cramps, pelvic pressure, or persistent low backache. Of symptoms, bleeding is by far the most predictive risk factor for pregnancy loss.


Obstentrics_Williams

Obstentrics_Williams. Even if miscarriage does not follow threatened abortion, rates of later adverse pregnancy outcomes are increased as shown in Table Of these, highest risks are for preterm delivery. Weiss and coworkers (2004) noted greater risks for adverse outcomes in later pregnancy if early bleeding was heavy rather than light. Compared with those without bleeding, women with first-trimester bleeding in an initial pregnancy have higher recurrence rates in their second (Lykke, 2010). TABLE 18-1. Adverse Outcomes That Are Increased in Women with Threatened Abortion Placenta previa Preterm ruptured membranes Placental abruption Preterm birth Manual removal of placenta Low-birthweight infant Cesarean delivery Fetal-growth restriction From Lykke, 2010; Saraswat, 2010; Weiss, 2004; Wijesiriwardana,s2006.


Obstentrics_Williams

Obstentrics_Williams. From Lykke, 2010; Saraswat, 2010; Weiss, 2004; Wijesiriwardana,s2006. Every woman with an early pregnancy, vaginal bleeding, and pain should be evaluated. he primary goal is prompt diagnosis of ectopic pregnancy, and serial quantitative serum S-hCG levels and transvaginal sonography are integral tools. Because these are not 100-percent accurate to confirm early embryo death or location, repeat evaluations are often necessary. With a robust uterine pregnancy, serum S-hCG levels should rise at least 53 to 66 percent every 48 hours (Barnhart, 2004c; Kadar, 1982). Although a less-used marker, serum progesterone concentrations <5 ng/mL suggest a dying pregnancy. Values >20 ng/mL support the diagnosis of a healthy one (Daily, 1994).


Obstentrics_Williams

Obstentrics_Williams. Transvaginal sonography is used to locate the pregnancy and determine viability. If this cannot be done, then a PUL is diagnosed, and serial surveillance is implemented for clinically stable women. The gestational sac-an anechoic fluid collection that represents the exocoelomic cavity-may be seen by 4.5 weeks (Fig. 9-3, p. 159). At this same time, S-hCG levels generally measure 1500 to 2000 mIU/mL (Barnhart, 1994; Timor-Tritsch, 1988). Connolly and colleagues (2013) observed that this value could be as low as 390 mIU/mL. However, they also noted that a threshold as high as 3500 mIU/mL may be needed to identiY the gestational sac in some cases that ultimately yield a viable singleton IUP.


Obstentrics_Williams

Obstentrics_Williams. Another caveat is that a gestational sac may appear similar to other intrauterine fluid accumulations-the so-called pseudogestational sac (Fig. 19-4, p. 375). his pseudosac may be blood derived from a bleeding ectopic pregnancy and is easier to exclude once a yolk sac is seen. Typically, the yolk sac is visible by 5.5 weeks and with a mean gestational-sac diameter of 10 mm. Thus, the diagnosis of an IUP should be made cautiously if the yolk sac is not yet seen (American College of Obstetricians and Gynecologists, 20 16h). For management of threatened abortion, observation is the norm. Acetaminophen-based analgesia will help relieve discomfort from cramping. Bed rest is often recommended but does not improve outcomes. The hematocrit and blood type is determined. If anemia or hypovolemia is signiicant, then pregnancy evacuation is generally indicated. In cases in which there is a live fetus, some instead may choose transfusion and further observation.


Obstentrics_Williams

Obstentrics_Williams. During abortion, bleeding follows partial or complete placental separation and dilation of the cervical os. Before 10 weeks' gestation, the fetus and the placenta are frequently expelled together, but later, they deliver separately. hus, tissue may remain entirely within the uterus or partially extrude through the cervix. Products lying loosely within the cervical canal can be easily extracted with ring forceps. In contrast, with incom plete expulsion, three management options include curettage, expectant management, or misoprostol (Cytotec), which is prostaglandin EI (PGEI) (Kim, 2017). he last two are deferred in clinically unstable women or those with uterine infection.


Obstentrics_Williams

Obstentrics_Williams. Each option has its own risks and benefits. With all three, infection and need for transfusion are uncommon. However, misoprostol and expectant care are associated with unpredictable bleeding, and some women will undergo unscheduled curettage. Expectant management of spontaneous incomplete abortion has failure rates that approximate 25 percent in randomized trials (Nadarajah, 2014; Nielsen, 1999; Trinder, 2006). Some observational studies have shown failure rates of 10 to 15 percent (Blohm, 2003; Casikar, 2012; Luise, 2002). Medical therapy carries failure rates of 5 to 30 percent (Dao, 2007; Shochet, 2012; Trinder, 2006). In many studies for this, an oral misoprostol dose of 600 1g has been used (American College of Obstetricians and Gynecologists, 2009). Alternatively, an 800-l1g vaginal or a 400-1g oral or sublingual misoprostol dose is suitable. Last, curettage usually results in a quick resolution that is 95-to 100-percent successful. However, it is invasive and not necessary for


Obstentrics_Williams

Obstentrics_Williams. or a 400-1g oral or sublingual misoprostol dose is suitable. Last, curettage usually results in a quick resolution that is 95-to 100-percent successful. However, it is invasive and not necessary for all women.


Obstentrics_Williams

Obstentrics_Williams. At times, complete expulsion of the entire pregnancy may ensue, and the cervical os subsequently closes. A history of heavy bleeding, cramping, and passage of tissue is typical. Patients are encouraged to bring in passed tissue, in which a complete gestation should be discerned from blood clots or a decidual cast. he latter is a layer of endometrium in the shape of the uterine cavity that when sloughed can appear as a collapsed sac (Fig. 19-2, p. 373).


Obstentrics_Williams

Obstentrics_Williams. If an expelled complete gestational sac is not identified, transvaginal sonography is performed to diferentiate a complete abortion from threatened abortion or ectopic pregnancy. Characteristic findings of a complete abortion include a minimally thickened endometrium without a gestational sac. However, this does not guarantee a recent uterine pregnancy. Condous and associates (2005) described 152 women with heavy bleeding, an empty uterus with endometrial thickness < 15 mm, and a diagnosis of completed miscarriage. Six percent were subsequently found to have an ectopic pregnancy. Thus, a complete abortion cannot be surely diagnosed unless: (1) true products of conception are seen grossly or (2) unless sonography confidently documents first an intrauterine pregnancy and then later an empty cavity. In unclear settings, serial serum hCG level measurements aid clariication. With complete abortion, these levels drop quickly (Table 18-2).


Obstentrics_Williams

Obstentrics_Williams. This describes dead products of conception that have been retained for days or weeks in the uterus with a closed cervical os. Diagnosis is imperative prior to intervention and avoids interruption of a potentially live IUP. Transvaginal sonography is the primary tool. TABLE 18-2. Percentage Decline of Initial Serum FIGURE 18-1 Transvaginal sonogram displays a large anechoic sac consistent with an anembryonic gestation. Calipers measure uterine length and anteroposterior thickness in a sagittal plane. aThe percentage decline is given as the expected decline. The minimum expected decline in parentheses is the 95th percentile value. Declines less than this minimum may reflect retained either intrauterine or extrauterine trophoblast. Data from Barnhart, 2004a; Chung, 2006.


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Obstentrics_Williams. Data from Barnhart, 2004a; Chung, 2006. At 5 to 6 weeks' gestation, a 1-to 2-mm embryo adjacent to the yolk sac can be seen (Daya, 1993). As listed in Table 18-3, absence of an embryo in a sac with a mean sac diameter (MSD) ::25 mm signiies a dead fetus (Fig. 18-1). Fetal cardiac activity can typically be detected at 6 to 6.5 weeks with a crown-rump length (CL) of 1 to 5 mm and an MSD of 13 to 18 mm (Goldstein, 1992; Levi, 1990). A threshold CL ::7 mm with absent cardiac activity is also used to diagnose nonviability (Doubilet, 2013). Preisler and associates (2015) implemented the guidelines in Table 18-3 and conirmed' these CL and MSD thresholds. However, for cases in which a gestational sac had no embryo or yolk sac and measured < 12 mm, they TABLE 18-3. Guidelines for Early Pregnancy Loss Diagnosisa


Obstentrics_Williams

Obstentrics_Williams. TABLE 18-3. Guidelines for Early Pregnancy Loss Diagnosisa CRL ::7 mm and no heartbeat MSD ::25 mm and no embryo An initial US scan shows a gestational sac with yolk sac, and after ::11 days no embryo with a heartbeat is seen An initial US scan shows a gestational sac without a yolk sac, and after ::2 weeks no embryo with a heatbeat is seen Transvaginal preferable to transabdominal US M-mode imaging used to document and measure heartbeat Doppler US not used to evaluate a normal early embryo aFrom the Society of Radiologists in Ultrasounds; American College of Radiology. CRL = crown-rump length; MSD = mean sac diameter; US = ultrasound. From Doubilet, Lane, 2013. recommended that to diagnose nonviability after 2 weeks, in addition to the lack of an embryo with a heartbeat, the MSD should have failed to double.


Obstentrics_Williams

Obstentrics_Williams. From Doubilet, Lane, 2013. recommended that to diagnose nonviability after 2 weeks, in addition to the lack of an embryo with a heartbeat, the MSD should have failed to double. During scanning, because of theoretical temperature elevation in tissues exposed to pulsed Doppler beam, this modality is applied only when needed for additional diagnostic purposes. M-mode should be used to document cardiac activity and measure the rate (Lane, 2013). Finding of an IUP and cardiac activity lowers subsequent miscarriage rates (Siddiqi, 1988).


Obstentrics_Williams

Obstentrics_Williams. In addition to the diagnostic parameters of Table 18-3, other softer sonographic markers may portend early pregnancy failure. Values for yolk sac diameters (measured inner-to-inner ring) for each gestational week in normal pregnancy have been established. Yolk sac diameters ::6 mm in pregnancies < 10 weeks' gestation are suspicious for pregnancy failure (Berdahl, 2010; Lindsay, 1992). The fetal heart rate in the irst trimester rises from 110 to 130 beats per minute (bpm) at 6 weeks' gestation to 160 to 170 bpm at 8 weeks (Achiron, 1991; Rauch, 2009). A slower heart rate is unfavorable, especially those <85 bpm (Laboda, 1989; Stefos, 1998). Even with cardiac activity, fetuses with a small MSD may presage embryonic loss. Speciically, a diference <5 mm between the MSD and CRL values raises concern (Bromley, 1991; Dickey, 1992). Last, subchorionic hematoma, that is, blood collected between the chorion and uterine wall, often accompanies threatened miscarriage. Studies are contradictory as


Obstentrics_Williams

Obstentrics_Williams. (Bromley, 1991; Dickey, 1992). Last, subchorionic hematoma, that is, blood collected between the chorion and uterine wall, often accompanies threatened miscarriage. Studies are contradictory as to its association with ultimate pregnancy loss (Pedersen, 1990; Stabile, 1989; Tuuli, 2011). Bennett and associates (1996) noted that miscarriage risk correlated with larger hematoma size, older maternal age, and bleeding at a gestational age :;8 weeks.


Obstentrics_Williams

Obstentrics_Williams. With rapid confirmation of embryonic or fetal death, surgicalior medical evacuation or expectant observation is an option. As with induced abortion, nonsurgical options balance their noninvasiveness against heavier procedural bleeding, longer completion times, and lower success rates. Of options, expectant care underperforms medical or surgical options, and failure rates range from 15 to 50 percent (Luise, 2002; Trinder, 2006; Zhang, 2005). Also, weeks may pass between pregnancy failure diagnosis and actual spontaneous miscarriage.


Obstentrics_Williams

Obstentrics_Williams. Alternatively, misoprostol can be given to hasten uterine evacuation. A single 800-l-1g dose vaginally is a common stan dard (American College of Obstetricians and Gynecologists, 20 16c). It may be repeated in 1 to 2 days, and one large trial reported that 22 percent of women required a second dose (Zhang, 2005). Overall, failure rates range from 15 to 40 per cent (Petersen, 2014; Trinder, 2006). Unlike induced abortion, adding mifepristone does not add value (Stockheim, 2006). Contraindications mirror those listed in the section describing induced abortion (p. 361). Confirmation of completion may include a history of heavy bleeding, cramping, and tissue passage followed by ebbing flow; ping serum hCG levels. That said, there is no consensus on intervention.


Obstentrics_Williams

Obstentrics_Williams. Confirmation of completion may include a history of heavy bleeding, cramping, and tissue passage followed by ebbing flow; ping serum hCG levels. That said, there is no consensus on intervention. Pre term premature rupture of membranes (PPRO\1) at a pre viable gestational age complicates 0.5 percent of pregnancies (Hunter, 2012). Rupture may be spontaneous or may follow an invasive procedure such as amniocentesis or fetal surgery. Risks for spontaneous rupture at a previable gestation are prior PPROM, prior second-trimester delivery, and tobacco use (Kilpatrick, 2006).


Obstentrics_Williams

Obstentrics_Williams. Risks for spontaneous rupture at a previable gestation are prior PPROM, prior second-trimester delivery, and tobacco use (Kilpatrick, 2006). A gush of vaginal fluid that is seen pooling during sterile speculum examination confirms the diagnosis. In suspect cases, amnionic luid will fern on a microscope slide or will have a pH >7, or oligohydramnios will be seen on sonography (Sugibayashi, 2013). lso, amnionic fluid proteins placental alpha microglobulin-1 and insulin growth factor binding protein-I, described in Chapter 22 (p. 235), can be assayed (Doret, 2013). In iatrogenic cases, defects are typically higher in the uterus and tend to self seal. Also, an occlusive plug-termed an amniopatch-can be created by intraamnionic instillation of autologous platelets and cryoprecipitate. Considered investigational, it is used to seal some surgical leaks (Richter, 2013).


Obstentrics_Williams

Obstentrics_Williams. Spontaneous rupture in the first trimester is nearly always followed by either uterine contractions or infection, and termination is typical. In some second-trimester cases not associated with pain, fever, or bleeding, fluid may have collected previously between the amnion and chorion. If this is documented, then diminished activity with observation is reasonable. After 48 hours, if no additional amnionic luid has escaped and if there is no bleeding, cramping, or fever, then a woman may resume ambulation and pelvic rest at home.


Obstentrics_Williams

Obstentrics_Williams. However, more typically with second-trimester spontaneous PPROM at a previable age, 40 to 50 percent of women will deliver within the first week, and 70 to 80 percent will do so after 2 to 5 weeks (American College of Obstetricians and Gynecologists, 2016f). Average latency is 2 weeks (Hunter, 2012; Kibel, 2016). Significant maternal complications attend previable PPROM and include chorioamnionitis, endometritis, sepsis, placental abruption, and retained placenta (Waters, 2009). With bleeding, cramping, or fever, abortion is considered inevitable, and the uterus is evacuated. Without these complications, expectant management is an option in the well-counseled patient (American College of


Obstentrics_Williams

Obstentrics_Williams. Without these complications, expectant management is an option in the well-counseled patient (American College of Obstetricians and Gynecologists, 20 17). Many will choose ter mination due to the just-described maternal risks and tenuous neonatal outcomes. In contemporary cohorts with PPROM at <24 weeks' gestation, only approximately 20 percent of fetuses survive until hospital discharge (Esteves, 2016; Everest, 2008; Muris, 2007). Of surviving infants, 50 to 80 percent sufer long-term sequelae (Miyazaki, 2012; Pristauz, 2008). Further stratification of outcomes by gestational age is described in


Obstentrics_Williams

Obstentrics_Williams. Muris, 2007). Of surviving infants, 50 to 80 percent sufer long-term sequelae (Miyazaki, 2012; Pristauz, 2008). Further stratification of outcomes by gestational age is described in Chapter 42 (p. 806). Overall, prognosis is improved if previa ble PPROM occurred at a later gestation, latency is longer, and oligohydramnios is absent. Neonatal mortality predominantly stems from pulmonary dysfunction, which has higher rates when oligohydramnios persists (Winn, 2000). Fetal deforma tions may also result from scant amnionic luid. Amnioinfusion has been investigated but is currently investigational (Roberts, 20i14). If expectant care is elected, management is described in Chapter 42 (p. 807). Antibiotics are considered and given for 7 days to extend latency. Other topics include lung-maturing corticosteroids, magnesium sulfate neuroprophylaxis, group


Obstentrics_Williams

Obstentrics_Williams. Chapter 42 (p. 807). Antibiotics are considered and given for 7 days to extend latency. Other topics include lung-maturing corticosteroids, magnesium sulfate neuroprophylaxis, group B streptococcus antibiotic prophylaxis, tocolytics, and neo natal resuscitation eforts. After initial hospitalization, the patient may be discharged home, with instruction for careful surveillance for complications until viability, at which time readmission is usual (American College of Obstetricians and Gynecologists, 20 16). In subsequent pregnancies, the risk for recurrent preterm birth is great, and in one cohort study, the rate neared 50 percent (Monson, 2016).


Obstentrics_Williams

Obstentrics_Williams. Gynecologists, 20 16). In subsequent pregnancies, the risk for recurrent preterm birth is great, and in one cohort study, the rate neared 50 percent (Monson, 2016). With abortion legalization, horriic infections and maternal deaths associated previously with criminal septic abortions are now rare. Still, with spontaneous or induced abortion, organisms may invade myometrial tissues and extend to cause parametritis, peritonitis, and septicemia. Most bacteria causing septic abortion are part of the normal vaginal lora. Particularly worrisome are severe necrotizing infections and toxic shock syndrome caused by group A streptococcus-S pyogenes (Daif, 2009).


Obstentrics_Williams

Obstentrics_Williams. Rare but severe infections with otherwise low-virulence organisms can complicate medical or spontaneous abortions. Deaths have been reported from toxic shock syndrome due to Clostridium peringens (Centers for Disease Control and Prevention, 2005). Similar infections are caused by Clostridium sordellii and have clinical manifestations that begin within a few days after an abortion. Women may be afebrile when first seen with severe endothelial injury, capillary leakage, hemoconcentration, hypotension, and a profound leukocytosis. Maternal deaths from these clostridial species approximate 0.58 per 100,000 medical abortions (Meites, 2010).


Obstentrics_Williams

Obstentrics_Williams. Management of clinical infection includes prompt administration of broad-spectrum antibiotics as discussed in Chapter 37 (p. 668). If there are retained products, then suction curettage is also performed. Most women respond to this treatment within 1 to 2 days and are discharged when afebrile. Follow-up oral antibiotic treatment is likely unnecessary (Savaris, 2011). In a very few women, severe sepsis syndrome develops, and intensive supportive care is essential. Although rare, clinical decline in the patient and widespread peritonitis despite curettage should raise concerns. Imaging that shows free air or air within the uterine wall typically prompts laparotomy (Eschenbach, 2015). If the uterus is necrotic, hysterectomy is indicated.


Obstentrics_Williams

Obstentrics_Williams. With spontaneous miscarriage, 2 percent of h D-negative women will become alloimmunized if not provided passive isoimmunization. With an induced abortion, this rate may reach 5 percent. The American College of Obstetricians and Gynecologists (2017g) recommends anti-Rho (D) immunoglobulin given as 300 �g intramuscularly (IY!) for all gestational ages. Doses may also be graduated, with 50 �g given Hvl for pregnancies :;12 weeks and 300 �g for ::13 weeks. This is administered immediately following surgical evacuation. For planned medical or expectant management, the injection is given within 72 hours of pregnancy failure diagnosis. With threatened abortion, immunoglobulin prophylaxis is controversial because of sparse evidence-based data (Hannafin, 2006). hat said, it is reasonable to administer anti-D immunoglobulin for a threatened abortion and a live fetus, and this is our practice.


Obstentrics_Williams

Obstentrics_Williams. Afecting approximately 1 percent of fertile couples, recurrent pregnancy loss (RPL) is classically deined as three or more consecutive pregnancy losses <20 weeks' gestation or with a fetal weight < 500 g. Mindful of this threshold, data from two large studies showed the risk for a subsequent miscarriage to be similar whether following two or three prior pregnancy losses (Bhattacharya, 2010; Brigham, 1999). And, the American Society for Reproductive Medicine (2013) now deines RPL as two or more failed pregnancies conirmed by sonographic or histopathological examination. Primary PL refers to multiple losses in a woman who has never delivered a liveborn, and secondary PL refers to multiple pregnancy losses in a patient with a prior live birth. Remarkably, the chances for a successful pregnancy arei> 50 percent even after five losses (Table 18-4). TABLE 18-4. Predicted Success Rate of Subsequent Pregnancy According to Age and Number of Previous Miscarriages


Obstentrics_Williams

Obstentrics_Williams. TABLE 18-4. Predicted Success Rate of Subsequent Pregnancy According to Age and Number of Previous Miscarriages No. of Previous 2 3 4 5 Miscarriages at Predicted Success of Subsequent Evaluation for RPL addresses the major etiologies, described next (American Society for Reproductive Medicine, 2012). Treatment considerations reach beyond the scope of this book, and interested readers are referred to Chapter 6 in Wiliams Gynecoloy, 3rd edition (Halvorson, 2016). hree widely accepted causes of RPL are parental chromosomal abnormalities, antiphospholipid antibody syndrome, and structural uterine abnormalities. First-trimester losses in PL have a signiicantly lower incidence of genetic abnormalities than sporadic miscarriage (Stephenson, 2002; Sullivan, 2004).


Obstentrics_Williams

Obstentrics_Williams. The timing of recurrent loss can ofer clues, and in some women, each miscarriage may occur near the same gestational age (Heuser, 2010). Genetic factors usually result in early embryonic losses, whereas autoimmune or uterine anatomical abnormalities more likely cause second-trimester losses (Schust, 2002). Approximately 40 to 50 percent of women have idiopathic RPL (Li, 2002; Stephenson, 1996). Although these account for only 2 to 4 percent of RPL cases, karyotyping of both parents is considered by many to be essential. Of abnormalities, reciprocal translocations are most common and followed by robertsonian translocations (Fan, 2016). heir genesis and reproductive sequelae are discussed in Chapter 13 (p. 261).


Obstentrics_Williams

Obstentrics_Williams. After thorough genetic counseling, couples with an abnormal karyotype can be ofered in vitro fertilization (IVF) followed by preimplantation genetic diagnosis (American Society for Reproductive Medicine, 2012; Society for Assisted Reproductive Technology, 2008). This technique is described in Chapter 14 (p. 295). However, in couples with RPL who are chromosomaly normal, PGD is not currently recommended. Several genital tract abnormalities have been implicated in RPL and other adverse pregnancy outcomes (Reichman, 2010). According to Devi Wold and colleagues (2006), 15 percent of women with three or more consecutive miscarriages will be found to have a congenital or acquired uterine anomaly.


Obstentrics_Williams

Obstentrics_Williams. Of acquired abnormalities, uterine synechiae-Asherman syndrome-usually result from destruction of large areas of endometrium. This can follow uterine curettage, hysteroscopic surgeries, or uterine compression sutures (Conforti, 2013; Rathat, 2011). Characteristic multiple illing defects are seen with hysterosalpingography or saline-infusion sonography. Treatment is hysteroscopic adhesiolysis. In many, this lowers miscarriage rates and improves live birth rates (Yu, 2008). Uterine leiomyomas are common and may cause miscarriage, especially iflocated near the placental implantation site. That said, data indicating them to be a significant cause ofRPL are not con 77 73 68 62 vincing (Saravelos, 2011). Uterine cavity distortion is apparently 69 64 58 52 not requisite for bad outcomes (Sunkara, 2010). But in women undergoing IVF, pregnancy outcomes are adversely afected by Data fror Brigham, 1999 submucous but not subserosal or intramural leiomyomas a un,


Obstentrics_Williams

Obstentrics_Williams. Data fror Brigham, 1999 submucous but not subserosal or intramural leiomyomas a un, TABLE 18-5. Clinical and Laboratory Criteria for Diagnosis of Antiphospholipid Antibody Syndromea Obstetric: One or more unexplained deaths of a morphologically normal fetus at or beyond 10 weeks, Severe preeclampsia or placental insufficiency necessitating delivery before 34 weeks, Vascular: One or more episodes of arterial, venous, r small vessel thrombosis in any tissue or organ Presence of lupus anticoagulant according to guidelines of the International Society on Thrombosis and Hemostasis, Medium or high serum levels of IgG or IgM anticardiolipin antibodies, IgG = immunoglobulin G; igM = immunoglobulin M. Modified from Branch, 2010; ETkan, 201s1; Miyakis, 2006. 2001; Ramzy, 1998). s discussed in Chapter 63 (p. 1197), most agree that excision of submucosal leiomyomas in women with RPL can be considered.


Obstentrics_Williams

Obstentrics_Williams. 2001; Ramzy, 1998). s discussed in Chapter 63 (p. 1197), most agree that excision of submucosal leiomyomas in women with RPL can be considered. Congenital genital tract anomalies often originate from abnormal mlillerian duct formation. These have an overall incidence of approximately 1 in 200 women (Nahum, 1998). Depending on their anatomy, some may raise risks for early miscarriage, whereas others may cause midtrimester abortion or preterm delivery. Unicornuate, bicornuate, and septate uteri are associated with all three types of loss (Reichman, 2010). A fuller discussion of these anatomical abnormalities and their reproductive efects is found in Chapter 3 (p. 41).


Obstentrics_Williams

Obstentrics_Williams. Miscarriages are more common in women with systemic lupus erythematosus (Clowse, 2008). Many of these women, as well as some without lupus, carry antiphospholipid antibodies, a family of autoantibodies that bind to phospholipid-binding plasma proteins (Erkan, 201 1). Women with RPL have a higher frequency of these antibodies compared with normal controls (Branch, 2010). As shown in 1 able 18-5, the antiphospholipid antibody syndrome APS) is deined by these antibodies in combination with various forms of reproductive loss and substantively increased risks for venous thromboembolism (American College of Obstetricians and Gynecologists, 20 17b,i). Mechanisms that cause pregnancy loss are discussed along with treatment in Chapter 59 (p. 1144).


Obstentrics_Williams

Obstentrics_Williams. Regarding alloimmunity, one provocative theory suggests that normal pregnancy requires formation of blocking factors that avert maternal rejection of foreign fetal antigens that are paternally derived (Chap. 5, p. 95). Factors that prevent this tolerance may underlie RPL (Berger, 2010). However, proposed therapies using paternal or third-party leukocyte immunization or intravenous immunoglobulin (IlG) have not proved beneicial in aAt least one clinical and one laboratory criteria must be present for diagnosis. bThese tests must be positive on two or more occasions at least 12 weeks apart. women with idiopathic RPL (Christiansen, 2015; Stephenson, 2010).


Obstentrics_Williams

Obstentrics_Williams. women with idiopathic RPL (Christiansen, 2015; Stephenson, 2010). According to Arredondo and Noble (2006), 8 to 12 percent of recurrent miscarriages are caused by endocrine factors. Studies to evaluate these have been inconsistent and generally underpowered. Two examples, both controversial, are progesterone deficiency caused by a luteal-phase dect and poycystic ovarian syndrome (Bukulmez, 2004; Cocksedge, 2008). In contrast, the well-known abortifacient action of uncontrolled diabetes mellitus is detailed in Chapter 57 (p. 1099). Optimal periconceptional glycemic control will mitigate many of these losses.


Obstentrics_Williams

Obstentrics_Williams. In contrast, the well-known abortifacient action of uncontrolled diabetes mellitus is detailed in Chapter 57 (p. 1099). Optimal periconceptional glycemic control will mitigate many of these losses. Likewise, the efects of overt hypothyroidism and severe iodine deficiency on early pregnancy failure are well known and discussed in Chapter 58 (p. 1124). Correction with supplementation reverses these actions. Also, the influence of subclinical hypothyroidism and antithyroid antibodies are sporadic, and thus any efects on recurrent miscarriage rates have been debated (Garber, 2012). That said, two metaanalyses reported convincingly positive associations between these antibodies and a greater risk for sporadic and recurrent miscarriages (Chen, 2011; Thangaratinam, 2011). One ongoing randomized trial regarding potential beneits of treatment will help guide future management (Vissenberg, 2015).


Obstentrics_Williams

Obstentrics_Williams. he timespan that deines a mid trimester fetal loss extends from the end of the first trimester until the fetus weighs < 500 g or gestational age reaches 20 weeks. Less than in the irst trimester, TABLE 18-6. Some Causes of Midtrimester Spontaneous Abruption, previa the spontaneous loss rate in the second ranges from 1.5 to 3 percent and, after 16 weeks, is only 1 percent (Simpson, 2007; Wyatt, 2005). Unlike earlier miscarriages that frequently are caused by chromosomal aneuploidies, these later fetal losses are due to a multitude of causes (Table 18-6). One frequently overlooked factor is that many second-trimester abortions are medically induced because of fetal abnormalities detected by prenatal screening programs for chromosome aneuploidy and structural defects.


Obstentrics_Williams

Obstentrics_Williams. .Midtrimester abortions are classified similarly to first-trimester miscarriages (p. 348). Management is similar in many regards to that used for second-trimester induced abortion, described later (p. 362). One exception is cervical cerclage, which may be employed for cervical insuiciency. Also known as incompetent cervix, this is a discrete obstetrical entity characterized classically by painless cervical dilatation in the second trimester. It can be followed by prolapse and ballooning of membranes into the vagina, and ultimately, expulsion of an immature fetus. his sequence oten repeats in uture pregnancies.


Obstentrics_Williams

Obstentrics_Williams. Although the cause of insuiciency is obscure, previous cervical trauma has been implicated. One Norwegian cohort study of more than 15,000 women with prior cervical conization found a fourfold risk of pregnancy loss before 24 weeks' gestation (lbrechtsen, 2008). However, cerclage is not beneicial for women solely with this risk and without a preterm birth history (Zeisler, 199 ). Of other surgeries, dilation and evacuation carries a 5-percent risk of cervical injury, but neither it nor dilation and extraction raises the likelihood of cervical insuiciency (Chasen, 2005). In other instances, abnormal cervical development, including that following in utero exposure to diethylstilbestrol (DES), may playia role (Hoover, 2011). Last, cervical ripening changes, such as altered hyaluronan or collagen content, discussed in Chapter 21 (p. 409), may be contributory (Eglinton, 2011; Sundtoft, 2017).


Obstentrics_Williams

Obstentrics_Williams. Last, cervical ripening changes, such as altered hyaluronan or collagen content, discussed in Chapter 21 (p. 409), may be contributory (Eglinton, 2011; Sundtoft, 2017). For women with an unequivocal history of second-trimester painless delivery, prophylactic cerclage placement is an option and reinforces a weak cervix by an encircling suture. However, some women have a history and clinical findings that make it diicult to veriy-classic cervical insuiciency. In one randomized trial of almost 1300 women with an atypical history, cerclage was found to be only marginally beneicial-13 versus 17 percent-to prolong pregnancy past 33 weeks (MacNaughton, 1993). It seems likely that many of these women instead had preterm labor.


Obstentrics_Williams

Obstentrics_Williams. In addition to history, the physical inding of early dilation of the internal cervical os may be an indicator of insuiciency. In a systematic review, cerclages that were placed based on this finding provided superior perinatal outcomes compared with expectant management (Ehsanipoor, 2015).


Obstentrics_Williams

Obstentrics_Williams. Transvaginal sonography is yet another tool, and cervical length and the presence offunneling are sought. he latter is ballooning of the membranes into a dilated internal os, but with a closed external os. In women with these findings, early randomized trials were inconclusive in proving the clinical value of cerclage to prevent preterm birth (Rust, 2001; To, 2004). A multicenter randomized trial of 302 high-risk women with cervical length <25 mm reported that cerclage prevented birth before viability but not birth before 34 weeks (Owen, 2009). Subsequently, however, Berghella and coworkers (201i1) included ive trials in a metaanalysis and showed that cerclage for these high-risk women signiicantly reduced preterm birth before 24, 28, 32, 35, and 37 weeks.


Obstentrics_Williams

Obstentrics_Williams. Cervical length screening is now recommended by both the American College of Obstetricians and Gynecologists (2016b) and the Society for Maternal-Fetal Medicine (2015) for women with prior preterm birth. Between 16 and 24 weeks' gestation, sonographic cervical measurement is completed every 2 weeks. If an initial or subsequent cervical length is 25 to 29 mm, then a weekly interval is considered. If the cervical length measures <25 mm, cerclage is ofered to this group of women. Notably, for women without a history of preterm birth but with a short cervix incidentally identiied sonographically, progesterone therapy is ofered instead of cerclage. With twin gestations, one retrospective analysis found no improved outcomes in women with a cervical length <25 mm (Stoval, 2013). he College (2016b) does not recommend the use of cerclage in twin pregnancies.


Obstentrics_Williams

Obstentrics_Williams. Contraindications to cerclage usually include bleeding, contractions, or ruptured membranes, which substantially raises the likelihood of failure. Thus, prophylactic cerclage before dilatation is preferable. Surgery between 12 and 14 weeks' gestation allows this early intervention yet avoids surgery in a woman with a irst-trimester pregnancy destined for spontaneous loss. Preoperatively, screening for aneuploidy and obvious malformation is completed. Cervical secretions are tested for gonorrhea and chlamydial infection. hese and obvious cervical infections are treated.


Obstentrics_Williams

Obstentrics_Williams. At times, the cervix instead is found to be dilated, efaced, or both, and an emergent rescue cerclage is performed. However, there is debate as to how late this should be performed. The conundrum is that the more advanced the pregnancy, the greater the risk that surgical intervention will stimulate preterm labor or membrane rupture. At Parkland Hospital, cerclage procedures are generally not done once supposed fetal viability is reached after 23 to 24 weeks. Others, however, recommend placement later than this (Caruso, 2000; Terkildsen, 2003).


Obstentrics_Williams

Obstentrics_Williams. When outcomes of cerclage are evaluated, women with similar clinical presentations are ideally compared. For example, in the study of elective cerclage by Owen and associates (2009), approximately a third of women delivered before 35 weeks, and complications were few. By contrast, in a 10-year review of 75 women undergoing rescue cerclage procedures, Chasen and Silverman (1998) reported that only half were delivered after 36 weeks. Importantly, only 44 percent of those with bulging membranes at the time of cerclage reached 28 weeks. Terkildsen and associates (2003) had similar experiences. Caruso and coworkers (2000) described rescue cerclage done in 23 women with a dilated cervix and protruding membranes from 17 to 27 weeks' gestation. There were 11 liveborn neonates, and these researchers concluded that success was unpredictable. Our experiences at Parkland Hospital are that rescue cerclages have a high failure rate, and women are counseled accordingly.


Obstentrics_Williams

Obstentrics_Williams. If the clinical indication for cerclage is questionable, a woman may instead be observed. Most undergo cervical examinations weekly or every 2 weeks to assess efacement and dilatation. Unfortunately, rapid efacement and dilation can develop despite such precautions (Witter, 1984). Of the two vaginal cerclage operations, most use the simpler procedure developed by McDonald (1963) and shown in Figure 1i8-2. The more


Obstentrics_Williams

Obstentrics_Williams. Of the two vaginal cerclage operations, most use the simpler procedure developed by McDonald (1963) and shown in Figure 1i8-2. The more FIGURE 18-2 McDonald cerclage procedure for incompetent cervix. A. Start of the cerclage procedure with a no. 2 monofilament suture being placed in the body of the cervix very near the level of the internal os. B. Continuation of suture placement in the body of the cervix so as to encircle the os. C. Encirclement completed. D. The suture is tightened around the cervical canal sufficiently to reduce the diameter of the canal to 5 to 10 mm, and then the suture is tied. The efect of the suture placement on the cervical canal is apparent. A second suture placed somewhat higher may be of value if the first is not in close proximity to the internal os.


Obstentrics_Williams

Obstentrics_Williams. complicated operation is a modification of the procedure described by Shirodkar (1955) and shown in Figure 18-3. When either technique is performed prophylactically, women with a classic history of cervical incompetence have excellent outcomes (Caspi, 1990; Kuhn, 1977). For either vaginal or abdominal cerclage, there is insuicient evidence to recommend perioperative antibiotic prophylaxis (American College of Obstetricians and Gynecologist, 2016b,i). Thomason and coworkers (1982) found that perioperative tocolytics failed to arrest most labor. Regional analgesia is suitable and preferred. Ater this, the woman is placed in standard dorsal lithotomy position. he vagina and perineum are surgically prepared, and the bladder is drained. Some operators do not use potentially irritating antiseptic solution on the exposed amnionic membranes and instead use warm saline (Pelosi, 1990). Although steps are described subsequently, a thorough and illustrated review of cerclage technique is provided


Obstentrics_Williams

Obstentrics_Williams. solution on the exposed amnionic membranes and instead use warm saline (Pelosi, 1990). Although steps are described subsequently, a thorough and illustrated review of cerclage technique is provided by Hawkins (2017). For suturing, options include a no. 1 or 2 nylon or polypropylene monoilament suture or 5-mm Mersilene tape. During placement, the suture is placed as high as possible and into the dense cervical stroma. Two cerclage sutures do not appear more efective than one (Giraldo-Isaza, 2013).


Obstentrics_Williams

Obstentrics_Williams. FIGURE 18-3 Modified Shirodkar cerclage for incompetent cervix. A. A transverse incision is made in the mucosa overlying the anterior cervix, and the bladder is pushed cephalad. B. A 5-mm Mersilene tape on a swaged-on or Mayo needle is passed anterior to posterior. C. The tape is a cerclage in place with labor contractions. T ransvaginally placed cerclages are typically removed even with cesarean delivery to avoid rare long-term foreign-body complications (Hawkins, 2014). With scheduled cesarean delivery, the cerclage may be removed at 37 weeks or deferred until the time of regional analgesia and delivery. Again, the risk of labor ensuing before delivery must be considered. During extraction, particularly with a Shirodkar cerclage or a cerclage using Mersilene tape, analgesia helps ensure patient comfort B and adequate visualization.


Obstentrics_Williams

Obstentrics_Williams. B and adequate visualization. At times, suture placed at the uterine isthmus can be used and left until completion of childbearing. Because of significantly greater risks of bleeding and complications during placement, this approach is reserved for selected instances of severe cervical anatomical defects or prior transvagi c nal cerclage failure. Placement of a cervicoisthmic cerclage was originally described using laparotomy, but several reports additionally detail lapa then directed posterior to anterior on the other side of the cervix. Allis clamps are placed so as to bunch the cervical tissue. This diminishes the distance that the needle must travel submucosally cervicoisthmic cerclages. Steps are and aids tape placement. D. The tape is snugly tied anteriorly, after ensuring that all slack has been taken up. The cervical mucosa is then closed with continuous stitches of chromic suture. summarizedin Figure 18-4. Tulandi


Obstentrics_Williams

Obstentrics_Williams. Rescue cerclage with a thinned dilated cervix is more diicult and risks tissue tearing and membrane puncture. Replacement of the prolapsed amnionic sac back into the uterus will usually aid suturing (Locatelli, 1999). Options include steep Trendelenburg or filling the bladder with 600 mL of saline through an indwelling Foley catheter. However, these steps may carry the cervix cephalad and away from the operating field. Membrane reduction can also be achieved by pressure from a wide moist swab or by placing a Foley catheter through the cervix and inlating the 30-mL balloon to deflect the amnionie sac cephalad. The balloon is then deflated gradually as the cerclage suture is tightened around the catheter tubing, which is then removed. Simultaneous outward traction created by ring forceps placed on the cervical edges may be helpful. In some women with bulging membranes, transabdominal amnionic fluid aspiration to decompress the sac may be considered. If this is done, bacterial cultures


Obstentrics_Williams

Obstentrics_Williams. on the cervical edges may be helpful. In some women with bulging membranes, transabdominal amnionic fluid aspiration to decompress the sac may be considered. If this is done, bacterial cultures of the luid should be obtained.


Obstentrics_Williams

Obstentrics_Williams. For uncomplicated pregnancies without labor, the cerclage is usually cut and removed at 37 weeks' gestation. This balances the risk of preterm birth against that of cervical laceration from and coworkers (2014) evaluated 16 studies involving 678 pregnancies. Placement before pregnancy and during pregnancy was similar, whether performed laparoscopically or by laparotomy.


Obstentrics_Williams

Obstentrics_Williams. Zaveri and associates (2002) reviewed 14 observational studies in which a prior transvaginal cerclage had failed to prevent preterm delivery. The risk of perinatal death or delivery before 24 weeks' gestation was only slightly lower following transabdominal cerclage compared with the risk following repeat transvaginal cerclage-6 versus 13 percent, respectively. Importantly, 3 percent of women who underwent transabdominal cerclage had serious operative complications, whereas there were none in the transvaginal group. Whittle and coworkers (2009) described 31 women in whom transabdominal cervico isthmic cerclage was done laparoscopieally between 10 and 16 weeks. he procedure was converted to laparotomy in 25 percent, and there were four failures due to chorioamnionitis. Overall, fetal survival rate approximated 80 percent. Principal among these are membrane rupture, preterm labor, hemorrhage, infection, or combinations thereof. All are


Obstentrics_Williams

Obstentrics_Williams. FIGURE 18-4 Transabdominal cervicoisthmic cerclage. Following incision and sharp dissection in the vesicouterine space, the blad der is mobilized caudally. At the level of the internal os, a window is made in free space medial to the uterine vessels. This avoids vessel compression by the tightened cerclage. Care is also taken to avoid the ureter, which is lateral and posterior. The suture is passed anterior to posterior or vice versa. In this case, the knot is tied anteriorly, and the vesicouterine peritoneum is closed with absorbable suture in a running fashion. (Reproduced with permission from Hawkins JS: Lower genital tract procedures. In Yeomans ER, Hofman BL, Gilstrap LC III, et al: Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 2017.) uncommon with prophylactic cerclage. In the multicenter study by Owen and colleagues (2009), of 138 procedures, there was one instance each of ruptured membranes and bleeding. In the trial by MacNaughton


Obstentrics_Williams

Obstentrics_Williams. with prophylactic cerclage. In the multicenter study by Owen and colleagues (2009), of 138 procedures, there was one instance each of ruptured membranes and bleeding. In the trial by MacNaughton and associates (1993), membrane rupture complicated only 1 of more than 600 procedures done before 19 weeks. In our view, clinical infection mandates immediate removal of the suture with labor induced or augmented. Similarly, ¥lith imminent abortion or delivery, the suture should be removed at once because uterine contractions can tear through the uterus or cervix.


Obstentrics_Williams

Obstentrics_Williams. Following cerclage, if subsequent cervical thinning is detected by sonographic assessment, then some consider a reinforcement cerclage. In one retrospective study, however, reinforcing cerclage sutures placed later did not significantly prolong pregnancy (Contag, 2016). Membrane rupture during suture placement or within the irst 48 hours following surgery is considered by some to be an indication for cerclage removal because of the likelihood of serious fetal or maternal infection (Kuhn, 1977). That said, the range of management options includes observation, removal of the cerclage and observation, or removal of the cerclage and labor induction (O'Connor, 1999). he term induced abortion is defined as the medical or surgical termination of pregnancy before the time of fetal viability.


Obstentrics_Williams

Obstentrics_Williams. he term induced abortion is defined as the medical or surgical termination of pregnancy before the time of fetal viability. Deinitions used to evaluate these statistically include: (1) abortion ratio-the number of abortions per 1000 live births, and (2) abortion rate-the number of abortions per 1000 women aged 15 to 44 years. Overall, abortions most likely are underreported in the United States because clinics inconsistently list medically induced abortions. For example, the Guttmacher Institute found that 926,000 procedures were performed in 2014 Oones, 2017). But for 2013, only about 664,400 elective abortions were reported to the Centers for Disease Control and Prevention Oatlaoui, 2016). Of these, 66 percent were pregnancies aged ;8 weeks' gestation, and 92 percent of abortions were completed beforei; 13 weeks. he abortion ratio was 200 per 1000 live births, and the abortion rate was 12.5 per 1000 women.


Obstentrics_Williams

Obstentrics_Williams. herapeutic abortion refers to termination of pregnancy for medical indications. Inclusive medical and surgical disorders are diverse and discussed throughout this text. In cases of rape or incest, many consider termination. The most frequent indi cation currently is to prevent birth of a fetus with a signiicant anatomical, metabolic, or mental deformity. the interruption of pregnancy before viability at the request of the woman, but not for medical reasons. Most abortions done today are elective, and thus, it is one of the most frequently performed medical procedures. • Abortion in the United States


Obstentrics_Williams

Obstentrics_Williams. • Abortion in the United States The legality of elective abortion was established by the United States Supreme Court in the case ofRoe v. Wae. The Court defined the extent to which states might regulate abortion and ruled that firsttrimester procedures must be let to the medical judgment of the physician. ter this, the state could regulate abortion procedures in ways reasonably related to maternal health. Finally, subsequent to viability, the state could promote its interest in the potential of human life and regulate and even proscribe abortion, except for preservation of the life or health of the mother.


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Obstentrics_Williams. Other legislation soon followed. he 1976 Hyde Amendment forbids use of federal funds to provide abortion services except in case of rape, incest, or life-threatening circumstances. The Supreme Court in 1992 reviewed Planned Parenthood v. Casy and upheld the fundamental right to abortion, but established that regulations before viability are constitutional as long as they do not impose an "undue burden" on the woman. Subsequently, many states introduced counseling requirements, waiting periods, parental consent for minors, facility requirements, and funding restrictions. Such limits are often called targeted regulation of abortion providers (TRAP) laws. One major choice-limiting decision was the 2007 Supreme Court decision that reviewed Gonales v. Carhart and upheld the 2003 Partial-Birth Abortion Ban Act. This was problematic because there is no medically approved definition of partial-birth abortion according to the American College of Obstetricians and Gynecologists (20 14a). In


Obstentrics_Williams

Obstentrics_Williams. Abortion Ban Act. This was problematic because there is no medically approved definition of partial-birth abortion according to the American College of Obstetricians and Gynecologists (20 14a). In 2016, some TAP laws were dialed back by the Supreme


Obstentrics_Williams

Obstentrics_Williams. Court ruling in the case of Who/� Woman 5 Health v. Helerstedt. With this, the justices noted that abortion laws must confer health safety benefits that outweigh burdens on access. The American College of Obstetricians and Gynecologists (2014a, 2017 d) supports the legal right of women to obtain an abortion prior to fetal viability and advocates for improved access. he College also (2017 a) supports abortion training, and the Accreditation Council for Graduate Medical Education mandates that obstetrics and gynecology residency education must include access to experience with induced abortion. The Kenneth J. Ryan Residency Training Program was established in 1999 to work with residency programs to improve abortion and contraceptive training. Moreover, postresidency training in these techniques is available in formal 2-year Family Planning fellowships.


Obstentrics_Williams

Obstentrics_Williams. Other residency programs are less codified, but teach residents technical aspects through their management of early spontaneous abortions and pregnancy interruption for fetal death, severe fetal anomalies, and life-threatening medical or surgical disorders. he College (2016g) respects the need and responsibility of health-care providers to determine their individual positions on induced abortion. It also advocates for counseling and timely referral if providers have individual beliefs that preclude pregnancy termination. hree basic choices available to a woman considering an abortion are: (1) continued pregnancy with its risks and parental responsibilities; (2) continued pregnancy with arranged adoption; or (3) termination of pregnancy with its risks. Knowledgeable and compassionate counseling should objectively describe and provide information regarding these choices to permit informed decision-making (Templeton, 2011).


Obstentrics_Williams

Obstentrics_Williams. Pregnancy termination can be performed either medically or surgically by several methods. In the absence of serious maternal medical disorders, abortion procedures do not require hospitalization (Guiahi, 2012). However, outpatient surgical facilities should have the ability to provide emergency resuscitation and immediate transfer to a hospital (American College of Obstetricians and Gynecologists, 20 14b).


Obstentrics_Williams

Obstentrics_Williams. Surgical evacuation is performed transvaginally through an appropriately dilated cervix. For this, preoperative cervical ripening is favored by many and is typically associated with less manual intraoperative cervical dilation, a technically easier procedure, less pain, and shorter operative times (Kapp, 2010; Webber, 2015). On balance, cervical preparation adds a surgical delay and potential side efects. In a selective approach, some recommend cervical priming for irst-trimester suction curettage only for those at greater risk of complications from intraoperative cervical dilation, such as those with cervical stenosis and adolescents (Allen, 2016). Of note, surgical steps presented here apply to both induced abortion and miscarriage, discussed earlier (p. 347). FIGURE 18-5 Hygroscopic dilators. With each type, the dry unit (left) expands exponentially when exposed to water (right) as in the endocervical canal. A. Laminaria. B. Dilapan-S.


Obstentrics_Williams

Obstentrics_Williams. FIGURE 18-5 Hygroscopic dilators. With each type, the dry unit (left) expands exponentially when exposed to water (right) as in the endocervical canal. A. Laminaria. B. Dilapan-S. For ripening, hygroscopic dilators, also called osmotic dilators, are devices that draw water from surrounding tissues and expand to gradually dilate the endocervical canal. One type is derived from various species of Laminaria algae that are harvested from the ocean floor (Fig. 18-5). hese come in diferent diameters, which allow the number of inserted devices, also called tents, to be customized to a given cervix. Another device is Dilapan-S, which is composed of an acrylic-based gel. Each type expands to an ultimate diameter three to four times that of its dry state. However, Dilapan-S achieves this in 4 to 6 hours, which is faster than the 12 to 24 hours needed for laminaria (Fox, 2014).


Obstentrics_Williams

Obstentrics_Williams. With hygroscopic dilators, shallow insertion yields insuicient internal os dilation or tent expulsion, but deep placement risks dislodgement into the uterine cavity (Fig. 18-6). Accordingly, the numbers of sponges and dilators inserted are carefully counted and recorded in the patient's chart. Once tents are inserted, several gauze sponges at the external os help prevent spontaneous tent expulsion. Patients can ambulate, void, or stool without limitation. FIGURE 18-6 Insertion of laminaria before 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.


Obstentrics_Williams

Obstentrics_Williams. C. Laminaria inserted too far through the internal os; the laminaria may rupture the membranes. Schneider and associates (1991) described 21 cases in which women who had a hygroscopic dilator placed changed their minds. Of 17 women who chose to continue their pregnancy, there were 14 term deliveries, two preterm deliveries, and one miscarriage 2 weeks later. None sufered infection-related morbidity, including three untreated women with cervical cultures positive for Chlamydia trachomatis. In similar circumstances with four second-trimester terminations, Siedhof and Cremer (2009) described two preterm and two term deliveries.


Obstentrics_Williams

Obstentrics_Williams. Instead of hygroscopic dilators, misoprostol is often used for cervical ripening. he typical dose is 400 �g administered sublingually, buccally, or placed into the posterior vaginal fornix 3 to 4 hours prior to surgery. Instead, oral administration proves less efective and may take longer (Allen, 2016). Another efective cervical-ripening agent is the antiprogestin mifepristone, 200 mg given orally 24 to 48 hours before surgery (Ashok, 2000). Its cost and greater delay to the procedure, however, typically favor misoprostol use instead. In comparing hygroscopic dilators and misoprostol for ripening, randomized studies show equal or slightly greater dilation with hygroscopic dilators. Other surgical parameters do not vary significantly (Bartz, 2013; Burnett, 2005; Macisaac, 1999). Hygroscopic dilators extend procedure time and can be uncomfortable, whereas misoprostol introduces fever, bleeding, and gastrointestinal side efects.


Obstentrics_Williams

Obstentrics_Williams. If not done as part of early prenatal care, hemoglobin level and h status are assessed. Screening for gonorrhea, for syphilis, and for human immunodeficiency virus, hepatitis B, and chlamydial infections is also completed. Obvious cervical infections are treated and resolved before elective procedures. To prevent postabortal infection after a first-or second-trimester surgical evacuation, prophylactic doxycycline, 100 mg orally 1 hour before and then 200 mg orally after, is provided (Achilles, 2011; American College of Obstetricians and Gynecologists, 20 16a). Prophylaxis specifically for infective endocarditis prevention in those with valvular heart disease is not required in the absence of active infection (Nishimura, 2017). No recommendations speciically address venous thromboembolism prophylaxis for suction curettage in low-risk gravidas. At our hospital, we encourage early ambulation.


Obstentrics_Williams

Obstentrics_Williams. lso called suction dilation and curettage or suction curettage, vacuum aspiration is a transcervical approach to surgical abortion. he cervix is first dilated and then products of conception are evacuated. For this, a rigid cannula is attached either to an electric-powered vacuum source or to a handheld GO-mL syringe for its vacuum source. hese are electric vacuum aspiration (EVA) or manual vacuum aspiration (MVA), respectively. Sharp dilation and curettage (D -C) in which contents are mechanically scraped out soley by a sharp curette is currently not recommended for pregnancy evacuation due to greater blood loss, pain, and procedural time (National Abortion Federation, 2016; World Health Organization, 2012). Importantly, this practice is distinguished from brief sharp curettage following initial aspiration. In one survey, this combination is employed by nearly 50 percent of abortion providers (O'Connell, 2009).


Obstentrics_Williams

Obstentrics_Williams. After bimanual examination is performed to determine uterine size and orientation, a speculum is inserted, and the cervix is swabbed with povidone-iodine or equivalent solution. he anterior cervical lip is grasped with a toothed tenaculum. The cervix, vagina, and uterus are richly supplied by nerves of Frankenhauser plexus, which lies within connective tissue lateral to the uterosacral and cardinal ligaments. Thus, vacuum aspiration at minimum requires intravenously or orally administered sedatives or analgesics, and some add a paracervical or intracervical blockade with lidocaine (llen, 2009; Renner, 2012). For local blocks, 5 mL of 1-or 2-percent lidocaine is most efective if placed immediately lateral to the insertion of the uterosacral ligaments into the uterus at 4 and 8 o'clock. An intracervical block with 5-mL aliquots of I-percent lidocaine injected at 12, 3, 6, and 9 o'clock was reported to be equally efective (Mankowski, 2009). Alternatively, general or regional anesthesia


Obstentrics_Williams

Obstentrics_Williams. intracervical block with 5-mL aliquots of I-percent lidocaine injected at 12, 3, 6, and 9 o'clock was reported to be equally efective (Mankowski, 2009). Alternatively, general or regional anesthesia may be elected.


Obstentrics_Williams

Obstentrics_Williams. Uterine sounding measures the depth and inclination of the cavity before other instrument insertion. If required, the cervix FIGURE 18-7 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. is further dilated with Hegar, Hank, or Pratt dilators until a suction cannula of the appropriate diameter can be inserted. he degree of required cervical dilation roughly approximates gestational age. Hegar sizes reflect their diameter in millimeters. Pratt and Hank dilators are sized in French units, which can be converted to millimeters by dividing the French number by three.


Obstentrics_Williams

Obstentrics_Williams. With dilation, the fourth and fifth ingers of the hand introducing the dilator should rest on the perineum and buttocks as the instrument is pushed through the internal os (Fig. 18-7). his technique minimizes forceful expansion and provides a safeguard against uterine perforation.


Obstentrics_Williams

Obstentrics_Williams. Following dilation, for most first-trimester aspiration procedures, an 8-to 12-mm Karman cannula is appropriate. Small cannulas carry the risk of leaving retained intrauterine tissue postoperatively, whereas large cannulas risk cervical injury and more discomfort. To begin, the cannula is slowly moved toward the fundus until resistance is met. Suction is then activated. he cannula is gradually pulled back toward the os and is slowly turned circumferentially to cover the entire surface of the uterine cavity (Fig. 18-8). his is repeated until no more tissue is aspirated. A gentle sharp curettage can follow to remove any remaining tissue fragments (Fig. 18-9). Strong and consistent evidence supports high eicacy, safety, and patient acceptability for both MVA and EVA (Lichtenberg, 2013).


Obstentrics_Williams

Obstentrics_Williams. For abortion done at $6 weeks' gestation, a distinct drawback is that the pregnancy may be small and missed by the curette. To identiy placenta, the aspirated contents are rinsed in a strainer to remove blood, and then placed in a clear plastic container with saline and examined with back lighting (MacIsaac, 2000). Placental tissue macroscopically appears soft, luy, and feathery. A magniying lens, colposcope, or microscope can augment visualization. With gestations $7 weeks, the failed abortion rate approximates 2 percent (Kaunitz, 1985; FIGURE 18-8 A suction curette has been placed through the cervix into the uterus. The figure shows the rotary motion used to aspirate the contents. (Reproduced with permission from Hoffman BL, Corton MM: Surgeries for benign gynecologic disorders. In Hofman BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hili Education, 2016.)


Obstentrics_Williams

Obstentrics_Williams. Paul, 2002). hus, if products are not clearly identiied, serial serum heG levels can be informative (Dean, 2015). In women undergoing abortion, complication rates rise with gestational age. Of these, uterine perforation and lower-genitaltract laceration are uncommon but potentially serious. In one


Obstentrics_Williams

Obstentrics_Williams. FIGURE 18-9 A sharp curette is advanced into the uterine cavity while the instrument is held with the thumb and forefinger as shown in Figure 18-7. In the movement of the curette, only the strength of these two fingers should be used. (Reproduced with permission from Hofman BL, Corton MM: Surgeries for benign gynecologic disorders. In Hofman BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hili Education, 2016.) systematic review of irst-trimester abortion, the uterine per foration rate was � 1 percent, as was the cervical or vaginal laceration rate (White, 2015). Perforation is usually recognized when the instrument passes without resistance deep into the pelvis. isk factors include operator inexperience, prior cervi cal surgery or anomaly, adolescence, multiparity, and advanced gestational age (llen, 2016; Grimes, 1984). If the uterine per foration is small and fundal, as when produced by a uterine sound or narrow dilator, observation of vital


Obstentrics_Williams

Obstentrics_Williams. multiparity, and advanced gestational age (llen, 2016; Grimes, 1984). If the uterine per foration is small and fundal, as when produced by a uterine sound or narrow dilator, observation of vital signs and for uter ine bleeding is usually su.cient.


Obstentrics_Williams

Obstentrics_Williams. If a suction cannula or sharp curette passes into the peritoneal cavity, considerable intraabdominal damage can ensue. In these cases, laparotomy or laparoscopy to thoroughly examine the abdominal contents is oten the safest course. Uterine perforation is not a contraindication to completing the curettage under direct guidance during laparoscopy or laparotomy (Owen, 2017). Following curettage, uterine synechiae may form, and the risk of synechiae increases with the number of procedures. Most cases are mild and of unclear reproductive significance (Hooker, 2014). However, of Asherman syndrome cases, one series found that two thirds were linked to first-trimester curettage (Schenker, 1982).


Obstentrics_Williams

Obstentrics_Williams. Other irst-trimester abortion complications are hemorrhage, incomplete removal of products, and postoperative infections, and these are germane to both surgical and medical abortion techniques. Hemorrhage with abortion is variably defined. One supported by the Society for Family Planning is bleeding that prompts a clinical response or bleeding in excess of 500 mL (Kerns, 2013). For irst-trimester surgical abortions, hemorrhage complicates �1 percent (White, 2015). Atony, abnormal placentation, and coagulopathy are frequent sources, whereas surgical trauma is a rare cause. With medical abortion, bleeding is more common. In one study of more than 42,000 Finnish women undergoing pregnancy termination with pregnancies less 63 days, hemorrhage complicated 15 percent of medical abortion but only 2 percent of surgical cases (Niinimaki, 2009).


Obstentrics_Williams

Obstentrics_Williams. Infection is another risk. One review of surgical abortion found a cumulative rate of 0.5 percent in those given prophylaxis compared with 2.6 percent in those given placebo (Achilles, 2011). In another review of nearly 46,000 irst-trimester abortions, the postoperative infection rate was <0.3 percent for either surgical or medical methods (Upadhyay, 2015). Incomplete abortion may require reevacuation. For medical abortion, this neared 5 percent in one systematic review (Raymond, 2013). Reaspiration rates following surgical abortion are typically <2 percent (Ireland, 2015; Niinimaki, 2009). In sum, first-trimester surgical abortion ofers higher e.cacy rates (96 to 100 percent) than medical abortion (83 to 98 percent). Medical abortion also carries a greater cumulative risk of complications, although diferences are small (Lichtenberg, 2013). hese are balanced against the greater privacy of medical abortion and the more invasive steps of curettage.


Obstentrics_Williams

Obstentrics_Williams. In appropriately selected women, outpatient medical abortion is an acceptable option for pregnancies with a menstrual age <63 days (American College of Obstetricians and Gynecolo gists (20 16c). Although suitable at later gestational ages, success rates are lower. gestation, one third are completed medically in the United States Qatlaoui, 2016). hree medications are used alone or in combination: mifepristone, methotrexate, and misoprostol. Of these, mifepristone augments uterine contractility by reversing progesterone-induced myometrial quiescence, whereas misopro scol directly stimulates the myometrium. Both also ripen the cervix (Mahajan, 1997; Tang, 2007). Methotrexate acts on tro phoblast and halts implantation. It is used less frequently now due to current availability of the more efective mifepristone.


Obstentrics_Williams

Obstentrics_Williams. Contraindications to medical abortion have evolved from exclusion criteria that were used in initial clinical trials. Cau tions include current intrauterine device; severe anemia, coagu lopathy, or anticoagulant use; long-term systemic corticosteroid liver, renal, pulmonary, or cardiovascular disease; or uncon trolled hypertension (Guiahi, 2012). Of note, misoprostol is suitable for early pregnancy failure in those with prior uterine surgery (Chen, 2008). Methotrexate and misoprostol are both teratogens. Thus there must be a commitment to completing the abortion once these drugs are given (Aufret, 2016; Hyoun, 2012; Kozma, 2011). With mifepristone, for women who choose to continue their preg nancies after exposure, the ongoing pregnancy rate ranges from 10 to 46 percent (Grossman, 2015). The associated major mal formation rate was 5 percent in one series of 46 exposed preg nancies (Bernard, 2013).


Obstentrics_Williams

Obstentrics_Williams. Several dosing schemes are efective, and some are shown in Table 18-7. Because of its greater e.cacy, mifepristonel misoprostol combinations are favored. Presently, for gestations up to 63 days, the most widely accepted regimen is mifepristone, 200 mg given orally on day 0 and followed in 24 to 48 hours by misoprostol 800 �g, administered by a vaginal, buccal, or sublingual route (American College of Obstetricians and Gynecologists, 2016c). Another earlier regimen used a 600-mg oral mifepristone dose followed in 48 hours by a 400-�g oral misoprostol dose (Spitz, 1998). If desired, mifepristone and misoprostol may be self-administered at home (Chong, 2015). At Planned Parenthood clinics, for irst-trimester medical abortion, doxycycline 100 mg is taken orally daily for 7 days and begins with abortifacient administration (Fjerstad, 2009). he woman is then discharged home and appointed to return in 1 to 2 weeks.


Obstentrics_Williams

Obstentrics_Williams. Symptoms following misoprostol are common within 3 hours and include vomiting, diarrhea, fever, and chills. Bleeding and cramping with medical termination typically is signiicantly worse than with menses. Thus, adequate analgesia, usually including a narcotic, is provided. If bleeding soaks two or more pads per hour for at least 2 hours, the woman is instructed to contact her provider to determine whether she needs to be seen . At the follow-up appointment, routine postabortal sonographic examination is typically unnecessary (Clark, 2010). Instead, assessment of the clinical course along with bimanual pelvic examination is recommended. If sonography is indicated TABLE 18-7. Various Regimens for Medical Termination of Pregnancy aMifepristone, 200-600 mg orally; followed in 24-48 hr by: bMisoprostol, 200-600 �g orally or 400-800 �g vaginally, buccally, or sublingually


Obstentrics_Williams

Obstentrics_Williams. Methotrexate/Misoprostol dMethotrexate, 50 mg/m2 BSA intramuscularly or orally; followed in 3-7 days by: eMisoprostol, 800 �g vaginally. Repeat if needed 1 week after methotrexate initially given Mifepristone, 200 mg orally; followed in 24-48 hr byj Misoprostol, 400 �g vaginally or buccally every 3 hr up to 5 doses Misoprostol, 600-800 �g vaginally; followed by 400 �g vaginally or buccally every 3 hr up to 5 doses 50 units oxytocin in 500 mL of normal saline infused during 3 hr; then 1-hr diuresis (no oxytocin); then escalate sequentially in a similar fashion through 150,200,250, and finally 300 units oxytocin each in 500 mL normal saline aOoses of 200 versus 600 mg similarly effective. bOral route may be less effective and have more nausea and diarrhea. Sublingual route has more side effects than vaginal route.


Obstentrics_Williams

Obstentrics_Williams. 3-12 hours given vaginally; 3-4 hours given sublingually. dEficacy similar for routes of administration. eSimilar efficacy when given on day 3 versus day 5. BSA = body surface area. Pymar, 2001; Raghavan, 2009; Schaff, 2000; Shannon, 2006; von Hertzen, 2003, 2007, 2009, 2010; Winikof, 2008.


Obstentrics_Williams

Obstentrics_Williams. due to concern for failed abortion or for bleeding, unnecessary surgery can be avoided if scans are interpreted appropriately. Specifically, if no gestational sac is seen and there is no heavy bleeding, then intervention is unnecessary. This is true even when, as is common, the uterus contains sonographically evident debris (Paul, 2000). vleasurements < 15 mm and < 30 mm have been used as thresholds to signal evacuation success (Nielsen, 1999; Zhang, 2005). Another study reported that a multilayered sonographic pattern indicated a successful abortion (Tzeng, 2013). Last, hCG values may be informative. Compared with preprocedural levels, Barnhart and coworkers (2004b) found declines of 88 percent at day 3 and 82 percent at day 8 following misoprostol administration correlated with a 95-percent rate of successful abortion completion.


Obstentrics_Williams

Obstentrics_Williams. In the second trimester, fetal anomaly or death, maternal health complications, inevitable abortion, or desired termination may be indications for uterine evacuation. As in the irst trimester, available options are medical or surgical. But, in the second trimester, dilation and evacuation (D & E) rather than suction D & C is dictated because of fetal size and bony structure. Of options, D & E is a common means of second-trimester induced abortion in the United States. Of legally obtained abortions in 2013, 9 percent were performed by D & E at gestational agesi> 13 weeks Oarlaoui, 2016). Many of the surgical and medical steps for second-trimester abortion mirror those in the irst trimester, and diferences are emphasized here.


Obstentrics_Williams

Obstentrics_Williams. With D & E, wide mechanical cervical dilation precedes evacuation of fetal parts. he degree needed rises with fetal gestational age, and inadequate dilatation risks cervical trauma, uterine perforation, or tissue retention (Peterson, 1983). Thus, presurgical cervical preparation is advised, and main options include hygroscopic dilators or misoprostol. With laminaria, overnight preparation ofers optimal cervical dilation (Fox, 2014). Uncommonly, laminaria may fail to adequately dilate the cervix, and serialilaminaria insertion with an increasing number of tents over several days is one option (Stubblefield, 1982). Supplementing laminaria with misoprosrol or mifeprisrone is another choice (Ben-Ami, 201i5). Dilapan-S is also suitable for cervical preparation. It may be preferable for same-day procedures as this device achieves its maximal efect in 4 to 6 hours (Newmann, 2014).


Obstentrics_Williams

Obstentrics_Williams. Dilapan-S is also suitable for cervical preparation. It may be preferable for same-day procedures as this device achieves its maximal efect in 4 to 6 hours (Newmann, 2014). Misoprostol can be used instead of hydroscopic dilators for cervical preparation. The typical dose is 400 1g given vaginally or buccally 3 to 4 hours prior to D & E. Randomized trials vary regarding the ability of misoprostol to achieve results equal to that with hydroscopic dilators (Bartz, 2013; Goldberg, 2005; Sagiv, 2015). vIisoprostol added to laminaria ofers small increases in dilation but also greater side efects (Edelman, 2006).


Obstentrics_Williams

Obstentrics_Williams. Fewer studies have evaluated mifepristone for cervical ripening. In one, mifepristone alone provided less dilation than hydroscopic dilators (BO'gatta, 2012). In another trial, mifepristone added 48 hours before misoprostol created greater cervical dilation compared with misoprostol alone (Carbonell, 2007). Last, Goldberg and associates (2015) compared hygroscopic dilation with or without added mifepristone. They found no diferences for gestations < 19 weeks, but the combination aided procedures for later ages. In sum, hygroscopic dilators are consistently efective for cervical preparation before D & E. For those desiring same-day procedures, Dilapan-S alone or misoprostol alone may ofer advantages. Layering agents may be most helpful for later gestations or for an inadequate response from initial hygroscopic dilators alone. Yet, layering adds cost and potential side efects (Shaw, 2016).


Obstentrics_Williams

Obstentrics_Williams. With elective abortion, some choose to induce fetal demise prior to D & E to avert a live birth or to avoid violating the Partial Birth Abortion Ban Act, cited later (Diedrich, 2010). For this, an intracardiac potassium chloride injection or a 1-mg intraamnionic or intrafetal digoxin injection is frequently used prior to cervical ripening (Sfakianaki, 2014; White, 2016).


Obstentrics_Williams

Obstentrics_Williams. During D & E, sonography can be used as an adjunct in all cases or selectively in more challenging ones. Perioperative antibiotic prophylaxis mirrors that for first-trimester procedures (p. 359). To reduce postprocedure bleeding, vasopressin, 2 to 4 units in 20 mL of saline or anesthetic, can be injected intracervically or as part of a paracervical block (Kerns, 2013; Schulz, 1985). Once adequate cervical dilation is achieved, the initial surgical step drains amnionic fluid with an 11-to 16-mm suction cannula or with amniotomy and gravity. his reduces the risk of amnionic fluid embolism and brings the fetus into the lower uterine segment for removal (Owen, 2017; Prager, 2009). For pregnancies beyond 16 weeks, the fetus is extracted, usually in parts, using Sopher forceps or other destructive instruments. With complete removal of the fetus, a large-bore vacuum curette is used to remove the placenta and remaining tissue.


Obstentrics_Williams

Obstentrics_Williams. Major complications are infrequent with D & E, and rates range from 0.2 to 2 percent in large series (Cates, 1982; Lederie, 2015; Peterson, 1983). These include uterine perforation, cervical laceration, uterine bleeding, and postabortal infection. Rare complications include disseminated intravascular coagulopathy or amnionic luid embolism (Ray, 2004; York,i2012). Placenta previa or the accrete syndromes can raise D & E risks. Once diagnosed, placenta accreta typically prompts hysterec tomy (Matsuzaki, 2015). For placenta previa, D & E is preferred to quickly evacuate the placenta, but the ability to transfuse present (American College of Obstetricians and Gynecologists, 2017h; Perriera, 2017). Medical induction may be elected, but the risk for transfusion is greater than with D & E (Nakayama, 2007; Ruano, 2004). Data are few, but predelivery uterine artery embolization may lower bleeding risks (Pei, 2017).


Obstentrics_Williams

Obstentrics_Williams. Prior cesarean delivey is not a contraindication for 0 & E and may be preferred over prostaglandins for those with multiple prior hysterotomies (Ben-Ami, 2009; Schneider, 1994). During medical abortion, the uterine rupture rate is 0.4 percent with one prior cesarean delivery (Berghella, 2009). From fewer data, the rate may reach 2.5 percent with two or more prior cesarean deliveries (Andrikopoulou, 2016). If a medical agent is elected in those with prior cesarean hysterotomy, misoprostol is an option. Prostaglandin E2 (PGE2) appears to pose similar risk (Ie Roux, 2001; Reichman, 2007).


Obstentrics_Williams

Obstentrics_Williams. Of these, dilation and extraction (D & ) is similar to 0 & E except that a suction cannula is used to evacuate the intracranial contents after delivery of the fetal body through the dilated cervix. This aids extraction and minimizes uterine or cervical injury from large instruments or fetal bones. 0 & X is also called an intact D & . In political parlance, this procedure has been termed partial birth abortion. In some women with second-trimester pregnancies who desire sterilization, hysterotomy with tubal ligation is reason able. If there is signiicant uterine disease, then hysterectomy may provide ideal treatment. In some cases of a failed second trimester medical induction, either of these may be considered.


Obstentrics_Williams

Obstentrics_Williams. Principal among noninvasive methods is a mifepristone plus misoprostol regimen or misoprostol alone (see Table 18-7). Of these two options, the combined regimen yields a shorter termination duration (Kapp, 2007; Ngoc, 201l). Hygroscopic dilators may speed the time to delivery with this combined regimen (Mazouni, 2009; Vincienne, 2017). In selecting misoprostol routes, oral administration leads to a longer time to delivery compared with vaginal or sublingual routes (Dickinson, 2014). Prophylactic antibiotics are not typically given, and infection surveillance during labor is instead applied (Achilles, 2011).


Obstentrics_Williams

Obstentrics_Williams. Another induction agent, PGE2, shows similar eicacy and side efects compared with misoprostol Gain, 1994; Jansen, 2008). Simultaneous administration of an antiemetic such as metoclopramide (Reglan), an antipyretic such as acetaminophen, and an antidiarrheal such as diphenoxylate/atropine (Lomotil) will help prevent or treat symptoms. Dinoprostone (Prostin) is an available PGE2 in the United States. However, its greater cost and poor pharmacologic stability at room temperature may make it less attractive than misoprostol. Of other agents, high-dose intravenous oxytocin in saline will result in second-trimester abortion in 80 to 90 percent of cases (see Table 18-7). However, by comparison, misoprostol leads to higher successful induction rates and faster delivery times (Alavi, 2013).


Obstentrics_Williams

Obstentrics_Williams. Rarely used, ethacridine lactate is an organic antiseptic that activates myometrial mast cells to release prostaglandins (Olund, 1980). Placed extraovularly, that is, extraamnionically, it is associated with longer times to delivery and greater complication rates compared with misoprostol (Boza, 2008). For second-trimester gestations, D & E or medical induction is suitable clinically and psychologically. Thus, patient input and clinical indication guide selection (Burgoine, 2005; Kerns, 2012). Once delivered, viewing and holding the fetus mayior may not be desired by the patient (Sloan, 2008).


Obstentrics_Williams

Obstentrics_Williams. Evaluation of a stillborn fetus is described in Chapter 35 (p. 646). One component is autopsy, which can also be valuable for second-trimester losses or terminations due to anomaly. For example, in a stud) of 486 women of all ages with secondtrimester miscarriage, fetal malformations were identiied in 13 percent 000, 2009). In another, a third of otherwise normal fetuses had associated chorioamnionitis that was judged to have preceded labor (Allanson, 2010). Indeed, according to Srinivas and associates (2008), 95 percent of placentas in midtrimester miscarriages are abnormal. Other abnormalities are vascular thromboses and infarctions. With either surgical or medical abortion, subsequent autopsy can yield information, but fragmented D & E specimens may provide less information than intact fetuses (Gawron, 2013; Lal, 2014). Karyotyping can be performed on samples from either method (Bernick, 1998).


Obstentrics_Williams

Obstentrics_Williams. Legally induced abortion in the United States has a low associated mortality rate, and from 2008 to 2012, the rate was < 1 death per 100,000 procedures Oatlaoui, 2016). Earlyiabortions are safer. For example, Zane and coworkers (2015) found a mortality rate of 0.3 deaths per 100,000 procedures at;8 weeks' gestation; a rate of2.5 at 14 to 17 weeks; and 6.7 at ::18 weeks. As emphasized by Raymond and Grimes (2012), mortality rates are 14-fold greater for pregnancies that are continued.


Obstentrics_Williams

Obstentrics_Williams. Data relating abortion to overall maternal health and to subsequent pregnancy outcome are limited. From studies, there is no evidence for excessive mental disorders (Biggs, 2017; Munk-Olsen, 2011). here are few data regarding subsequent reproductive health, although the rates of infertility or ectopic pregnancy are not increased. Exceptions may stem from postabortal infections, especially those caused by C trachomatis. Of subsequent adverse pregnancy outcomes, several studies note an approximate 1.5-fold greater incidence of preterm delivery following surgical evacuation (Lemmers, 2016; Makhlouf, 2014; Saccone, 2016). his risk accrues with the number of terminations (Hardy, 2013; Klemetti, 2012). Subsequent pregnancy outcomes are similar regardless of whether a prior induced abortion was completed medically or surgically (Mannisto, 2013; Virk, 2007).


Obstentrics_Williams

Obstentrics_Williams. After medical or surgical management of an early pregnancy termination or loss, ovulation na) resume as early as 8 days, but the average time is 3 weeks (Lahteenmaki, 1978; Stoddard, 2011). Thus, unless another pregnancy is imminently desired, efective contraception is initiated to help lower the unintended pregnancy rate, which was 45 percent in 2011 in the United States (Finer, 2016). In suitable candidates described in Chapter 38 (p. 685), an intrauterine device can be inserted after the procedure or medical abortion is completed (Bednarek, 2011; Korjamo, 2017). Alternatively, any of the various forms of hormonal contraception can be initiated at this time (Curtis, 2016).


Obstentrics_Williams

Obstentrics_Williams. For women who desire another pregnancy, conception need not be delayed. Specifically, Wong and colleagues (2015) found similar live-birth rates in groups conceiving within 3 months of first-trimester pregnancy loss compared with groups with later conception. Others have found similarly reassuring results using an interval-to-conception threshold of 6 months (Kangatharan, 2017; Love, 2010). Achilles SL, Reeves MF, Society of Family Planning: Prevention of infection after induced abortion: release date October 2010: SFP guideline 20102. Contraception 83(4):295, 201r1 Achiron R, Tadmor 0, Mashiach S: Heart rate as a predictor of first-trimester spontaneous abortion after ultrasound-proven viability. Obstet Gynecol 78(3 Pt 1):330 Alavi A, Rajaei M, mirian M, et al: Misoprostol versus high dose oxytocin and laminaria in termination of pregnancy in second-trimester pregnancies. Electron Physician 5(4):713, 2013


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Obstentrics_Williams. Alavi A, Rajaei M, mirian M, et al: Misoprostol versus high dose oxytocin and laminaria in termination of pregnancy in second-trimester pregnancies. Electron Physician 5(4):713, 2013 Albrechtsen S, Rasmussen S, Thoresen S, et al: Pregnancy outcome in women before and after cervical conization: population based cohort study. BMJ 18:337,r2008 Allanson B, Jennings B, Jacques A, et al: Infection and fetal loss in the midsecond trimester of pregnancy. Aust N Z J Obstet Gynaecol 50(3):221, 2010 Allen RH, Fitzmaurice G, Liford L, et al: Oral compared with intravenous sedation for first-trimester surgical abortion: a randomized controlled trial. Obstet Gynecol 113(2 Pt 1):276, 2009 Allen RH, Goldberg AB: Cervical dilation before first-trimester surgical abortion « 14 weeks' gestation). Contraception 93(4):277, 2016 American College of Obstetricians and Gynecologists: Misoprostol for postabortion care. Committee Opinion No. 427, February 2009


Obstentrics_Williams

Obstentrics_Williams. American College of Obstetricians and Gynecologists: Misoprostol for postabortion care. Committee Opinion No. 427, February 2009 American College of Obstetricians and Gynecologists: Abortion policy. College Statement of Policy. January 1993, Reairmed 2014a American College of Obstetricians and Gynecologists: Induced abortion. In Guidelines for Women's Health Care, 4th ed. Washington, 2014b American College of Obstetricians and Gynecologists: Antibiotic prophylaxis for gynecologic procedures. Practice Bulletin No. 104, May 2009, Reaffirmed 2016a American College of Obstetricians and Gynecologists: Cerclage for management of cervical insuiciency. Practice Bulletin No. 142, February 2014, Reairmed 2016b


Obstentrics_Williams

Obstentrics_Williams. American College of Obstetricians and Gynecologists: Cerclage for management of cervical insuiciency. Practice Bulletin No. 142, February 2014, Reairmed 2016b American College of Obstetricians and Gynecologists: Medical management of irst-trimester abortion. Practice Bulletin No.143, March 2014, Reairmed 2016c American College of Obstetricians and Gynecologists: Microarray and next generation sequencing technology: the use of advanced genetic diagnostic tools in obstetrics and gynecology. Committee Opinion No. 682, December 2016d American College of Obstetricians and Gynecologists: Moderate cafeine consumption during pregnancy. Committee Opinion No. 462, August 2010, Reairmed 2016e American College of Obstetricians and Gynecologists: Premature rupture of membranes. Practice Bulletin No. 172, October 2016f American College of Obstetricians and Gynecologists: he limits of conscientious refusal in reproductive medicine. Committee Opinion No. 385, November 2007, Reairmed 2016g


Obstentrics_Williams

Obstentrics_Williams. American College of Obstetricians and Gynecologists: he limits of conscientious refusal in reproductive medicine. Committee Opinion No. 385, November 2007, Reairmed 2016g American College of Obstetricians and Gynecologists: Ultrasound in pregnancy. Practice Bulletin No. 175, December 2016h American College of Obstetricians and Gynecologists: Use of prophylactic antibiotics in labor and delivery. Practice Bulletin No. 120, June 2011, Reaffirmed 2016i American College of Obstetricians and Gynecologists: Abortion training and education. Committee Opinion No. 612, November 2014, Reairmed 2017a American College of Obstetricians and Gynecologists: Antiphospholipid syndrome. Practice Bulletin No. 132, December 2012, Reairmed 2017b American College of Obstetricians and Gynecologists: Early pregnancy loss. Practice Bulletin No. 150, May 2015, Reairmed 2017c


Obstentrics_Williams

Obstentrics_Williams. Practice Bulletin No. 150, May 2015, Reairmed 2017c American College of Obstetricians and Gynecologists: Increasing access to abortion. Committee Opinion No. 613, November 2014, Reairmed 2017d American College of Obstetricians and Gynecologists: Inherited thrombophilias in pregnancy. Practice Bulletin No. 138, September 2013, Reairmed 2017e American College of Obstetricians and Gynecologists: Periviable birth. Obstetric Care Consensus No.r6, October 2017f American College of Obstetricians and Gynecologists: Prevention of h D alloimmunization. Practice Bulletin No. 181, August 2017g American College of Obstetricians and Gynecologists: Second-trimester abortion. Practice Bulletin No. 135, June 2013, Reairmed 2017h American College of Obstetricians and Gynecologists: hromboembolism in pregnancy. Practice Bulletin No. 123, September 2011, Reairmed 2017i American Society for Reproductive Medicine: Definitions of infertility and recurrent pregnancy loss. Fertil Steril 99:63, 2013


Obstentrics_Williams

Obstentrics_Williams. American Society for Reproductive Medicine. Evaluation and treatment of recurrent pregnancy loss: a committee opinion. Fertil Steril 98: 1103, 2012 Ammon Avalos L, Galindo C, Li OK: A systematic review to calculate background miscarriage rates using life table analysis. Birth Defects Res A Clin Mol TeratoIr94(6):417, 2012 Andrikopoulou M, Lavery JA, Ananth CV, et al: Cervical ripening agents in the second trimester of pregnancy in women with a scarred uterus: a systematic review and metaanalysis of observational studies. Am J Obstet Gynecol 215(2):177,r2016 Arredondo F, Noble LS: Endocrinology of recurrent pregnancy loss. Semin Reprod Med 1 :33, 2006 Ashok PW, Flett GM, Templeton A: Mifepristone versus vaginally administered misoprostol for cervical priming before irst-trimester termination of pregnancy: a randomized, controlled study. Am J Obstet Gynecol 183(4):998,r2000


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Obstentrics_Williams. Aufret M, Bernard-Phalippon N, Dekemp J, et al: Misoprostol exposure during the first trimester of pregnancy: is the malformation risk varying depending on the indication? Eur J Obstet Gynecol Reprod Bioi 20 : 188, 2016 Avalos LA, Roberts SC, Kaskutas LA, et al: Volume and type of alcohol during early pregnancy and the risk of miscarriage. Subst Use Misuse 49: 1437,r2014 Balsells M, Garcia-Patterson A, Corcoy R: Systematic review and meta-analysis on the association of prepregnancy underweight and miscarriage. Eur J Obstet Gynecol Reprod Bioi 207:73, 2016 Barnhart K, Mennuti MT, Benjamin I, et al: Prompt diagnosis of ectopic pregnancy in an emergency department setting. Obstet GynecoI84(6): 1010, 1994 Barnhart K, Sammel MD, Chung K, et al: Decline of serum human chorionic gonadotropin and spontaneous complete abortion: deining the normal curve. Obstet Gynecol 104:975, 2004a


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Obstentrics_Williams. Barnhart K, Sammel MD, Chung K, et al: Decline of serum human chorionic gonadotropin and spontaneous complete abortion: deining the normal curve. Obstet Gynecol 104:975, 2004a Barnhart K, van Mello NM, Bourne T, et al: Pregnancy of unknown location: a consensus statement of nomenclature, deinitions, and outcome. Fertil Steril 95(3):857,r201r1 Barnhart KT, Bader T, Huang X, et al: Hormone pattern after misoprostol administration for a nonviable irst-trimester gestation. Fertil Steril 81(4):1099,r2004b Barnhart KT, Sammel MD, Rinaudo PF: Symptomatic patients with an early viable intrauterine pregnancy: hCG curves redeined. Obstet Gynecol 104:50, 2004c Bartz 0, Maurer R, llen RH, et al: Buccal misoprostol compared with synthetic osmotic cervical dilator before surgical abortion: a randomized controlled trial. Obstet GynecoIr122(1):57, 2013


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Obstentrics_Williams. Bartz 0, Maurer R, llen RH, et al: Buccal misoprostol compared with synthetic osmotic cervical dilator before surgical abortion: a randomized controlled trial. Obstet GynecoIr122(1):57, 2013 Bednarek PH, Creinin MD, Reeves MF, et al: Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med 364(21):2208, 2011 Ben-Ami I, Schneider D, Svirsky R, et al: Safety of late second-trimester pregnancy termination by laminaria dilatation and evacuation in patients with previous multiple cesarean sections. Am J Obstet Gynecol 201 (2): 154.e1, 2009 Ben-Ami I, Stern S, Vaknin Z, et al: Prevalence and risk factors of inadequate cervical dilation following laminaria insertion in second-trimester abortioncase control study. Contraception 91(4):308, 2015 Bennett GL, Bromley B, Lieberman E, et al: Subchorionic hemorrhage in irsttrimester pregnancies: prediction of pregnancy outcome with sonography. Radiology 200(3):803, 1996


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Obstentrics_Williams. Bennett GL, Bromley B, Lieberman E, et al: Subchorionic hemorrhage in irsttrimester pregnancies: prediction of pregnancy outcome with sonography. Radiology 200(3):803, 1996 Berdahl DM, Blaine J, Van Voorhis B, et al: Detection of enlarged yolk sac on early ultrasound is associated with ad-verse pregnancy outcomes. Fertil Sterilr94(4):1535,r2010 Berger OS, Hogge WA, Barmada MM, et al: Comprehensive analysis ofHLA G: implications for recurrent spontaneous abortion. Reprod Sci 17(4):331, 2010 Berghella V, Airoldi J, O'Neill M, et al: Misoprostol for second trimester pregnancy termination in women with prior caesarean: a systematic review. BJOG 116(9):1151,2009 Berghella V, Mackeen D: Cervical length screening with ultrasound-indicated cerclage compared with history-indicated cerclage for prevention of preterm birth: a meta-analysis. Obstet GynecoIr118(1):148, 2011