What are the types of abortion and their management approaches?

Types of Abortion and Management Approaches

Abortion management should be tailored to the specific type of abortion, with procedural abortion (D&E) being preferred over medication abortion due to significantly lower rates of complications including hemorrhage (9.1% vs 28.3%) and infection (1.3% vs 23.9%). 1

Classification of Abortion Types

• Threatened abortion: Characterized by vaginal bleeding with a closed cervix and viable fetus 1
• Inevitable abortion: Vaginal bleeding with cervical dilation but without tissue expulsion 1
• Incomplete abortion: Partial expulsion of conception products 1
• Complete abortion: Complete expulsion of all conception products 1
• Missed abortion (retained): Embryonic or fetal death without spontaneous expulsion 1
• Septic abortion: Infection associated with any of the above forms 1
• Previable/periviable preterm prelabor rupture of membranes (PPROM): A specific condition leading to abortion before fetal viability (typically before 23-24 weeks) 2

Diagnostic Approach

• Clinical evaluation: History of amenorrhea followed by bleeding and pain 1
• Transvaginal ultrasound: Primary diagnostic method to assess fetal viability, gestational sac characteristics, and placental status 1, 3
• Serial β-hCG measurements: Levels that fail to rise appropriately or decrease suggest abortion 1, 4
• For anembryonic pregnancy: Diagnosis requires a gestational sac ≥25 mm without an embryo or absence of embryo on serial examinations 3

Management Options

1. Expectant Management

• Involves waiting for spontaneous resolution of pregnancy 1
• Most appropriate for complete abortions or incomplete abortions with minimal bleeding 1
• In cases of previable PPROM, expectant management carries significantly higher maternal morbidity (60.2%) compared to abortion care (33.0%) 2
• The most common complication with expectant management of PPROM is intraamniotic infection (38.0% vs 13.0% with abortion care) 2

2. Medical Abortion

• First trimester regimen:

  • Mifepristone 200 mg orally followed by misoprostol 800 mcg vaginally 24-48 hours later 5, 6
  • Effective up to 70 days (10 weeks) gestation 7
  • Vaginal administration of misoprostol is more effective than oral administration 8

• Second trimester regimen:

  • Mifepristone followed by repeated doses of misoprostol is the preferred medical approach 9
  • For 63-90 days gestation: mifepristone 200 mg orally followed by misoprostol 800 mcg vaginally 48 hours later, with repeated oral doses every 3 hours if needed 4
  • Success rate of 91.7% for late first trimester (63-90 days) 4

• Contraindications:

  • Severe hepatic impairment 5
  • Hemorrhagic disorders or concurrent anticoagulant therapy 6
  • Known allergy to medications 5, 6

3. Surgical Abortion

• First trimester: Vacuum aspiration or manual vacuum aspiration (MVA) 1
• Second trimester: Dilation and evacuation (D&E) is the preferred method 10, 9
• Advantages over medical abortion:
  • Lower risk of hemorrhage (9.1% vs 28.3%) 1
  • Lower risk of infection (1.3% vs 23.9%) 1
  • Lower risk of retained tissue requiring additional procedures (1.3% vs 17.4%) 1
  • Faster completion of the procedure 1

Management Algorithm Based on Abortion Type

For Threatened Abortion:

• Monitor for progression 1
• Pelvic rest and follow-up ultrasound to confirm viability 1

For Inevitable, Incomplete, or Missed Abortion:

• If <12 weeks gestation:

  • Medical management with misoprostol or surgical evacuation (MVA) 1
  • Surgical approach preferred if heavy bleeding, infection, or hemodynamic instability 1, 3

• If 12-24 weeks gestation:

  • D&E is the safest procedure with lowest complication rates 1, 10
  • Medical abortion with mifepristone and misoprostol if D&E not available 9

For Septic Abortion:

• Immediate surgical evacuation plus broad-spectrum antibiotics 1
• Fluid resuscitation if signs of sepsis 1

For PPROM before viability:

• Counsel patients on higher maternal morbidity with expectant management (60.2%) versus abortion care (33.0%) 2
• Offer abortion care to all patients with previable PPROM 2
• If choosing expectant management, monitor closely for signs of infection 2

Complications and Prevention

• Hemorrhage: More common with medical abortion (28.3%) than surgical methods (9.1%) 1
• Infection: Higher risk with medical abortion (23.9%) than surgical methods (1.3%) 1
• Retained tissue: More frequent with medical abortion (17.4%) than surgical methods (1.3%) 1
• Uterine perforation: Potential complication of surgical procedures 1
• Asherman syndrome: Risk increases with multiple or aggressive curettage procedures 1
• Rh alloimmunization: Administer Rh immunoglobulin to Rh-negative women 1

Key Considerations in Management Decisions

• Gestational age is a critical factor in determining the most appropriate method 2, 1
• Patient preference should be considered, but procedural methods have lower complication rates 1
• Access to emergency services should be ensured regardless of chosen method 8
• For anembryonic pregnancy, confirm complete evacuation to prevent complications 3
• The risk of infection increases significantly after 18 hours of ruptured membranes 11