Definition: Termination of pregnancy before the period of viability or fetus weighing less than 500 grams. Expulsion or Extraction of an embryo or fetus before viability Period of viability: Developing countries – 28 weeks. UK, USA – Less than 22 to 24 weeks
Clinical features: Vaginal bleeding Mild lower abdominal pain Vitals stable Vaginal examination – Cervix is closed and uterus size will correspond to pregnancy Diagnosis – CBC, Ultrasound, Serum Progesterone and Serum HCG levels Treatment – Rest, sedation and synthetic progesterone and HCG injections?
Clinical features: Vaginal Bleeding with passage of products of gestation Pain lower abdomen Vitals - disturbed according to the blood loss Vaginal examination: Cervix is dilated with hanging of fetal products and uterus size will be lesser than amenorrhea Diagnosis - Ultrasound Treatment – Stabilize vitals and Suction evacuation / curettage After 12 weeks – Under GA and IV oxytocin drip products are removed by ovum forceps / Curettage
Clinical features: Vaginal Bleeding with passage of products of gestation Pain may be less or absent Vitals - disturbed according to the blood loss Vaginal examination: Cervix is closed and uterus size is lesser than amenorrhea Diagnosis - Ultrasound Treatment – No active intervention
Clinical features: Vaginal Bleeding Pain lower abdomen Vitals - disturbed according to the blood loss Vaginal examination: Cervix is dilated with hanging of fetal products and uterus size will correspond to amenorrhea Diagnosis - Ultrasound Treatment – Stabilize vitals and Suction evacuation / curettage After 12 weeks – IV oxytocin drip
Fetus is dead and retained for variable period [ 4 – 6 weeks ] Clinical Features: Brownish vaginal dischage Subsidence of pregnancy symptoms Retrogression of breast changes Vaginal examination: Uterus will be less than amenorrhea and cervix is closed Diagnosis – Ultrasound
Complications: Disseminated intravascular Coagulation Coagulation Profile is essential Treatment: Dialatation and Curettage – less than 12 weeks After 12 weeks – IV Oxytocin drip / Prostaglandin vaginal pessaries or Gel / IM injections of PG F2 alfa.
Any abortion associated with evidence of infection in the uterus and its contents Clinical features: Temperature – 100.4 degree F for 24 hrs or more Offensive or purulent vaginal discharge Lower abdominal pain and tenderness This is mostly due to incomplete and illegal abortions or also following spontaneus abortion
Peritonitis features may be present Vaginal examination – cervix may be closed or dilated, pus like offensive discharge Tender uterus and size of uterus will be lesser than amenorrhea Organisms responsible for sepsis: E.coli, Klebsiella, Staph.aureus, Clostridium welchi and perfringens etc., Complications - Endotoxemic shock, acute renal failure, DIC, Peritonitis and Gas gangrene
Investigations: Endo cervical swab for culture & sensitivity High vaginal swab for culture & Sensitivity CBC DIC profile if required Blood culture Urine Culture Ultrasound
Treatment: IV Antibiotics – for aerobic, anaerobic organisms – IV Ampicillin, Gentamycina and Metronidazole Anti Gas Gangrene serum Treatment of complications Surgery – Evacuation of uterus and Laparotomy if necessary depending on peritonitis features
Development of gestational sac without any evidence of fetus or fetal parts Diagnosis – Ultrasound Treatment – Dilatation and Curettage Tissue should be sent for Fetal karyotyping
A sequence of three or more consecutive abortions before 20 weeks Incidence – 1 % Causes: First Trimester – Genetic, Endocrine and Metabolic, Infection, Inherited thrombophilia, Immunological and unexplained Second Trimester – Bicornuate uterus, Unicornuate uterus, septate uterus, Cervical incompetence.
Cervix is unable to with hold the fetus faulty defect in the sphincteric mechanism. Retentive power of cervix is impaired Causes: Congenital Iatrogenic – Dilatation and Curettage, Amputation of the cervix, cone biopsy Clinical features: History of recurrent mid trimester abortions where leaking followed by painless expulsion of fetus
Diagnosis: Ultrasound – Cervical length less than 2.5 cm and cervical dilatation more than 1.5 cm with funneling of cervix and bulging of membranes Periodic per speculum examination Treatment: Cervical Circlage with Merseline tape at 16 – 18 weeks – Mc Donald operation Shiridkar’s operation
Medical Termination of Pregnancy Indications: Failure of contraception Rape Medical diseases that may deteriorate mother’s health Congenital anomalies
First Trimester Surgical : Manual Vacuum Aspiration Dilatation and Curettage Suction and Evacuation Medical: Prostaglandin preparations Mifepristone Misoprostol
Second Trimester: Intraamnitic instillation of PGF2 alfa or Hypertonic saline Extraamniotic ethacrydine lactate or PGf2 alfa Oxytocin Infusion Hysterotomy