definition A process of expulsion or extraction of embryo / fetus from womb before it reaches to viability period (or less than 500gm in weight), is called abortion.

viability The period after which fetus is capable of independent survival. *According to WHO it is 22 wks. *In India it is 28 wks/1000gm. The period after which fetus is capable of independent survival. *According to WHO it is 22 wks. *In India it is 28 wks/1000gm.

types Spontanous / Miscarriage Induced Threatened Inevitable Incomplete Complete Missed Septic Legal Illegal MTP Unsafe

continuing pregnancy complete inevitable abortion abortion incomplete abortion continuing pregnancy complete inevitable abortion abortion incomplete abortion The development of abortion : threatened abortion

Spontaneous abortion or miscarriage

definition Spontaneous abortion is the expulsion from its mother of an embryo or fetus before its viability when it is not capable of independent survival.

Early abortion- When abortion occurs before 12 weeks of gestation Late abortion- When abortion occurs after 12 weeks of gestation Late abortion- When abortion occurs after 12 weeks of gestation

incidence % of all pregnancies

causes Genetic Endocrine and metabolic Anatomic Infection Immunological Thrombophilias Environmental

Genetic Chromosomal abnormalities -Monosomy (45X) -Autosomal Trisomy- commonest is chr-16 -Polyploidy (3n)

Endocrine and metabolic Luteal phase defect Thyroid abnormalities Diabetes mallitus

Anatomic Congenital malformation Cervical incompetence Uterine fibroid

Infection Viral Bacterial Parasitic -Rubella -Cytomegalo -Variola -Vaccinia -HIV -Ureaplasma –Chlamydia -Brucella. -Ureaplasma –Chlamydia -Brucella. -Malaria -Toxoplasma

Immunological Autoimmune Alloimmune Antibody formation against self placenta Antibodies responsible are- -Anti nuclear -Anti DNA -Antiphospholipid Due to paternal antigen Mother Rh negative & fetus positive Anti fetal Ab ABO incompatibility - Mother with blood group O & father A

Thrombophilias Due to intravascular coagulation

Environmental factors Smoking Alcoholism IUD contraceptive Drugs & Chemical

THREATENED ABORTION

definition A clinical entity where process of miscarriage has started but not progressed to a state from which recovery is impossible

Clinical features Scanty and Brown / Red in colour Usually absent, Slight lower abdominal pain or backache Bleeding per vagina Pain

On examination Vaginal Inspection Amount of bleeding Digital Examination Cervical Os - Closed Uterus Size- Correspondent to Amenorrhoea Feel- Soft Size- Correspondent to Amenorrhoea Feel- Soft Pelvic examination is avoided if USG facilities are available

investigations CBC, ABO & Rh Blood Gestational Sac, fetal cardiac movement USG Serum progesterone value of 25 ng/mL or more generally indicates a viable pregnancy

management Rest- Complete Bed rest till bleeding stops Medication- Diazepam to relieve pain Limit activities & Heavy weight lifting for 2 weeks Repeated USG at 3-4 week interval

Blighted ovum Also known as silent miscarriage- Fetus dies and remains inside uterus, it is a sonographic diagnosis. There is absence of fetal pole in a gestational sac with diameter of 3 cm or more. Uterus is to be evacuated once the diagnosis made. Also known as silent miscarriage- Fetus dies and remains inside uterus, it is a sonographic diagnosis. There is absence of fetal pole in a gestational sac with diameter of 3 cm or more. Uterus is to be evacuated once the diagnosis made.

inevitable ABORTION

definition A clinical entity where process of miscarriage has progressed to a state from which continuation of pregnancy is impossible.

Clinical features Increased Colicky lower abdominal Bleeding per vagina Pain

On examination Vaginal Inspection Amount of bleeding Digital Examination Cervical Os – Dilated Uterus Size- Smaller than Amenorrhoea

investigations Same as threatened

management General: Control bleeding & replace fluid Active management < 12 wks > 12 wks -D & E followed by blunt curette -Suction evacuation with curette -D & E followed by blunt curette -Suction evacuation with curette -Oxytocin drops /min

incomplete ABORTION

definition When some parts of conception are expelled while others remain in uterine cavity, it is called incomplete abortion

Clinical features continuous Colicky lower abdominal Bleeding per vagina Pain History of expulsion of fleshy mass per vagina

On examination Vaginal Inspection Amount of bleeding Digital Examination Cervical Os – Dilated Uterus Size- Smaller than Amenorrhoea Expelled mass Incomplete

Complication Profuse bleeding Sepsis Placental polyp

management General: Control bleeding & replace fluid Active management < 12 wks > 12 wks -D & E followed by blunt curette -Suction evacuation with curette -D & E followed by blunt curette -Suction evacuation with curette -Evacuation & removal of products with ovum forceps/ blunt curette Med management- Tab misoprostol 200 micro gm PV/ 6 hr Surgical

complete ABORTION

definition When all products of conception are expelled en mass, it is called complete abortion

Clinical features Scanty/ absent Light / absent Bleeding per vagina Pain History of expulsion of fleshy mass per vagina

On examination Vaginal Inspection Amount of bleeding Digital Examination Cervical Os –Closed Uterus Size- Smaller than Amenorrhoea, Firm Expelled mass Complete

management TVS- To visualize uterine cavity -D & E followed by blunt curette -Suction evacuation with curette -D & E followed by blunt curette -Suction evacuation with curette Surgical

missed ABORTION

definition When the fetus is dead and retained inside the uterus for a variable period, it is called missed miscarriage or early fetal demise.

pathology Cause is not known <12 wk >12 wk carneous mole fleshy mole blood mole OR Fetus-Mummified/ macerated Placenta- Pale, Thin Liquor- Absorbed

Recurrent small hemorrhage in Choriodecidual space Disruption of villi from attachment Blood clots deposition Blood mole Embryo die Completely Absorbed Rudimentary Surrounding blood absorbed Fleshy mole Carneous mole

Clinical features Continuous brownish Absent Vaginal discharge Pain features of threatened miscarriage followed by: Others -Subsidence of pregnancy Symptoms -Retrogression of breast changes -Subsidence of pregnancy Symptoms -Retrogression of breast changes

On examination Vaginal Inspection Amount of vaginal discharge Digital Examination Cervix- Firm Uterus Size- Smaller than Amenorrhoea, Firm

investigation USG- Empty gestational sac Immunological test for pregnancy negative

complications Psychological upset Infection Blood coagulation disorders

management Expectant Medical Surgical

Expectant -Wait for spontaneous expulsion. -Generally it expel out with in 2 wks of death -Wait for spontaneous expulsion. -Generally it expel out with in 2 wks of death

Medical <12 weeks Prostaglandin E1 (Misoprostol) 800 mg vaginally in the posterior fornix & repeated after 24 hours if needed. Expulsion usually occurs within 48 hours Prostaglandin E1 (Misoprostol) 800 mg vaginally in the posterior fornix & repeated after 24 hours if needed. Expulsion usually occurs within 48 hours >12 weeks Medical induction - Oxytocin Prostaglandins PV

Surgical Dilatation and evacuation Suction - evacuation

septic ABORTION

definition Any abortion associated with clinical evidences of infection of the uterus and its contents, is called septic abortion.

Clinical features Symptoms – Abdominal pain – Fever – Vaginal discharge (foul smelling) Signs – Sick looking, febrile or jaundiced – Tender uterus – Offensive vaginal discharge or bleeding – Cervix is usually soft and may be dilated

CLINICAL GRADING Grade I Grade II Grade III

Grade-III is almost always associated with illegal induced abortion. Grade-I is commonest & is usually associated with spontaneous abortion.

investigations Cervical or high vaginal swab Routine blood investigations

complications Immediate Hemorrhage Peritonitis Pelvic abscess, endometritis, Septicemia, Septic/hemorrhagic shock Late PID Pelvic adhesions 2° Infertility Chronic LAP

management 1.Resuscitation – IV fluids: RL, NS 2.Insert urethral catheter – Monitor Input/output 3.Blood grouping & Cross matching 4.Antibiotics: 5.Evacuation after controlling infection 6.Haematenics

abortion

Recurrent miscarriage

Other names Habitual abortions Habitual miscarriage Recurrent abortions Recurrent miscarriages. Habitual abortions Habitual miscarriage Recurrent abortions Recurrent miscarriages.

Habitual aborter A woman who has history of three or more consecutive abortions

causes

Genetic Factors Endocrine Factors Anatomic Causes – Congenital anomalies, in competencies Infectious causes Immunologic problems Rh incompetability Etiology: Can be established in only 30%

Cervical incompetency Commonest cause of mid trimester abortions May be congenital / acquired Diagnosis can be made by –history / Examination

investigations

Blood Blood Grouping – Client & husband Sugar- Fasting & PP VDRL Thyroid function test Toxoplasma antibodies IgG and IgM Autoimmune screening—lupus anticoagulant and anticardiolipin antibodies Serum LH on D2/D3 of the cycle Karyotype

Ultra sound To detect -Congenital malformation of uterus -Polycystic ovaries -Uterine fibroid To detect -Congenital malformation of uterus -Polycystic ovaries -Uterine fibroid

Hysterosalpinography Hysteroscopy Laparoscopy

Endocervical swab To detect Chlamydia, Mycoplasma Bacterial vaginosis. Other infection To detect Chlamydia, Mycoplasma Bacterial vaginosis. Other infection

Management of recurrent abortion

INTERCONCEPTIONAL PERIOD Counseling the couple Surgery for congenital defects Medications for endocrine dysfunction Treatment for infection

During pregnancy Reassurance and loving care Ultra sound Rest & avoid strenuous exercise & sexual intercourse For LPD- progesterone for 12 wks

Incompetent cervix- general management - complete bed rest Surgery - Encirclage operation Time- Around 14 weeks of pregnancy or at least two weeks earlier than lowest period of previous wastage. Incompetent cervix- general management - complete bed rest Surgery - Encirclage operation Time- Around 14 weeks of pregnancy or at least two weeks earlier than lowest period of previous wastage.

Unsafe abortion The procedure of termination of unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal standards or both. *90% of unsafe abortions are in the developing countries comprising 13% of all maternal deaths (WHO 1998). The procedure of termination of unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal standards or both. *90% of unsafe abortions are in the developing countries comprising 13% of all maternal deaths (WHO 1998).