Purpose ABORTION Definition Etiology Signs and symptoms Types of abortion

Abortion Definition: According to WHO , abortion or miscarriage is the spontaneous termination of a pregnancy before 20 weeks or if the fetus weighs less than 500g. Incidence: The incidence varies from 15% to 20%

Etiology Involves fetal factors and maternal factors Fetal factors: Chromosomal abnormalities( autosomal trisomy, trisomy 16 ..) Other genetic abnormalities Hydropic degeneration of villi , hydatidiform mole Multiple congenital defects Multiple pregnancy Blighted ovum

Maternal factors: General factors Maternal infections like TORCH Maternal diseases (hypertension,chronic renal disease , uncontrolled diabetes and hyper/hypothyroidism) Drugs, many drugs in toxic doses can induce abortions e.g. anticonvulsant , antimalarials,anaesthetic drugs, radiation. Severe hypoxia shock from hemorrhage Surgery and trauma Luteal phase defects : progesterone deficiency

local factors Uterine development anomalies: bicornuate, arcuate,subseptate Retroversion (3rd month of gestation) Fibomyoma of uterus Cervical incompetence , esp due to past birth trauma. It occurs in 2nd trimester by which time the gestational sac has grown large enough to occupy the uterine cavity. Surgery during pregnancy esp myomectomy, appendix or ovarian cyst removal in first trimester Local trauma

Signs and symptoms Amenorrhea Abdominal pain due to uterine contractions Hemorrhage or bleeding pv as a result of separation of ovum Dilatation of cervix due to uterine contractions Expulsion of a part or the entire ovum Patient presents with a H/O amenorrhea followed by more or less severe pain in the lower abdomen and back accompanied by vaginal bleeding. Extent of hemorrhage varies and continues for some days.

CLINICAL TYPES OF ABORTION Threatened abortion Inevitable abortion Incomplete and complete abortion Missed abortion Recurrent abortion Septic abortion,when infection is present.

Threatened abortion In threatened abortion choriodecidual haemorrhage has begun but not progressed to stage of irreversibility. Cervix is closed and products of conception are not expelled or displayed yet. Clinical features: Symptoms: Amenorrhea Pain in lower abdomen and backache Slight vaginal bleeding Sometimes frequency of micturition

Signs: Normal temperature No pallor unless patient has anaemia before No hypotension mild or moderate tachycardia PA uterus compatible with duration of amenorrhea( if more than 3 months can be palpated) Per speculum examination reveal closed cervical os an slight bleeding through os On bimanual pelvic examination cervix is soft and size of uterus corresponds to the period of amenorrhea

Investigations: Hb estimation to determine severity of bleeding , blood grp n cross matchin USG : if a live fetus is seen on USG pregnancy is likely to continue in over 95% cases Serum beta hcg may be serially done to determine any abnormality in doubling which would indicate high risk of fetal loss. Treatment : The only aim is to extend maximum support to pregnancy in order to increase the chances of survival of the pregnancy. The patient may be hospitalized. Complete rest is advised until bleeding has stopped and then progressive ambulation is allowed. Patient must be reassured periodically hCG 5000 IU intramuscularly for every 5 to 7 days Allyloestrenol (5mg) in three divided doses. Hormone therapy is given to supplement the function of corpus luteum. Patient is advised to continue treatment, restrict activity and avoid lifting any heavy weight. Sexual intercourse is best avoided.

INEVITABLE & INCOMPLETEBORTION INEVITABLE ABORTION: In this type of abortion the process of abortion has begun and progressed to such an extent that expulsion of products of conception seems inevitable. INCOMPLETE ABORTION: The abortion has occurred but the process is incomplete. The cervical os is open and products of conception are partly expelled C/F : History of amenorrhoea Lower abdominal pain Heavy bleeding from vagina History of expulsion of products of coception

Signs: Tachycardia and hypotension On abd palpation uterus size may correspond to period of amenorrhea On vaginal examination cervical os is dilated and product of conception felt in uterine cavity In incomplete abortion products of conception may be protruding thru cervical canal in process of expulsion USG: Confirms if products of conception (POC) are expelled fully or retained within uterine cavity or in cervical canal as it is being expelled. Management: Most often patient expels the POC by herself but interference required if bleeding is severe. Check curettage is done to remove any retained bits of POC or to ensure complete emptying of uterine cavity.

General management: Start IV with NS If bleeding is severe arrange for blood. A single dose of parenteral antibiotic may be given IV sedation prior to evacuation If theres excessive bleeding and patient is in shock she requires anesthesiologist care for evacuation procedure. If not immunized TT should be given Evacuation of uterus when cervix is sufficiently dilated If POC are protruding out of external os they can be removed by gently introducing a sponge holding forceps and twisting POC with it. manual vacuum aspiration(MVA) used for emptyin uterine cavity MVA is safe and ensure complete evacuation.

If MVA is not available then either D&C or suction evacuation should be done These 2 procedues have risk of uterine perforations When cervix is not dilated Same MVA and if its not available then D&C sucton evacuation has to be done Post evacuation care: Continue antibiotics Counsel regardin family planning Give anti D whenever indicated

COMPLETE ABORTION Products of conception are expelled completely from uterus and uterine cavity is empty. C/F: Symptoms: H/o amenorrhea Lower abdominal pain Vaginal bleeding with passage of products Vaginal discharge usually subsides in a week Signs: General condition is usually stable On abd palpation uterine size is less than the period of gestation On vaginal examination cervical os is closed uterus is smaller and no significant bleeding Usg used to confirm such cases

MISSED ABORTION There is intrauterine death of the fetus and it is then passively retained within the uterine cavity. C/F: Symptoms: H/O amenorrhea Vaginal bleeding or brownish discharge and spotting Signs: Uterine size is smaller On vaginal examination bleeding is minimal

Management: If missed abortion terminate spontaneously process of expulsion is same as in any abortion. If missed abortion occurs early in pregnancy the entire contents of uterus are changed into dark red mass known as carneous mole. If missed abortion occurs in late pregnancy it becomes shriveled sac containing macerated fetus , depending on duration of fetal death. The pregnancy test is negative at this stage. USG will confirm non viability of fetus Minimal criteria for diagnosing miscarriage are: Crown rump length of atleast 7mm and no heartbeat. Mean gestational sac diameter of atleast 25mm and no embryo Absence of embryo with heartbeat atleast two weeks after an ultrasound scan that showed a gestational sac without a yolk sac. Absence of embryo with heartbeat at least 11 days after an ultrasound can that showed a gestational sac with a yolksac

Specific management: All missed abortions will be expelled but there may be a delay. There’s a risk of developin coagulation disorders if dead fetus is retained for more than 5 to 6 weeks If size of uterus is less 10 weeks evacuation can be done using MMA(medical method of abortion). Misprotosol tablets 600 to 800 microgram inserted vaginally are effective in expulsion of POC MVA once again can be used as surgical alternative for evacuation Anti D should be given

Septic abortion Its an infected abortion complicated by fever,endometritis and parametritis. It results from unsafe or illegal abortions Etiology: Polymicrobial , Gram positive and Gram negative aerobes and facultative or obligate aerobes Clostridium perfringes reported to be associated with illegal abortion. Patient presents with: Fever, chills, abdominal pain, vaginal discharge, vaginal bleeding , h/o recent pregnancy Disseminated sepsis is suggested by High fever and prostration,Tachycardia,Tachypnea,Respiratory didiffulty , low BP There may be peritonitis

Investigation: Routine blood and urine tests Blood,urine high vaginal swab, cervical cultures taken High dose broad spectrum antibiotics begun IV Management: Start 2 large dose IV lines with NS Start oxygen SOS A combination of ampicillin combined with aminoglycosides is given initially Blood and component transfusion SOS USG examination would reveal presence/absence of retained POC For perforation of bowel X ray abdomen erect view demonstrate air in peritoneal cavity Removing focus of sepsis is aim of treatment If retained POCs are demonstrated in uterine cavity evacuation of uterine cavity done by D&C If ruptured or perforation of uterus is suspected then laparotomy under antibiotic cover is best option Hysterectomy may be needed in some septic abortion patients

If suspected case of septic abortion is received in PHC Start two IV Monitor vitals Start oxygen SOS Give initial dose of antibiotic and transfer her to next level of care Differential diagnosis of septic abortion Acute apendicitis Ectopic pregnancy Ovarian tumour PID shock

Cervical incompetence Definition: Inability of uterine cervix to retain a pregnancy in second trimester in absence of uterine contractions Characterised by painless cervical dilatation in second trimester with membranes bulging thru cervical canal followed by expulsion of immature fetus which is apparently normal and may show signs of life alongwith placenta Etiology: Lack of sphincteric action of internal os During pregnancy diagnosis may be by transvaginal ultrasound , shortening of cervix or funelling of internal os Management: Surgical treatment and consist of reinforcing the weak cervix with suture Suture placed after 14 weeks of gestation usg

Recurrent abortion Definition: Described as three or more consecutive pregnancy losses at 20 weeks or less or fetal weight less than 500gm Etiology: Parental chromosomal abnormalities Uterine causes Immunological factors Autoimmmune factors Inherited thrombophilias

Bibliography Mudaliar and Menon’s Clinical Obstetrics Textbook of obstetrics – Sheila Balakrishnan Manual of obstetrics- Sudip Chakravarti Wikipedia Google images