2. Purpose ABORTION Definition Etiology Signs and symptoms
Types of abortion

3. 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%

4. 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

5. 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

6. 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

7. 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.

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

9. 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

10. 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

11. 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 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.

12. 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

13. 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.

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

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