1. Dr.Suresh Babu Chaduvula Professor Dept. of OBGyn, College of Medicine, KKU, Abha, KSA

2.  1] Abortion  2] Ectopic Pregnancy  3] Hydatidiform mole  4] Implantation bleeding  5] Local causes – Erosion, Polyp, Varicose veins rupture, Cervical malignancy

3.  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

4.  10 – 20%  75 % occur before 16 th week  75 % occur at 8 th week

5.  1] Spontaneous  2] Threatened  3] Inevitable  4] Incomplete  5] Complete  6] Missed  7] Septic  8] Recurrent  9] Induced – Legal or Illegal [ Criminal ]

6.  1] Genetic factors –  Chromosomal abnormalities – Autosomal trisomy – 50 % - Trisomy 16 is common  Polyploidy – 20 % - Presence of extra haploid number of chromosomes – 69 or 92 chromosomes – Triploidy is common  Chromosomal rearrangements – Inversion, deletion, translocation  Others - Mosaic

7.  2] Endocrine factors:  Luteal Phase defect  Deficient Progesterone  Hyper & Hypothyroidism  Uncontrolled Diabetes Mellitus

8.  3] Uterine Anomalies:  Cervical incompetence  Bocornuate uterus  Septate uterus  4] Sub-mucus Fibroid:  5] Intra-uterine synechiae: [ Asherman’s syndrome ]

9.  6] Infections:  Viral – Rubella, Cytomegalo, varicella, variola  Parasitic: Toxoplasmosis, Malaria  Bacterial: Chlamydia, Ureaplasma, Brucella  Spirochetes: Treponema pallidum

10.  7]Immunological disorders:  Antinuclear Antibodies  Anti phospholipid antibodies like Lupus anticoagulant and Anti cardiolipin antibodies

11.  8] Medical Disorders:  Cyanotic heart diseases  Hemoglobonopathies  9] Paternal Factors:  Sperm chromosomal anomaly  10] Inherited Thrombophilia  11] Environmental - Smoking, Radiation, Teratogenic drugs, chemicals, Alcohol  12] Unexplained – 40- 60%

12.  1] Genetic  2] Endocrine disorders  3] Immunological disorders  4] Infections  5] Unexplained

13.  1] Cervical Incompetence  2] Bicornuate uterus  3] Septate uterus  4] Uterine synechiae  5] Submucus fibroid  6] Maternal Diseases  7] Unexplained

14.  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?

15.  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

16.  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

17.  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

18.  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

19.  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.

20.  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

21.  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

22.  Investigations:  Endo cervical swab for culture & sensitivity  High vaginal swab for culture & Sensitivity  CBC  DIC profile if required  Blood culture  Urine Culture  Ultrasound

23.  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

24.  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

25.  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.

30.  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

32.  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

34.  Medical Termination of Pregnancy  Indications:  Failure of contraception  Rape  Medical diseases that may deteriorate mother’s health  Congenital anomalies

35.  First Trimester  Surgical :  Manual Vacuum Aspiration  Dilatation and Curettage  Suction and Evacuation  Medical:  Prostaglandin preparations  Mifepristone  Misoprostol

36.  Second Trimester:  Intraamnitic instillation of PGF2 alfa or Hypertonic saline  Extraamniotic ethacrydine lactate or PGf2 alfa  Oxytocin Infusion  Hysterotomy