कर हर मैदान फ़तेह

Abortion

• Expulsion of products of conception Before

completed 22 wks (154 days) of pregnancy.

• Expulsion of fetus weighing <500 gm or less

wh

• en it is not capable of independent survival.

• Abortion is spontaneous termination of

pregnancy before the period of viability.

• 75 % cases of abortion occurs before 16th

wk and of these 80 % occurs before 12th
wk.
 • Incidence –
Miscarriage – 10 – 20% of clinical
preganancies.
Induced – 10 % of clinical pregnancy.

# Etiology –
1.Genetic –

• Majority (50%) of early miscarriages are

due to chromosomal abnormality.

• Most common in 1st trimester. (50 – 75 %).

• 15 % cases due to defect in maternal

Gametogenesis.

• 50% are d/t defect in father

gametogenesis.
 • Autosomal trisomy is the commonest
(50%) abnormality.

• The most common trisomy is trisomy 16

(30%). Polyploidy (22%) , monosomy
(20%) 45,X .

2.ENDOCRINE AND METABOLIC FACTORS (10–

15%) –

• Luteal Phase Defect (LPD) – Deficiency of

Progesterone release from Corpus luteum.

• Thyroid abnormalities – Hypo or

Hyperthyroidism can cause Miscarriage.
3.ANATOMICAL ABNORMALITIES (3–38%) –
Seen in 2nd Trimester.

• Cervical incompetence
• Congenital malformation of the uterus.
• Intrauterine adhesions (synechia).

4.INFECTIONS (5% ) –

(i) Viral: Rubella, cytomegalovirus, variola,

vaccinia or HIV.
(ii) Parasitic: Toxoplasma, malaria.
(iii) Bacterial: Ureaplasma, chlamydia,
brucella. Spirochetes hardly cause abortion
before 20th week because of effective
thickness of placental barrier.

5. IMMUNOLOGICAL DISORDERS (5–10%)

 • Antiphospholipid antibody syndrome
(APAS) –
A. Lupus anticoagulant (LAC),
B. Anticardiolipin antibodies (ACAs).

• Autoimmunity –
Failure of maternal recognition of
trophoblast lymphocyte cross reactive Ag.

6. Maternal illness –
• Cardiac ds.
• HTN
• Heamoglobinopathies.

7.Environmental factors –
• Smoking.
• Alcohol.
 • Caffeine
• Exposure to radiation.

#Machenism of Abortion –
• Before 8 weeks: The ovum, surrounded by
the villi with The decidual coverings, is
expelled out intact. Sometimes, The
external os fails to dilate so that the entire
mass is Accommodated in the dilated
cervical canal and is called Cervical
miscarriage.

• Between 8 weeks and 14 weeks: Expulsion

of the fetus Commonly occurs leaving
behind the placenta and the Membranes. A
part of it may be partially separated with
brisk Hemorrhage or remains totally
attached to the uterine wall.
 • Beyond 14th week: The process of expulsion
is similar to That of a “mini labor”. The fetus
is expelled first followed by Expulsion of the
placenta after a varying interval.

# Types of Abortion –

1.Threatened –
It is a clinical entity where the process of
miscarriage has started but has not progressed
To a state from which recovery is impossible.
i.e. it is possible to continue the pregnancy.

# Clinical features –
• P/V Bleeding –
Sudden, recurrent, Bright red,
brownish. Bleeding usually stop
spontaneously.

• Pain – Painless. Or lower abdominal dull

pain.

• Internal Cervical OS – closed

# Investigation –
• USG – live fetus inside uterine cavity.
 • FHS – present.

• Blood – hemoglobin, hematocrit, ABO and

Rh grouping.

• Urine – for immunological test of pregnancy

is not Helpful as the test remains positive
for a variable period even after the fetal
death.

# Management –
• Complete bed rest for 2 – 3 wks
• Avoid coitus.
• Emotional support
• IV infusion (RL or NS)
• Sedative – Diazepam 5mg BD.
#Prognosis –
• In about two-thirds, the pregnancy
continues beyond 28 weeks.

• In the rest, it terminates either as inevitable

or missed miscarriage.

• If the pregnancy continues, there is

increased frequency of preterm labor,
placenta previa, intrauterine growth
restriction of the fetus and fetal anomalies.

2. Inevitable Abortion
It is the clinical type of abortion where the
changes have progressed to a state from Where
continuation of pregnancy is impossible.
#Clinical Features –
• P/V Dark red,moderate to severe bleeding
with pain in the lower abdomen and colicky
in nature.

• Internal cervical OS open and product of

conception are felt.

# Investigation –
• USG – dead fetus inside uterus.

• FSH – absent.

• Symphysis fundal height – decrease or may

correspond.
 • CBC, HB, Bhcg (-nt),

# Management –
• Termination of pregnancy (DNC, DNE,
suction evacuation {safest } )
• Prophylactic antibiotic –
Cefexime – 200 mg BD
Metronidazole – 500 mg BD
Doxycycline – 100mg BD
• Methergine – 0.2mg.

• The blood loss is corrected by intravenous

(IV) fluid therapy and blood transfusion.

• Before 12 weeks: (1) Dilatation and

evacuation followed by curettage of the
uterine cavity by blunt Curette using
analgesia or under general anesthesia. (2)
Alternatively, suction evacuation followed
By curettage is done.

• After 12 weeks: (1) The uterine contraction

is accelerated by oxytocin drip (10 units in
500 mL of Normal saline) 40–60 drops per
minute. If the fetus is expelled and the
 placenta is retained, it is Removed by ovum
forceps, if lying separated. If the placenta is
not separated, digital separation Followed
by its evacuation is to be done under
general anesthesia.

3. Incomplete Abortion

When the entire products of conception are not

expelled, instead a part of it is left Inside the
uterine cavity, it is called incomplete
miscarriage.

#It is most common type of abortion.

#Clinical features –

1 . Continuation Of pain in lower abdomen.

2. Persistence of vaginal bleeding.

3. Internal examination reveals—

• Uterus smaller than the period of
amenorrhea.
• Patulous cervical os often admitting tip of
the Finger.

4. on examination, the expelled mass is found

incomplete.

• USG – Reveals products of conception

within the cavity.
# COMPLICATIONS:
• The retained products may cause –
(a) profuse bleeding (b) sepsis
(c) placental polyp

# Management –
• Surgical Management same.
 • Medical management –
Misoprostol 200 mcg. Vaginally 4 hrly.

4. Complete Miscarriage
• When the products of conception are
expelled completely.
# Clinical Features –
• Subsidence of abdominal pain.

• Vaginal bleeding becomes trace or absent.

• Internal examination Reveals:

(a) Uterus is smaller than the period of
amenorrhea and a little firmer.
(b) Cervical os is closed
C. Bleeding is trace.
 • Examination of the expelled fleshy mass is
found complete.

#USG – Empty cavity.

#Management –
• TVS to see cavity – if not empty then do
DNC.

# Rh-NEGATIVE WOMEN –
A Rh-negative patient without antibody in
her system should be protected by Anti-D
gamma globulin 50 μg or 100 μg
intramuscularly in cases of early miscarriage
or late miscarriage Respectively within 72
hours. However, anti-D may not be required
in a case with complete miscarriage Before
12 weeks of gestation where no
instrumentation has been done.

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

# Clinical Features –
• Features of threatened abortion.
• Persistence Of brownish vaginal
bleeding.
• Pregnancy symptoms subside
 • No increase fundal height.
• Smaller and firmer uterus.
• Absence of FSH.
• Empty sac in USG.

#Management –
• If < 12 wks –
Misoprostol 800 mg per Vaginal in the
post. Fornix. And repeat after 24 hrs if
needed. May expulsion after 48 hrs
occurs.
Then DNE.

• If > 12 wks. –
Misoprostol 200 µg tablet is inserted into
the posterior vaginal Fornix every 4 hours
for a maximum of 5 such.

Oxytocin—10–20 units of oxytocin in 500

mL of normal saline at 30 drops/min is
started.

If fails, escalating dose of oxytocin to the

maximum of 200 mlU/min may be used
with Monitoring.

• Many patients need surgical evacuation

following medical treatment. Following
medical Treatment, ultrasonography
should be done to document empty
uterine cavity. Otherwise Evacuation of
 the retained products of conception
(ERPC) should be done.

DNE is done once the cervix becomes soft

with use of PGE1

Otherwise Cervical canal is dilated using

the mechanical dilators or by laminaria
tent Evacuation of the uterine cavity is
done thereafter slowly.
 6. Septic Abortion

• Any abortion associated with clinical

evidences of infection of the uterus and its
contents is called septic abortion.
#Clinical Criteria –
• Rise of temperature of at least 100.4°F
(38°C) for 24 hours or more.

• Offensive or purulent vaginal discharge.

• other evidences of pelvic infection such as

lower abdominal pain and tenderness.

# Incidence –
• 10 % of total abortion in hospital.
• Occurs mostly due to incomplete abortion
or following illegal induced abortion.

• Micro-organism –
Streptococci, clostridium welchii, E-
coli, klebsella, staphylococcus.
#Clinical features –
• Fever ( >100.4°F)

• Abdominal pain, vomiting, Diarrhea.

• Purulent discharge and bleeding per

vagina.

• Tachycardia.

# Grades –
1. Grade -1st –
Localised to uterus, commonest grade
and usually a/w spontaneous abortion.

2. Grade 2nd –
 The infection spreads beyond uterus to
parametrium, tubes, ovarian or pelvic
peritoneum.

3. Grade 3rd –
Generalised peritonitis and endotoxic
shock, jaundice.
Always A/w illegal induced abortions.

#Investigation –
• Cervical or high vaginal swab. Smear for
Gram stain.

• Gram-negative organisms are—E. coli,

Pseudomonas, Bacteroides, etc.
 • Gram-positive organisms Are—
Staphylococci, anaerobic Streptococci,
group A beta-hemolytic, Streptococci, Cl.
Welchii.

• Blood test – Hb , CBC.

• Urine culture.

• USG – to detect retained bits of

conception, fluid in the peritoneal cavity or
pouch of Douglas.

#Complications –
• Heamorrhage
• Generalised peritonitis.
 • Endotoxic shock.
• Acute renal failure – due to cortical
necrosis or acute tubuler necrosis.
(cl.welchii)
• Thrombophlebitis.

#Management –
• Hospitalization.

Grade 1st MGMT -

• Antibiotics -
Penicillin – for Gram +ve bacteria.
Gentamycin – For grade 1st
Cefixime – for gram -ve.
• Analgesics and sedatives.
 • Evacuation should be performed at a
Convenient time within 24 hours following
antibiotic therapy.

Grade 2nd –
• Antibiotics.
- Piperacillin-tazobactam.
- Clindamycin.

• Blood transfusion.
Surgery:
(1) Evacuation of the uterus—Evacuation
should be withheld for at least 48 hours
when the Infection is controlled and is
llocalize.
• (2) Posterior colpotomy—When the
infection is localized in the pouch of
Douglas, pelvic abscess is Formed.
Grade 3rd

Active Surgery:

Indications are—
(1) Injury to the uterus. (2) Suspected injury to
bowel.
(3) Presence of Foreign body in the abdomen
as evidenced by the sonography or X-ray or
felt through the fornix on bimanual
Examination.
(4) Unresponsive peritonitis suggestive of
collection of pus.

• The laparotomy should be done by

experienced surgeon with a skilled
 anesthetist. Removal of The uterus
should be done irrespective of parity.

7.Recurrent Abortion
A sequence of three or more consecutive
spontaneous Abortion before 20 weeks. Some,
however, consider two or more as a standard.

# It may be –
• Primary – Never gave a birth.
• Secondary – Having previous viable
birth.

INCIDENC – Affecting approximately 1% of all

women of reproductive Age.
The risk increases with each successive
abortion reaching over 30% after three
consecutive losses.

• Most common cause –

1. 1st Trimester –
Genetic factor
 2. 2nd trimester – cervical incompetence.

#Mx –
Cervlage operation ( Around 14th wk or 2 wk
earlier then last wastage.
• Shirodkar - purse-string fashion
• Macdonald
At 14th wk use of Non absorable suture then
remove at 37th wk of pregnancy.
 • Shirodkar Needle.

इति सिद्धम ्