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ABORTIONS

Submitted to:Ms. Amandeep


Tutor

Submitted by:Ms. EKTA


Msc Nursing 1st year

INTRODUCTION:Abortion is the termination of


pregnancy before the period of
viability which is considered to
occur at 20 and 24 weeks of
gestation with the weight over
500gm, a crown-rump length
longer than 16.5 to 18 cm , or any
sign of life such as heartbeat or a
gasp.

SPONTANEOUS ABORTION
Definition:-Abortion is the termination of pregnancy
before the period of viability which is considered to
occur at 20th week.
Classification or Varieties:
Threatened abortion
-Inevitable abortion
-Complete abortion
-Incomplete abortion
-missed abortion
-Septic abortion

ETIOLOGY:The etiology of abortion is often complex and


obscure .The causes of abortion are usually divided
into :- Ovular or fetal , Maternal environment ,
paternal factor , unknown.
Ovo Fetal Factor:- (a) The ovo-fetal factors : Chromosomal abnormality (commonest one being
autosomal trisomy, monosomy), gross congenital
malformation, blighted ovum (ovum without
embryo and hydropic degeneration of the villi. In
early weeks, death or disease of the fetus often
precedes the expulsive action of the uterus.

CONT:

(b) interference with the circulation in the


umbilical cord by knots, twists or
entanglements may cause death of the fetus
and its expulsion.
(c) Low attachment of the placenta or
faulty placental formation (circumvallate)
may interfere with placental circulation.
(d) Twins or hydramnios (acute) by rapidly
stretching the myometrium may cause
abortion.

MATERNAL FACTORS (15%) :

Maternal factors usually operate in late


abortion leading sometimes to expulsion of a
living fetus which, of course, is too small to
survive.

-Maternal illness :
1) Infection: a) Viral Infection specially of
rubella and cytomegalic inclusion disease
produces congenital malformation and
abortion . The viruses of hepatitis, parvovirus,
influenza have got lethal action on the fetus
causing its death and expulsion.

CONT:

b) Parasitic (Malaria) and protozoal


infection: (toxoplasmosis) may produce
abortion if contracted in early pregnancy.

- Spirochetes hardly produce abortion


before 20th week because of effective
thickness of the placental barrier.

-Hyperpyrexia may precipitate abortion by


increasing uterine irritability.

CONT:2. Maternal hypoxia and shock: Acute or


chronic respiratory disease, heart failure,
severe anemia or anesthetic complications may
produce anoxic state which may precipitate
abortion.
Severe gastroenteritis or cholera which is
prevalent in the tropics is often an important
cause.

CONT:3. chronic illness: Hypertension chronic nephritis


and chronic wasting diseases are responsible for
late abortion by producing placental infarction
resulting in fetal anoxia.

4. Endocrine factors: An increased association of


abortion is found in conditions of hypothyroidism,
hyperthyroidism and diabetes mellitus.
Inadequate corpus luteal state is considered to be
related with unsatisfactory, ovular growth and
development and hence its expulsion.

CONT:5) Inadequate corpus luteal state is considered to


be related with unsatisfactory, ovular growth and
development and hence its expulsion.

-Trauma: (1) Direct trauma on the abdominal wall


by blow or fall may be related to abortion. But
fortunately except in abortion prone women,
pregnancy remains undisturbed

(2) Psychic: Emotional upset or change in


environment may lead to abortion by affecting the
uterine activity.

CONT:(3). In susceptible individual, even a minor


trauma in the form of a journey along rough road,
internal examination in early months or eliciting
Hegars sign or sexual intercourse in early months
is enough to excite abortion.
(4) Amniocentesis, chorion villus sampling or
abdominal surgery in early months may cause
abortion.

CONT:

-Toxic agents : Environmental toxins like lead,


arsenic, anesthetic gases, tobacco, caffeine,
alcohol, radiation in excess amount increase the
risk of abortion. Drugs used for epilepsy or
antimalarial preparations (quinine) are not so
much harmful when used in therapeutic does so
as to cause abortion.

CONT:-Cervico- uterine factors: these are related


mostly to the second trimester abortions

(1) Cervical incompetence: either congenital


or acquired is one of the commonest causes of
midtrimester and recurrent abortions.

(2) Congenital malformation of the uterus in


the form of bicornuate or septate uterus may be
responsible for midtrimester or recurrent
abortion.

CONT:(3) Uterine tumor (fibroid) specially of the uterine


cavity and increased uterine irritability.

(4) Retroverted uterus, is not responsible for


abortion but its association might be due to its
failure to rectify between 12-14 week due to
adhesions or due to trauma during sexual
intercourse or it could be due to disturbance in
uterine vascularity.

CONT:-Immunological: Presence of autoimmune factors


like lupus anticoagulant and antiphosolipid
antibodies increase the risk of abortion.

- Alloimmune factors have been observed in cases


with-recurrent pregnancy loss.

-Blood group incompatibility: Incompatible ABO


group mattings may be responsible for early
pregnancy wastage and often recurrent but Rh
incompatibility is a rare cause of death of the fetus
before 28th week. Couple with group A husband and
group O wife have got higher incidence of abortion.

CONT:-Premature rupture of the membrane inevitable


leads to abortion.

-Dietetic factors: Deficiency of folic acid or


Vitamin E is often held responsible.

CONT:-PATERNAL FACTORS: Defective sperm,


contributing half of the number of the
chromosomes to the ovum, may result in
abortion
-First trimester:
(1) Defective germ plasma
(2) Hormonal deficiency
(3) Trauma
(4) Acute infection.

CONT:-Mid trimester:
(1) Cervical incompetence
(2) Uterine malformation such as bicornuate,
septate or double uterus
(3) Uterine fibroid
(4) Low implantation of placenta
(5) Twins and hydramnios.

MECHANISM OF ABORTION:
-MECHANISM OF ABORTION: in the early weeks,
death of the ovum occurs first, followed by its
expulsion, in the later weeks, maternal
environmental factors are involved leading to
expulsion of the fetus which may have signs of life
but is too small to survive.

THREATENED ABORTION
-DEFINITION: It is a clinical entity where the process of
abortion has started but has not progressed to a state
from which recovery is impossible.

CLINICAL FEATURES: The patient, having symptoms


suggestive of pregnancy, complains of :

1)Bleeding per vagina: the bleeding is usually slight


and bright red in colour. On rare occasion, the bleeding
may be brisk and sharp, specially in the late second
trimester, suggestive of low implantation of placenta.
The bleeding either stops spontaneously or continues
with change of colour to brown or dark or remains as
bright red.

CONT:2)Pain: Bleeding is usually painless but there may be mild


backache or dull pain in lower abdomen

-INVESTIGATIONS:
1)Blood: for estimation, ABO and Rh grouping.
2)Urine: for immunological test of pregnancy. This is
done to confirm the fetal death in cases of continued
bleeding
Special investigation:
(1) A well formed gestation ring.
(2) observation of fetal cardiac motion.
(3) A blighted ovum.

CONT:-Bed rest: the patient should be in bed for few


days until bleeding stops. With history of previous
early pregnancy wastage, the period of rest should
be extended to about two weeks beyond the period
at which the previous wastage occurred.
-Drugs: Sedation and relief of pain may be
ensured by phenobarbitone 30 mg-or diazepam 5
mg tablet twice daily.

GENERAL MEASURE
(1) the patient is advised to preserve the vulval pads
and anything expelled out per vaginam, for inspection.
(2) to repot if bleeding and / or pain becomes
aggravated.
(3) Routine note of pulse temperature and vaginal
bleeding.
-ADVICE ON DISCHRGE: The patient should limit her
activities for at least two weeks and avoid heavy work,
strenuous exercise and excitement. Coitus is
contraindicated during this period. She should be re
examined after one month to note the growth of the
uterus and advised to consult the physician if bleeding
recurs.

INEVITABLE ABORTION
DEFINITION: It is the clinical type of abortion
where the changes have progressed to a state from
where continuation of pregnancy is impossible.
CLINICAL FEATURES:
(1) increased vaginal bleeding.
(2) aggravation of pain in the lower abdomen
which may be colicky in nature.
(3) the general condition of the patient is
proportionate to the visible blood loss.
(4) Internal examination reveals dilated internal os
of the cervix through which the products of
conception are felt.

CONT:-MANAGEMENT: The principles in the management


are:
(1) to take appropriate measures to look after the
general condition.
(2) To accelerate the process of expulsion.
(3) To maintain strict asepsis.
-General measures: Morphine 15 mg is given
intramuscularly. Excessive bleeding should be
promptly controlled by administering methergin
0.2 mg if the cervix is dilated and the size of the
uterus is less than 12 week.
The shock is corrected by intravenous fluid therapy
and blood transfusion.

ACTIVE TREATMENT
Before 12 weeks :
(1) Dilatation and evacuation followed by curettage
of the uterine cavity by blunt curette under general
anesthesia is quite effective and a safe procedure.
(2) Alternatively suction evacuation followed by
curettage may be employed.
After 12 weeks :
(1) The uterine contraction is accelerated by
oxytocin drip (10 units is 500 ml of 5% dextrose) 4060 drops per minute.
If the fetus is expelled and the placenta is retained,
it is removed by ovum forceps, if lying separated.

CONT:

If the placenta is not separated, digital


separation followed by its evacuation is to be
done under general anesthesia.

(2) If bleeding is profuse with the cervix close


(suggestive of low implantation of placenta)
evacuation of the uterus may have to be done by
abdominal hysterotomy.

COMPLETE ABORTION
DEFINITON: When the products of conception are expelled
en masse, it is called complete abortion.

CLINICAL FEATURES : There is history of expulsion of a fleshy


mass per vaginam followed by:
(1) Subsidence of abdominal pain.
(2) Vaginal bleeding become trace or absent
(3) 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
(4) Examination of the expelled fleshy mass is found intact.

CONT:-MANAGEMENT: The effect of blood loss, if any,


should be assessed and treated.
-If there is doubt about complete expulsion of the
products, uterine curettage should be done.
-Transvaginal sonography is useful to prevent
unnecessary surgical procedure.
-Rh-Negative WOMEN: A Rh-negative patient
without antibody in her system should be
protected by Anti-D gamma globulin-50 microgram
or 100 microgram intramuscularly in cases of early
abortion or late abortion respectively within 72
hours.

INCOMPLETE ABORTION
-

DEFINITION: When the entire products of conception are


not expelled, instead a part of it is left inside, the uterine
cavity, it is called incomplete abortion.

-CLINICAL FEATURES: History of expulsion of a flesh mass


per vaginam followed by:
(1) Continuation of pain lower abdomen, colicky in
nature, although in diminished magnitude
(2) Persistence of vaginal bleeding of varying magnitude.

CONT:(3) Internal examination reveals:(a) uterus smaller than the period of amenorrhea
(b) patulous cervical os often admitting tip of the finger
and
(c) varying amount of bleeding

(4) On examination, the expelled mass is found


incomplete.

-TERMINATION: The products left behind may lead to


(1) profuse bleeding,
(b) sepsis, (c) placental polyp and (d) rarely
choriocarcinoma.

MANAGEMENT
MANAGEMENT:
-In recent cases The same principles are to be
followed like that to the inevitable abortion.
-Early abortion: Dilatation and evacuation under
general anesthesia is to be done.
-Late abortion: The uterus is explored under
general anesthesia by finger and the products left
behind is either removed by ovum forceps or by
blunt curette.
-In late cases- dilatation and curettage operation is
to be done to remove the bits of tissues left
behind. The removed materials are subjected to a
histological examination.

MISSED ABORTION
-DEFINITION : When the fetus is dead and retained
inside the uterus for more than four weeks, it is
called missed abortion.
-CLINICAL FEATURES: The patient usually presents
with features of threatened aborting followed by:
(1) Persistence of brownish vaginal discharge.
(2) Subsidence of pregnancy symptoms.
(3) Retrogression of breast changes.
(4) Cessation of uterine growth which in fact
becomes smaller in size.

CONT:(5) Non audibility of the fetal heart sound even with


Doppler cardio scope if it had been audible before.
(6) Cervix feels firm.
(7) Immunological test for pregnancy becomes
negative.
(8) Radio logical evidence of collapsed fetal
skeleton if the pregnancy has proceeded to over 16
weeks.
(9) Real time ultra sonography reveals an empty sac
early in the pregnancy or the absence of fetal
motion or fetal heart movement. Later in the
pregnancy.

CONT:-MANAGEMENT:
-Uterus less than 12 week: Vaginal evacuation can be
carried out without delay. This can be effectively done by
suction evacuation.
-Uterus more than 12 week: the same principles of the
management protocol as advocated in the intrauterine fetal
death are to be followed.
-Oxytocin to start with 10-20 units of oxytocin in 500 ml of
5% dextrose saline is administered in drip with 30 drops per
minute. If fails, escalating dose of oxytocin to the maximum
of 100 units, in a pint of 5% dextrose saline at a drip rate of
30 drops per minute, may be used with precaution.

CONT:-Prostaglandins Prostaglandin is more effective


than oxytocin in such cases. The following
procedures may be employed.

a)Intramuscular administration of 15 methyl PGF2a


(Carboprost promethazine) 250mg 3 hours intervals
for a maximum of 10 such.
-Prostaglandin E1 (gemipost) 1 mg pessary is
inserted into the posterior vaginal fornix every 3
hours for a maximum 5 such.

SEPTIC ABORTION
-DEFINITION: Any abortion associated with
clinical evidences of infection of the uterus and its
contents, is called septic abortion. Although
clinical criteria vary, abortion is usually considered
septic when there are:
(1) rise of temperature of at least 100.4 F (38 C)
for 24 hours or more
(2) offensive or purulent vaginal discharge and
(3) other evidences of pelvic infection such as
lower abdominal pain and tenderness.

CONT:-CLINICAL FEATURES: Depending upon the severity


and the extent of infection, the clinical picture varies
widely but the basic features almost remain constant.
The patient, with history of recent termination of
pregnancy, presents the following features. History of
illegal termination by an unauthorized person is
mostly concealed.

-Pyrexia : is an important clinical manifestation.


Associated chills and rigors suggest blood stream
spread of infection. However, if subnormal
temperature is present, it is an ominous feature of
endotoxic shock.

CONT:-Pain abdomen: of varying degrees is almost a constant


feature.
-A rising pulse rate of : 100-120/ minute or more is a
significant finding than even pyrexia. It indicates spread
of infection beyond the uterus.

-Variable systemic and abdominal findings: depending


upon the spread of infection.

-Internal examination: reveals offensive purulent vaginal


discharge or a tender uterus usually with patulous os or a
boggy feel of the uterus associated with variable pelvic
findings depending upon the spread of infection.

CONT:-CLINICAL GRADING: Clinically, the cases are


graded as:
-Grade I : The infection is localized in the uterus.
-Grade - II : The infection spreads beyond the
uterus to the Perimetrium, tubes and ovaries or
pelvic peritoneum
-Grade III : Generalized peritonitis and/or
endotoxic shock or jaundice or acute renal failure.
-Grade I is the commonest and is usually
associated with spontaneous abortion Grade III is
almost always associated with illegal induced
abortion.

INVESTIGATIONS
(1) Cervical or high vaginal swab is taken prior to
internal examination for:(a) culture in aerobic and anaerobic media to find
out the dominant micro-organisms,
(b) sensitivity of the micro-organisms to antibiotics
(c) smear for Gram stain. Gram negative organisms
are E. coli, pseudomonas, Bacteroides etc.
-Gram positive organisms are Staphylococci,
anaerobic streptococci, Cl. Welchii, cl. Tetani etc.

CONT:(2) Blood for hemoglobin estimation, total and


differential count of white cells, ABO and Rh
grouping.
(3) Urine analysis including culture.
Special investigations
(1)Ultrasonography pelvis and abdomen to detect
intrauterine retained products of conception,
physometra, foreign body intrauterine or intraabdominal, free fluid in the peritoneal cavity or in
the pouch of Douglas.

CONT:Special investigations
(2) X-ray abdomen and pelvis not commonly done
these days.
(3) Blood (a) Culture if associated with spell of
chills and rigors,
(b) Serum electrolytes as an adjunct to the
management protocol of endotoxic shock.
(c) Coagulation profile

CONT:-COMPLICATIONS:
-Immediate: The major complications of septic
abortion are dependent more on the nature of the
abortion in which the sepsis occurs: Practically all
the fatal complications are associated with illegally
induced abortions confined to the grade III types.
-Hemorrhage: related due to abortion process and
also due to the injury inflicted during the
interference.
-Injury: may occur to the uterus and also to the
adjacent structures particularly gut.

CONT:GENERAL MANGEMENT:
-Hospitalization: even with a case of mild infection is
preferable. The patient should be kept in isolation, if
possible.
-To take high vaginal or cervical swab: for culture,
drug sensitivity test and Gram stain.
-Vaginal examination: is then made to note the state
of the abortion process and extension of the
infection. If the products are found loosely lying in
the cervix, they should be removed by sponge holding
forceps.
-Overall assessment of the case: is to be done and
the patient is put in accordance with the clinical
grading.

CONT:Investigation protocols: as outlined before are


done, as required and where available.
To formulate the line of treatment : which aims at
(a) To control sepsis.
(b) To remove the source of infection.
(c) To give supportive therapy to bring back the
normal homeostatic and cellular metabolism.
(d) To remain vigilant in order to assess the
response of treatment.

CONT:-GRADE-I
Drugs : (1) Antibiotics
(2)Prophylactic anti gas-gangrene serum of 8000 units
and 3000 units of antitetanus serum intramuscularly
are given
(3) Blood transfusion
(4) Evacuation of the uterus
-GRADE II
-Antibiotics Mixed infections including gram positive,
gram negative and anaerobic organisms are common.
-For gram positive aerobes: (a) Aqueous penicillin G 5
million units I.V. every 6 hours (b) Ampicillin 0.5 1
gm. I.V. every hours. B. Gram negative aerobes: (a)
Gentamicin 1.5 mg/kg I.V. every 8 hours.

CONT:-Clinical monitoring: To note pulse, respiration,


temperature, urinary output and progress of the pain,
tenderness and mass in lower abdomen.
-Surgery: (1) Evacuation of the uterus
(2)Posterior colpotomy : Posterior colpotomy and
drainage of the pus relieve the symptoms and improve
the general outlook of the patient.
GRADE III
-Antibiotics: are discussed above Clinical monitoring is
to be conducted as outlined in
grade- II. Supportive therapy is directed to treat
generalized peritonitis by gastric suction and
intravenous saline infusion. Management of endotoxic
shock or renal failure.

RECURRENT ABORTION
-DEFINITION: Recurrent abortion is defined as a
sequence of three or more consecutive spontaneous
abortions some however, consider two or more as a
standard. It may be primary or secondary (having
previous viable birth)

-ETIOLOGY
-FIRST TRIMESTER ABORTION:
-Genetics a recurring aneuploid abnormality of
the conceptus is probably responsible. It may be a
chance event or related to maternal age. The most
common type of parental chromosomal abnormality
is a balance translocation.

CONT:-Endocrinal: (1) Poorly controlled diabetic


patients do have an increased incidence of early
pregnancy failure.
(2) Presence of thyroid autoantibodies.
(3) Inadequate luteal.
(4) Polycystic ovarian syndrome.

-Infection: the organisms implicated are


Mycoplasms, Ureaplasma, Chlamydia and bacterial
vaginosis. Systemic infection with toxoplasma and
brucella are also implicated.

CONT:-Immunological cause:
-Autoimmunity: the association of raised
circulating lupus anticoagulant (LA) and antiphospholipid antibodies (APAS) with recurrent fetal
loss is now well established. APAS positive women
demonstrate a tendency to miscarry at
progressively lower gestational ages.

-Alloimmunity: There is failure of maternal


recognition of trophoblast lymphocyte cross
reactive antigen

CONT:-Idiopathic: In the majority, the cause remains


unknown, but the following are often related
(i) Psychological strain by raising the intrauterine
pressure can cause abortion in susceptible individual.
(ii) incompatible ABO group mentioned earlier.

-SECOND TRIMESTER ABORTION:


-Cervical incompetence
-Congenital
-Acquired

CONT:Diagnosis is based on the following criteria:


-History: Repeated mid trimester abortions
without apparent cause, starting with escape of
liquor amnii followed by painless expulsion of the
products of conception is very much suggestive.
-Internal examination: (i) interconceptional
period Bimanual examination reveals presence
of unilateral or bilateral tear and / or gaping of
the cervix up to the internal os.

CONT:(ii) During pregnancy:- Periodic inspection of the


cervix through speculum from 10th week onward at
weekly intervals is to be done. Detection of
dilatation of the internal os with herniation of the
membranes is diagnostic

-INVESTIGATIONS:
-Interconceptional period
(i)Passage no.6-8 Hagar dilator: beyond the
internal os without any resistance and pain and
absence of internal os snap on its withdrawal
specially in premenstrual period indicate
incompetence.

CONT:-Premenstrual hystero-cervicography: shows


funnel shaped shadow the internal os is supposed
to be tight due to action of progesterone during
this phase of cycle.

-During pregnancy:
-Ultrasonography findings of cervical length less
than 3 cm and width of internal os more than 1.5
cm in first trimester with or without bulging of the
membranes are suggestive.
-Defective mullerian fusion: such as double
uterus, septate or bicornuate uterus.

CONT:-Uterine synechae: - may be responsible for recurrent


fetal loss due to defective placentation over the
adhesions.
-Uterine fibroid: - Causing accommodation problem,
defective implantation or increase in uterine irritability.
-Retroverted uterus: - as mentioned previously.
-Chronic maternal illness:-Infection:-Idiopathic:INVESTIGATIONS
-Diagnostic test: (1) Blood glucose (fasting and post
prandial), VDRL, Thyroid function test, ABO and Rh
grouping (husband and wife), Toxoplasma antibodies IgG
& IgM

CONT:(2) Autoimmune screening lupus anticoagulant


and anticardiolipin antibodies. If positive to
repeat the test after 6 weeks to avoid false
positive results.
(3) Serum LH on D2/D3 of the cycle.
(4) Ultrasonography to detect congenital
malformation of uterus, polycystic ovaries and
uterine fibroid.
(5) Hysterosalphinography in the secretory phase
to detect cervical incompetence, uterine
synechae and uterine malformation

CONT:(6) this is supported by hysteroscopy and or


laparoscopy.
(7) Karyotyping husband and wife
(8) Endocervical swab to detect Chlamydia,
mycoplasma and bacterial vaginosis.

-TREATMENT
INTERCONCEPTIONAL PERIOD:
-To alleviate anxiety and to improve the
psychology:

CONT:
-To correct the uterine pathology metroplasty for
double or bicornuate uterus, removal of septum
(hysteroscopically preferred) or myomectomy for
sub mucous fibroid distorting the uterine cavity.

-Chromosomal problems:- if chromosomal


abnormality is detected in the couples karyotyping
of the products of conception from future
miscarriage is mandatory.

CONT:-In cases of PCOS with elevated LH, pituitary


suppression by GnRH analogues followed by
ovulation induction with gonadotropins improve the
fetal salvage.

-To treat the endocrine dysfunction or genital tract


infections, if any.
DURING PREGNANCY:
-Reassurance and tender loving care are very much
helpful.
-Ultrasound should be used at the earliest to
detect a viable pregnancy.

CONT:-Rest- The patient should take adequate rest for


a period of at least two weeks beyond the
expected time of abortion.
-Strenuous activities, intercourse and travelling
are to be avoided.
-In proved cases of corpus luteum insufficiency
Natural progesterone 25 mg as vaginal
suppositories thrice daily is started 2 days after
ovulation.
-Patients with antiphosolipid antibodies are

CONT:-treated with low dose aspirin (50 mg/day) and


prednisone (40-60 mg/day) or low dose aspirin and
heparin (500 units subcutaneously daily) up to 34
weeks.
-In couple, with balanced translocation, the
ongoing pregnancy should have prenatal
diagnosis by either chorion villus sampling or
amniocentesis.
-Circlage operation for cervical incompetence is to
be performed.

NURSING DIAGNOSIS:

Pain related to abortion process.


Bleeding related to abortion process.
Impaired mobility
Impaired nutritional status less than body
requirement.
Self care deficit related to decrease mobility.
Ineffective coping.
Risk for fluid volume deficit related to
bleeding.
Risk for infection.

SUMMARY
SUMMARY:- Abortion is the termination of
pregnancy before the period of viability which is
considered to occur at 20th week. Its
Classification are:-Threatened abortion
-Inevitable abortion
-Complete abortion
-Incomplete abortion
-missed abortion
-Septic abortion

BIBLIOGRAPHY:

Leonard Deitra ,Maternity Nursing, Mosby, 1999,


fifth edition, pp- 140- 267.

Dutta D.c, Textbook of Gyaecology including


Contraception, New central book agency, fifth
edition, pp-45-47.

Dutta D.C Textbook of Obstetrics, New central


book agency, fifth edition, pp-170-189.