Hemorrhage in early pregnancy

Those related to the pregnant sate

Abortion, ectopic pregnancy
Hydatidiform mole implantation
bleeding.
Those associated with the pregnant
state
Lesions unrelated to pregnancy
either preexisting
or aggravated during pregnancy.
Cervical lesions such as vascular
ectopy (erosion),
polyp, ruptured varicose veins and
malignancy are important causes
 ABORTION
•
 DEFINITION
Abortion is the expulsion or extraction
from its mother of an embryo or fetus
weighing 500gm or less when it is
not capable of independent survival.
WHO
This 500 g of fetal development
is attained approximately at 22
weeks (154 days) of gestation
Early Abortion: Before 12 weeks

Late Abortion: From 12-20 weeks

 Viability
• Survival by Gestational age
– Weeks % survival
22 0
23 25
24 55
25 65
26 75
27 90
28 92
 INCIDENCE:

• 10-20% of all clinical

pregnancy

• 10% Illegal

• 75% occur before 16wks

CLASSIFICATION
ABORTION

Spontaneous
Induced

Isolated Recurrent
Legal Illegal (criminal )

Septic

Threatened Inevitable Complete Incomplete Missed Septic

 ETIOLOGY:
1.Ovular or Fetal factors(60%):
a) Ovo-fetal factors-

Chromosomal abnormality

 Gross congenital malformation

 Blighted ovum

 Hydropic degenaration of villi

 Contd…
b) Interference with circulation-

 Knots

 Twists

Entanglements
c) Low attachment of placenta
d) Twins or Hydramnios.
2. Unknown factors
 Contd…
3. Maternal factors(15%):
 Maternal medical illness
-Cyanotic heart diseases
Infections

 Maternal hypoxia

 Chronic illness
 Contd…

Anatomical abnormalities
Cervico-uterine factors-
-Cervical ompetenc
inc e
-Congenital malformation of
uterus
-Uterine fibroid
-Intrauterine adhesions
-Retroverted uterus
 Trauma- Direct
-Psychic Susceptible individual
-Amniocentesis
 Toxic agents
4.Blood group incompatibility

5. Premature Rupture of
6.Environmental factors – Smoking,
alcoholism, X-ray, Radiation,
Chemotherapy.
7.Dietic factors
8.Paternal factors:Chromosomal anomaly in
sperm
9.Infections – Viral, Bacterial or Parasitic

10. Inherited Thrombophilia

11.Immunological disorder
• Autoimmune disease (mother's immune system
will form antibody against her own placenta and
fetus) or
• Alloimmune disease ( Paternal antigen which
enters mothers body will produce antibody against
it. Maternal antibody accepts as its own so there will
be decreased foetal-maternal immunologic
interaction and ultimately fetal rejection).
• 11. Immunological disorder –
• Autoimmune disease (mother's immune system
will form antibody against her own placenta and
fetus) or
• Alloimmune disease ( Paternal antigen which
enters mothers body will produce antibody against
it. Maternal antibody accepts as its own so there will
be decreased foetal-maternal immunologic
interaction and ultimately fetal rejection).
 Common cause
• First trimester
• Genetic factors -50%
• Endocrine disorders
• Immunological
• Infections
• Unexplained (40-60%)
• Second trimester
1.Anatomic abnormalities
a)Cervical incompetence
b)Mullerian fusion defects (Bicornuate uterus, septate
uterus )
c)Uterine synechiae (intra uterine adhesion )
d)Uterine fibroid
2.Maternal medical illness
3.Unexplained
 Mechanism of Abortion
Before 8 weeks: Ovum surrounded by the villi with
the decidual coverings is expelled out. Because the
external os fails to dilate the entire mass remains in the
cervix. Called as “Cervical Abortion”.

8-14 weeks: Expulsion of the fetus commonly

occurs leaving behind the placenta and membranes,
so that there will be bleeding.

Beyond 14th week: Expulsion is similar to that of

“mini labour”. The fetus is expelled first followed by
expulsion of placenta.
 Spontaneous Abortion:
Definition:
It is defined as the involuntary loss of the
products of conception prior to 20 weeks
of gestation.
Incidence:
15% of all confirmed pregnancy
80% occur in first trimester
 Causes
1.Abnormal fetal formation due to
-Teratogenic factor
-chromosomal aberration
50-80%of early abortion has structural
abnormalities 2.Immunological factors –rejection
by immune
response
3.Implantation abnormalities –Poor implantation result
from
• inadequate endometial formation
• An inappropriate site of implantation
• improper implantation placental circulation
function affected inadequate fetal nutrition
4. Corpus luteum fails to produce enough
progesterone to maintain the decidua basalis –
proge therapy is neeed
5. UTI
7.Ingestion Of Teratogenic Drugs
7.Infections -rubella
syphilis,cytomegalo,toxoplasmosi
s
Which readily cross the placenta
 Changes
Infection

Fetus fails to grow

Estrogen and progesterone production by

placenta
fails

Endometrial sloughing
 Prostaglandins are released

Uterine contraction expulsion of products of

pregnancy

Cervical dilatation

Expulsion of products of pregnancy

Schematic Diagram of Abortion

Infection
Abnormal Fetal Immunologi Teratogenic
Formation c Factors Factors
Crosses (smoking,
placent alcohol,
a drugs)
Rejection of the
embryo through Fetus fails
immunologic to grow
response
Decrease estrogen
and
progesterone
production

Endometria
l sloughing
Release of
Miscarriag prostaglandin which
causes uterine
e
contractions and
cervical dilatation
 1.Threatened abortion:

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
Bleeding per vagina:Slight and bright
red in colour.
Pain: Mild backache or dull pain in
lower abdomen.
Pelvic examination:
a)Speculum examination-bleeding if any,escapes through
the external os.

b) Digital examination-reveals closed

external os.

c) The uterine size corresponds to the period of

amenorrhoea.
Investigation
d)Blood investigation

e) USG

f) Urine for immunological test for pregnancy

Treatme
nt
Rest : 2weeks of bed rest.

Drugs : sedation and analgesics

Phenobarbitone 30mg or
Diazepam 5mg

Advised to preserve vulval pads and anything expelled out per

vaginam for inspection.

To report if bleeding or pain gets aggravated.

Routine note of pulse, temperature and vaginal bleeding.

Advice on
discharge
-Limit her activities at least for 2 weeks.

- Avoid heavy work.

-Coitus is contraindicated during this period.

-Follow up after 1month to assess the growth of fetus.

 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
-Increased vaginal bleeding

-Severe lower abdominal pain- colicky type

-General condition is proportionate to

visible blood loss.
Internal examination

Reveals dilated internal os of the cervix through

which the product of conception are felt.

Management

Principles :

a. To take appropriate measures to look after the

general condition.

b. To accelerate the process of expulsion.

c. To maintain strict asepsis.

Active treatment

Before 12weeks : dilatation and evacuation followed

by curettage of uterine cavity.

After 12weeks :

i.Uterine contraction is accelerated by oxytocin drip

(10 U in 500ml NS) 40-60drops/min.

ii.If the product is expelled and placenta retained, it

is removed by ovum forceps(if lying separate)
 Contd…
iii. If placenta is not seperated, digital
seperation followed by evacuation under GA.

If bleeding is severe and cervix is closed then

evacuation of uterus is done by Abdominal
hysterectomy.
 3. COMPLETE ABORTION
• When the products of conception are
completely expelled, it is called
complete abortion.
 Clinical features

-Thereis history of expulsion of a fleshy

mass per vagina followed by:

-Subsidence of pain

-Vaginal bleeding becomes trace or

absent
Cont....

Internal examination reveals:

-Uterus is smaller than the period of amenorrhoea

-Cervical os is closed

-Bleeding is trace

-Examination of the expelled fleshy mass is found

intact.
 Managemen
t
i. Blood loss should be assessed and treated.

i. If there is doubt about complete expulsion of

products, uterine curettage should be done.

i. Transvaginal sonography is useful to prevent

unnecessary surgical procedure.

i. In case of Rh negative mother antiD gamma

globulin should be given.
 4. Incomplete abortion
• When the entire products of
conception are not expelled, instead a
part of it is left inside the uterine
cavity, is called incomplete
abortion.
 Clinical features.

-History of expulsion of fleshy mass per vaginam

followed by:

-Continuation of pain lower abdomen

-Persistence of vaginal bleeding

 Internal examination

-Uterus smaller than the period of

amenorrhoea
-Cervical os may admit the tip of
the finger
-Varying amount of bleeding
-On examination,the expelled mass is found
incomplete.
 Termination

If the products left behind it leads to


Profuse bleeding

Sepsis

Placental polyp

Choriocarcinoma
 Management
The principles to be followed are same as Inevitable
abortion.

Patient may be in a state of shock due to blood loss.,

she should be resuscitated before any active
treatment.

Early abortion: Dilatation and evacuation

Late abortion: Uterus is evacuated under GA and the

products are removed by ovum forcep or by blunt
curette.
 miscarriage or early
fetal
demise
• When the fetus is dead and retained
inside the uterus for a variable
period,it is called as missed abortion
or silent miscarriage.
 Pathology
Beyond 12wks: Fetus become macerated or
mummified, liquor amnii get absorbed, placenta
becomes pale,thin and adherent.

Before 12wks: Because of haemorrhage blood will get

collected around ovum called as “blood mole".,
water content from the blood gets absorbed and
flesh remains around the ovum called as “Fleshy
mole or Carneous mole”.
 Clinical features
Persistence of brownish vaginal discharge

Subsidence of pregnancy symptoms

Retrogression of breast changes

Non audibility of fetal heart sound even with doppler

Cervix feels firm

Immunological test for pregnancy becomes negative

USG reveals an empty sac

 Management
If less than 12wks:
vaginal evacuation by suction
evacuation or slow dilatation of
the cervix by laminaria tent
followed by dilatation and
evacuation of the uterus under
GA.
If more than 12wks:
Induction is done
-Oxytocin 10-20U in 500ml NS at
30drops/min. If fails increase dose to
maximum of 200mlU/min
-Prostaglandins:misoprostol tab
inserted into
the posterior vaginal fornix
:IM administration of 15methyl PGF2α
(carboprost tromethamine)
 6. Septic abortion
• Any abortion associated with
clinical evidences of infection of
the uterus and its contents.
 Criteria

• Rise of temperature 100.4*for 24 hrs

• Offensive or purulent vaginal discharge

• Lower abdominal pain and tenderness

 Mode of infection

Usually the micro-organisms present in the

vagina are involved in sepsis when the
resistance power of the mother becomes
low.

Majority of cases the infection occurs

following illegal induced abortion.
 Reasons for infection
• Proper antiseptic and asepsis are not taken
• Incomplete evacuation
 Clinical features
Pyrexia associated with chills and rigors.

Purulent vaginal discharge

Shock

Pain abdomen of varying degrees

Internal examination reveals:

-Offensive purulent vaginal
discharge
- Tender uterus
 Clinical
grading
Grade I : Infection localised to uterus
(commonest)

Grade II : infection spreads beyond the

uterus to the tubes and ovaries.

Grade III : Generalised peritonitis / shock /

jaundice or acute renal failure
(associated with illegal induced
abortion).
 Investigation
s
Routine
-Cervical or highinvestigations
vaginal swab for
: culture and
sensitivity test.
-Blood for haemoglobin, total and differential
count,
ABO and Rh grouping.
-Urine analysis including culture

Special investigations :

-USG abdomen and pelvis

-Blood for culture, serum electrolytes, coagulation
profile
 Complication
Immediate :
Haemorrhages
Injury to uterus and adjacent
structures
Spread of infection causes
Peritonitis
Acute renal failure
Thrombophlebitis
 Remote :

Chronic pelvic pain, Backache

Dyspareunia
Ectopic pregnancy
Secondary infertility due to tubal
blockage
Emotional depression.
Prevention

i. Use family planning method

ii. Encourage to go for legal abortion

 Management
• Hospitalization
• High vaginal or cervical swab
• Vaginal examination to note the
state of abortion process
Principles of management:
• To control the sepsis
• To remove the source of infection
• To give the supportive therapy
• To bring back the normal homeostatic
and cellular metabolism
• To assess the response to treatment
 Specific management
Drugs : 1.Antibiotics
Gram positive aerobes
a)Aqueous Penicillin G 5million U IV every 6 hours

(b)Ampicillin 0.5-1gm IV every 6 hours.

Gram negative aerobes

(a) Gentamicin 1.5mg/kg IV every 8 hours.

(b) Ceftriaxone 1.5gm IV every 12 hours

For Anaerobes
(a) Metronidazole 500mg IV every 8hours

(b) Clindamycin 600mg IV every 6hours

Grade I
1.Antibiotics

2.
Prophylactic
anti gas-
gangrene
Serum of 8000 U and 3000 U of anti tetanus
serum IM are given.
3. Analgesics and Sedatives

-Blood transfusion

-Evacuation of the uterus within 24hours following

antibiotic therapy
Grade II

Antibiotics

Clinical monitoring- to note pulse, temperature,

urinary output and progress of pain, tenderness
and mass in lower abdomen.

Surgery

i. Evacuation of the Uterus

ii. Posterior colpotomy(pouch of douglas)

Grade III

Antibiotics

Clinical monitoring

Supportive therapy with IV fluids.

Active surgery
-Laparotomy
 Recurrent /
Spontaneous
• Recurrent miscarriage
miscarriage is defined
as a sequence of three or more
consecutive spontaneous
abortion before
20weeks.
 Etiology
During 1st trimester
-Genetic factors
-Endocrine and metabolic
-Infection
-Inherited Thrombophiliaintra vascular
coagulation .(protein C-natural inhi-of
coag)
-Immunological cause : Auto & Allo
immunity
-Unexplained
During 2nd trimester
Cervical incompetence

Defective mullerian fusion-double uterus,bicornuate

uterus,septate uterus.
Cervical incompetence

Uterine fibroid

Retroverted uterus

Chronic maternal illness

Infection, Unexplained
 Investigations

i. History on previous abortion.

ii. Any chronic illness
iii. Histology of placenta
 Diagnostic tests
a.Blood glucose , VDRL , Thyroid
function test, ABO and Rh grouping
b. Autoimmune screening
c.USG
d. Hysterosalpingography
e.Hysteroscopy / Laparoscopy
f. Endocervical swab
 Treatment
During Inter conceptional Period

 To alleviate anxiety and improve

psychology
 Hysteroscopic resection of
uterine septate
 Uterine unification operation (metroplasty)
for bicornuate uterus.
 Genetic counselling if chromosomal
abnormality .
 Endocrine dysfunction has to be
 During pregnancy

Reassurance and tender loving care.


Ultrasound

 Adequate rest

 Avoid strenuous activity

 Intercourse

 Travelling.
• Luteal phase defect:
Progesterone 100mg as vaginal
suppository TID started 2days after
ovulation. During this time if
pregnancy test is positive continue
treatment 12weeks of pregnancy.
(corpus luteal insufficiency)
Inherited Thrombophilia :
 antithrombotic therapy improves the pregnancy
outcome.heparin 5000IUtwice daily.S/C upto 34
weeks


Medical complications : Specific management is
continued.

Unexplained :

Supportive therapy improves pregnancy outcome.
• Circlage operation :non absorbable encircling suture
is placed around the cervix at the level of internal
OS.
Done at 14 weeks of pregnancy or at least two
weeks earlier than the previous pregnancy loss
-10th week
Nursing Diagnosis
• Risk for fluid volume deficit r/t maternal
bleeding

Nursing Interventions
• Report any tachycardia, hypotension, diaphoresis,
or pallor, indicating hemorrhage and shock.
• Draw blood for type and screen for possible blood
administration.
• Establish and maintain an IV with large-bore
catheter for possible transfusion and large quantities
of fluid replacement.
 Nursing
•Diagnosis
Anticipatory grieving r/t loss of pregnancy, cause of
abortion, future childbearing

Nursing Interventions
•Assess the reaction of patient and support person,
and provide information regarding current status, as
needed.
•Encourage the patient to discuss feelings about the
loss of the baby’ include effects on relationship with
the father.
•Do not minimize the loss by focusing on future
childbearing; rather acknowledge the loss and
allow grieving.
•Providing time alone for the couple to discuss
their feelings.
Nursing
Diagnosis
Risk for infection r/t dilated cervix and open uterine
•
vessels

Nursing Interventions
• Evaluate temperature q 4H if normal, and every 2H
if elevated.
• Check vaginal drainage for increased amount and
odor, which may indicate infection.
• Instruct on and encourage perineal care after each
urination and defecation to prevent
contamination.
Nursing
Diagnosis
Acute pain r/t uterine cramping and possible
•
procedures

Nursing Interventions
• Instruct patient on the cause of pain to decrease
anxiety.
• Instruct and encourage the use of relaxation
techniques to augment analgesics.
• Administer pain medication as needed and as
prescribed.
Nursing
Diagnosis
• Knowledge deficit r/t signs and symptoms of
possible complications

Nursing Interventions
• Teach the woman to observe for signs of infection (fever,
pelvic pain, change in character and amount of vaginal
discharge), and advise to report them to provider
immediately.
• Deal with client’s anxiety. Present information out of
sequence, if necessary, dealing first with material that is
most anxiety producing when the anxiety is interfering with
the client’s learning process.
• Teach client of the complications for a mother has
reason to be especially worried about her infant’s
health.
Thank you
Induced abortion
 Definition

Deliberate termination of
pregnancybefore the
viability of the fetus is
calledinduction of
abortion
Elective: if performed for a woman’s
desires

Therapeutic: if performed for reasons of

maintaining health of the mother
 MTP ACT -1971
• The continuation of pregnancy would
involve seroius risk of life or grave injury
to the physical and mental health of the
pregnant women
• There is a substantial risk of the child
being born with serious physical and
mental abnormalities so as to be
handicapped in life
• When the pregnancy caused by rape ,both in
case of major and minor girl and in
mentally imbalance women

• Pregnancy result as a result of contraceptive

failure
 Indication
• To safe the life of the mother
-Cardiac diseases
-Ch.Glomerulonephritis
-Malignant hypertension
-Hyperemesis gravidarum
-Cervical breast malignancy
-DM with retinopathy
-Epilepsy or psychiatric diaseases with
advice of psychiatrist
• Social indications
-unplanned pregnancy with low
socioeconomic status
-pregnancy caused by rape or failure of
contraceptive methods
• Eugenic
-Structural-anencephaly
,chromosomal (down syndrome) or
genetic (hemophilia)
-Teratogenic
drugs(warfarrin)radiation exposure more
than 10 rads in early pregnancy
- rubella infection
 RECOMMENDATIONS
1.Qualified Registered medical practitioner
a) One has assisted at least 25 MTP in
authorized centre and having certificate
b)6 months house surgeon training in OBG
c)Diploma or degree in OBG
2. Termination can only performed in hospitals
established or maintained by Govt or places approved
by Govt
3. Pregnancy can only terminated on the written consent
of the women. Husband's consent is not required
4. Pregnancy in a minor girl (below the age of 18 years )
can not be terminated without the written consent of
the parent or legal guardian.
5.Termination is permitted up to 20 weeks of pregnancy
When the pregnancy exceeds 12 weeks opinion of two
medical practitioners is required
• The abortion has to be performed
confidentially and to be reported to the
director of health services of state in the
prescribed form
 Induced abortion: statistics . . .
• 1,180,000 abortions • 79.7% of women
are reported to the obtaining abortions
CDC in 1997. This are unmarried
is constant since • 21 % of women
1980 obtaining abortions
• 305 abortions/1000 are younger 19 years
live births old
• National abortion • 55.2 % are younger
rate: 20/1000 than 24 years old
women aged 15-44
 Contd…
• 88% of women who • 2.5 % have minor
abort are in the complaints that are
handled in a physicians
first trimester of
office
pregnancy
• <0.5% require additional
• 97% of women
surgery
having first trimester
abortions have no
complications or post
abortion complaints
 Roe vs. Wade 1/22/73
• “We recognize the right of the individual, married or
single, to be free from unwanted governmental
intrusion into matters so fundamentally affecting a
person as the decision whether to bear or beget a
child. That right necessarily includes the right of
a woman to decide whether or not to terminate her
pregnancy.”
 Gestational age and procedure
–50% of abortion performed 8 weeks or
earlier

–12% of abortion performed past 12

weeks

–1.4% of abortion performed past 20

weeks
 First Trimester Abortion
• Early Uterine Evacuation (EUE),
Minisuction
• Menstrual Regulation
• Suction Abortion
• Vacuum Curettage
• Medical Abortion
 Minisuction
• Introduced in 1972 by Karman and Potts
 Surgical techniques for abortion

• Menstrual aspiration(menstrual regulation )

– Aspiration of endometrial cavity using a flexible cannula and syringe within

1-3 weeks after failure to menstruate

– Several points at early stage of gestation

• Woman not being pregnant

• Implanted zygote may be missed by the curette
• Failure to recognize an ectopic pregnancy
• Infrequently, a uterus can be perforated
Dilatation and curettage (D&C)
• Removal of pregnancy
contents by some
mechanical means
• Vacuum most
commonly used
• 12-13 weeks is the
upper limit of
gestational age
• Usually performed in
free standing clinics
 Medical Abortion
• Mifepristone (RU486)
–Analogue of progestin
norethindrone
–Strong affinity for the progesterone
receptor, acting as an antagonist
–A single oral dose given to women 5
weeks or less produces abortion in
 Mifepristone protocol
• Women less than 49 days LMP with
confirmed -hCG
• 600mg mifepristone on day 1
• On day three, return for prostaglandin,
Misoprostil 400 mcg orally
• Patient remain in clinic four hours, during
which time expulsion of pregnancy
usually occurs
Medical Surgical

Private Longer process with

More sense of unclear endpoint
autonomy More pain
More bleeding
“More natural”
Anxiety regarding
Earlier intervention abortion off site
unwanted pregnancy
Medical Surgical

Less skill needed to Increased anxiety re: off site

provide management
Methotrexate also More unscheduled care:
calls, ER visits
treats ectopic Need to guard against
pregnancy unnecessary intervention
Limited to 49 days
LMP
 Second Trimester Termination
• Dilatation and evacuation (D&E)
• Intrauterine injection
of abortifacients
• Prostaglandin vaginal
suppositories
• High dose oxytocin
• Hysterotomy
 D&E
• Mechanical and suction removal of
formed pregnancy after cervical dilation
• Technically more difficult than earlier
suction procedures
• Associated with fewer complications than
instillation and suppository methods
• General anesthesia is not required
• Picture of
laminaria
 Intrauterine injection of
abortifacients
• Prostaglandin, hypertonic saline,
hypertonic urea are introduced by
amniocentesis
• Fetus and placenta are aborted
vaginally
• Osmotic dilators are used to decrease time
to delivery and decrease complications
 Prostaglandin suppositories
20 mg suppositories of PGE2 typically given Prostaglandin F2alpha 250 mg IM q 2 hours
q 3 hours

 Mean time to  Mean time to

induction 13.4 hours, abortion 15-17 hours,
with 90% aborting by with 80% aborting by
24 hours 24 hours
GI side effects: GI side effects:
39% 83%
vomiting, 25% diarrhea vomiting, 71% diarrhea
Fever: temperature Misoprostil (PGE1
elevation of 1 degree c
 High Dose Oxytocin
• As effective as PGE2 when used in
appropriate doses
• Risk of water intoxication
 Hysterotomy
• Surgical method to remove pregnancy
abdominally (mini-cesarean section)
• Other methods are preferred
 Complications -
rates
• Varies as a function of the gestational age
they are performed

–Major complications:
• 0.25% < 7 weeks
• 1% < 12 weeks
• 2% over 12 weeks
 Complications -
Immediate
• Complications of local
anesthetic
• Cervical shock
• Cervical lacerations
• Uterine perforation
• Hemorrhage
 Complications -
Delayed
• Bleeding
–Retained products
• Infection
• Continued pregnancy
–Ectopic

–Intrauterine
•Thank you