ABORTION

z BY : PRIYANKA SADAFULE

1ST YEAR PBBSC STUDENT

SEMINAR
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DEFINITION

 Abortion is the process of partial or complete

separation of the products of conception from the
uterine wall with or without partial or complete
expulsion from the uterine cavity before the age of
viability.
 The age of viability is 28 weeks in india.
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INCIDENCE

 10-20% of all clinical pregnencies.

 75% abortion occurs before the 16th week.

 Rate varies with maternal age, also high in

women with history of past miscarriages.
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ETIOLOGY

 Fetal factors.
 Maternal factors.
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FETAL FACTORS

 GENETIC
 50% of early miscarriages is due to chromosomal abnormalities.

 Numerical defects like trisomy, polyploidy, monosomy.

 Structural defects like translocation, deletion and inversion.

 Multiple pregnancies.
 Degeneration of villi.
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MATERNAL FACTORS

 ENDOCRINE AND METABOLIC FACTORS:

 Luteal phase defect

 Thyroid abnormalities

 Diabetes mellitus

 ANATOMICAL ABNORMALITIES (10-15%)

Cervicouterine factors
 Cervical incompetence and insufficiency

 Congenital malformation of the uterus

 Uterine fibroid

 Intrauterine adhesions.
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 INFECTIONS (5%)
 Viral : rubella, cytomegalo , HIV.

 Parasitic : toxoplasma, malaria,

 Bacterial: ureaplasma, chlamydia.

 IMMUNOLOGICAL DISORDERS (5-10%)

 Autoimmune disease

 All immune disease

 Antifetal antibodies.
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 ENVIRONMENTAL FACTORS

 Cigarette smoking

 Alcohol consumption

 Contraceptive agents

 MATERNAL MEDICAL ILLNESS

 Cyanotic heart disease

 Hemoglobinopathies

 UNEXPLAINED (40-60%) – In majority, the exact cause is unknown.

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TYPES
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SPONTANEOUS ABORTION

 It is defined as the voluntary loss of the

product of conception prior to 28 weeks of
gestation, when the foetus weighs
approximately 1000g or less.
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ISOLATED
THREATENED ABORTION
 Condition in which miscarriage has started but not progressed to
a state from which recovery is impossible.
 CLINICAL FEATURES:
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 The patient having amenorrhea, complains of:
 Slight bleeding per vagina

 Pain: usually painless; there may be mild backache or dull pain in lower
abdomen
 Uterus & cervix feel soft.
 Digital examination revels closed external os.
 Differential diagnosis includes;
 Cervical ectopy

 Polyps or carcinoma

 Ectopic pregnancy

 Molar pregnancy

 USG is diagnostic and pelvic examination is avoided.

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MANAGEMENT AND PROGNOSIS

 Rest : patient should be in bed for few days until bleeding stops.
 Relief of pain : diazepam 5mg BD.
 Investigations include hemoglobin, blood grouping,VDRL, urine
routine and blood glucose. And thyroid test if patient is
suspected thyroid dysfuction.
 If a live fetus is seen in USG, pregnancy is likely to continue in
over 95% cases.
 If pregnancy continues, there is increased frequency of preterm
labour, placenta previa and IUGR.
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INEVITABLE ABORTION
 It is the clinical type of abortion where the changes have
progressed to a state from where continuation of pregnancy is
impossible because product is seen in vagina or protruding
through the os.
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CLINICAL FEATURES

 The patient having the feature of threatened abortion presents

with
 Vaginal bleeding

 Aggravation of colicky pain in the lower abdomen

 Internal examination reveals dilated os through which the

product of conception are felt.
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MANAGEMENT AND PROGNOSIS

 Management is aimed:

 To accelerate the process of expulsion

 To maintain strict asepsis

 If pregnancy <12 weeks, suction evacuation is done.

 If pregnancy >12 weeks, expulsion by oxytocin infusion

 General measures:

 Excessive bleeding is controlled by administering methergine 0.2mg

 Blood loss is corrected by iv fluid therapy and blood transfusion.

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INCOMPLETE ABORTION

 The process of abortion has already taken place, but the entire
products of conception is not expelled and a part of it is left inside the
uterine cavity
 z CLINICAL FEATURES

 History of expulsion of a fleshy mass per vagina;

 Continuation of pain in lower abdomen

 Persistence of vaginal bleeding

 Internal examination reveals

 Uterus smaller than the period of amenorrhea

 Open internal os

 Varying amount of bleeding

 On examination, the expelled mass is found incomplete.

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COMPLICATION

The retained products may cause:

 Bleeding

 Sepsis

 Placental polyp.
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MANAGEMENT:

 Evacuation of the retained products of conceotion (ERCP)

 Early abortion: dilatation and evacuation under analgesia or general
anesthesia is to be done.
 Late abortion: uterus is evacuated under general anesthesia and the
products are removed by ovum forceps or bt blunt curette. In late
cases D&C is to be done to remove the bits of tissues left behind.
 Prophylactic antibiotics are given ; removed materials are subjected to
a histological examination.
 Medical management; tab misoprostol 200ug is used vaginally every
4 hours.
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COMPLETE ABORTION

 When the products of conception are completely expelled from

the uterus, it is called complete abortion.
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CLINICAL FEATURES

 There is history of expulsion of a fleshy mass per vagina followed by

 Subsidence of abdominal pain

 Vaginal bleeding becomes trace or absent.

 Internal examination reveals;

 Uterus smaller than the period of amenorrhea

 Cervical os is closed

 Bleeding is trace.

 Transvaginal sonography confirms the uterus is empty.

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MISSED ABORTION

 The fetus is dead and retained passively inside the uterus for a
variable period.
 It is diagnosed when there is a fetus with a crown rump length of
5mm without a fetal heart.
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CLINICAL FEATURES:

 The patients usually presents with features of

threatened miscarriage followed by;
 Brown discharge from the degeneration of placental tissue is seen

 Uterus becomes smaller in size

 Cervix feels firm with closed internal os

 Nonaudibility of the fetal heart sound even with doppler ultrasound

 Immunological test for pregnancy becomes negative.

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COMPLICATIONS

 Retaining the products for long time can lead to sepsis

 DIC ( disseminated intravascular coagulation)
 Very rare in gestations exceeding 16 weeks.
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MANAGEMENT

 A coagulation profile is done because of the risk of

hypofibrinogenemia.
 Uterus is less than 12 weeks; 1st trimester
 Evacuation of uterus by dilation and curettage.

 Uterus more than 12 weeks; 2nd trimester

 Administration of prostaglandins intramuscularly.
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RECURRENT
HABITUAL ABORTION

 Recurrent miscarriages is defined as a sequence of three or

more consecutive spontaneous abortion.
 Seen in ~ 1% of all women
 Risk increases with each successive abortion
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ETIOLOGY
 FIRST TRIMESTER ABORTION:
 Genetic factors:

 Parental chromosomal abnormalities

 The most common abnormality is a balanced translocation causing

early miscarriage or live birth with congenital malformations.
 Endocrine and metabolic:

 Poorly controlled diabetic patients

 Presence of thyroid auto antibodies

 Luteal phase defect

 Hypersecretion of leutinizing hormone(eg.PCOD)

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 Infection:
 Infection in the genital tract-(transplacental fetal infection)

 Syphilis

 Inherited thrombophilia

 Protein c deficiency, protein s deficiency, prothrombin gene mutation

 Immunological cause:
 Antiphospholipid antibodies presence in mother

 Presence of lupus
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 SECOND TRIMESTER MISCARRIAGE:

 Anatomic abnormalities –
a. congenital – defect in the Mullerian duct fusion(eg. Unicornuate,
bicornuate, septate or double uterus)
b. Acquired – intrauterine adhesions, uterine fibroids and
endometriosis, cervical incompetence
c. Incompetence of cervix.
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CLINICAL FEATURES

History – repeated mid trimester painless cervical dilatation

 Escape of liquor amnii

 Painless expulsion of content.

 Internal examination

 Funnelling of internal os seen in hysterosalpingography.

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MANAGEMENT

 Surgical management –
 cervical cerclage by mcdonalds method or Shirodkar’s method
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 POSTOPERATIVE CARE:
 Bed rest for atleast 2-3 days

 Progesterone supplementation

 Education to avoid sexual intercourse

 REMOVAL OF STITCH:
 Stitch should be removed at 37th week, or earlier if labor pain
starts or features of abortion appears.
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COMPLICATIONS

 Uterine rupture or cervical tear

 Slipping or cutting through the suture
 Chorioamnionitis (bacteria ascending to amniotic fluid)
 Cervical scarring and dystocia requiring cesarean delivery.
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INDUCED ABORTION

 Induced abortion is deliberate interruption of an intact

pregnancy.
 Induced abortion are performed legally in india since
the medical termination pregnancy (MTP)ACT of
1971 (revised in 1975)
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MEDICAL TERMINATION OF
PREGNANCY

 Legal abortion is the delibrate induction of abortion

prior to 20 weeks gestation by a registered medical
practioner in the interest of mother’s life.
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PROVISIONS FOR MTP UNDER THE
MTP ACT

 The continuation of pregnancy would involve serious risk of life

or great injury to physical and mental health.
 Substitional risk of abnormality so as to born baby handicapped.
 The pregnancy is the result of rape.
 Failure of contraceptives.
 Where there are actual or reasonably foreseeable environments
(social or economic).
z INDICATION FOR MTP

 THERAPEUTIC :
 Deteriorating health due to pulmonary tb

 Cardiac disease grade with history od decompensation

 Chronic glomerulonephritis

 Malignant hypertension

 Intractable hyperemesis gravidarum

 Cervical malignancy

 DM or retinopathy

 Psychiatric illness
z SOCIAL :

 Parous women having unplanned pregnancy with low socio economic

status
 Pregnancy caused by rape

 Pregnancy due to failure of contraceptives

 EUGENIC :
 Risk of baby to born with physical and mental abnormalities include;

 Inherited chromosomal and gene disorders

 Exposure to teratogenic drugs or radiation

 Rubella infection in 1st trimester

 One or both parents being mentally defective

 Congenital malformation for siblings.

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METHODS OF TERMINATION

 IN FIRST TRIMESTER :
 Menstrual regulation –aspiration of uterine cavity and extraction of
endometrium within 14 days of missed periods.
 Suction evacuation and curettage –
 Dilation and evacuation
 Pharmacological methods –
 Mifepristone

 methotrexate
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 IN SECOND TRIMESTER (upto 20 weeks)

 Intrauterine instillation of hypertonic saline may be of intra
amniotic or extra-amniotic type.
 Extrauterine instillation
 Prostaglandins
 Oxytocin
 Hysterectomy
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SEPTIC ABORTION

 It is an abortion characterized by infection of the products of

conception and the uterus.
 This condition is most commonly a complication of induced or
incomplete abortion
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CAUSES

 Criminal abortion, which is inexpert attempts at termination of

pregnancy by passing sticks, catheters, pastes, soap solution
into the uterine cavity.
 Attempt at induced abortion by an untrained person without the
use of aseptic precautions.
z CLINICAL FEATURES
 Pyrexia
 Headache
 Nausea
 Foul smell of discharge per vagina
 Tenderness in lower abdomen
 On internal examination
 Infection in uterine cavity and tubes
 Adnexal masses
 Pelvic absess
 Septicemia
 Gas gangrene of uterus
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MANAGEMENT

 MILD CASES :
 Broad spectrum antibiotics

 Uterus is evacuated

 SEVERE CASES
 Vigorous iv infusion with crystalloid

 Oxygen given by nasal cannula

 Medication – combination of ampicillin, gentamycin,

metronidazole.
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THANK YOU