Pelvic Pain Acute

FIRST TRIMESTER
VAGINAL BLEEDING
BY DR. FATOUMA
BY DR. FATOUMA
4/05/15
4/05/15
INTRODUCTION
Vaginal bleeding is a common event at all stages of
pregnancy. The source is virtually always maternal, rather
than fetal. Bleeding may result from disruption of blood
vessels in the decidua (i.e., pregnancy endometrium) or from
discrete cervical or vaginal lesions. The clinician typically
makes a provisional clinical diagnosis based upon the
patient's gestational age and the character of her bleeding
(light or heavy, associated with pain or painless, intermittent
or constant). Laboratory and imaging tests are then used to
confirm or revise the initial diagnosis.
FIRST TRIMESTER BLEEDING
Overview ;
Vaginal bleeding is common in the first trimester, occurring
in 20 to 40% of pregnant women. It may be any combination
of light or heavy, intermittent or constant, painless or painful.
 The four major sources of non traumatic bleeding in

early pregnancy are:
1. Ectopic pregnancy
2. Miscarriage (threatened, inevitable, incomplete, complete)
3. Implantation of the pregnancy
4. Cervical, vaginal, or uterine pathology (e.g.,
polyps, inflammation/infection, trophoblastic disease)
Contents
 Definition
 Types of abortion
 Causes
 Management
 Complications
 Post abortal care
ABORTION
DEFINITION:
Abortion can defined as termination of pregnancy before 20
weeks of gestation or less than 500 g birth weight, or less
than 25 cm without medical or mechanical intervention.
Termination of pregnancy, either spontaneously or

intentionally
Definition vary according to state laws for reporting

abortions, fetal deaths, and neonatal deaths
ABORTION
DEFINITION:
The current WHO definition is termination of pregnancy
before 22 wks or when the fetus weigh 500 g or less without
medical or mechanical intervention.
Abortion is important as it contributes to approximately 50%

of maternal death !
Abortion is characterized by vaginal bleeding and abdominal

pain that is suprapubic, involves cramps, and varies in
intensity it is classified as:
I. Spontaneous
II. Induced
SPONTANEOUS ABORTION
Abortion occurring without medical or mechanical means to

empty the uterus is referred to as spontaneous
Another widely used term is miscarriage

Pathology
Hemorrhage into the decidua basinalis, followed by
necrosis of tissues adjacent to the bleeding
If early, the ovum detaches, stimulating uterine

contractions that result in its expulsion .
Gestational sac is opened , fluid surrounding a small

macerated fetus or alternatively no fetus is visible →
blighted ovum
Pathology
In later abortion, the retained fetus may undergo maceration
1. The skull bones collapse, the abdomen distends with
blood-
2. stained fluid, and the internal organs degenerate
3. The skin softens and peels off in utero or at the slightest
tough
When amniotic fluid is absorbed, the fetus may become
compressed and desiccated → fetal compressus
The fetus become so dry and compressed that it resembles

parchment - a fetus papyraceous
Etiology
More than 80 percent of abortions occur in the first 12 weeks

of pregnancy
At least half result from chromosomal anomalies
After the first trimester, both the abortion rate & the incidence
of chromosomal anomalies decrease
Spontaneous abortion
 Etiology
 The risk of spontaneous abortion increases with parity as

well as with maternal and paternal age
 The frequency of abortion increases from 12% in women

younger than 20 years to 26% in those older than 40 years
 If a woman conceives within 3 months following a term

birth
→ incidence of abortion ↑
Spontaneous abortion
 Etiology
 The exact mechanism responsible for abortion are not apparent
 In the first 3 months of pregnancy

Death of the embryo or fetus nearly always precedes
spontaneous expulsion of the ovum
Finding of the cause of early abortion involves ascertaining
the cause of fetal death
 In subsequent months
The fetus frequently does not die before expulsion
 Other explanations for its expulsion should be sought
Spontaneous abortion –
Fetal factors
I. Abnormal zygotic development
 Early spontaneous abortion commonly display a developmental
abnormality of the zygote, embryo, early fetus, or placenta
 1000 spontaneous abortions analyzed by Hertig and Sheldon
 Half demonstrated degenerated or absent embryos, that is,

blighted ova
Fetal factors
A. Abnormal number of chromosomes
a) Aneuploid abortion
 Approximately 50 to 60% of embryos and early fetuses that are

spontaneously aborted contain chromosomal abnormalities
accounting for most of early pregnancy wastage
 Jacobs and Hassold (1980)
 95 % of chromosomal abnormalities
 d/t maternal gametogenesis error
 5 % → d/t paternal error

T9-1
Table 2. Chromosomal Findings in Abortuses
.
Incidence in Percent
Chromosomal Studies Kajii et al. Eiben et al. Simpson

(1980) (1990) (1980
Normal (euploid): 46,XY and 46,XX 46 51 54
Abnormal (aneuploid)
Autosomal trisomy 31 31 22
Monosomy X (45,X) 10 5 9
Triploidy 7 6 8
Tetraploidy 2 4 3
Abnormal structure 2 2 2
Double or triple trisomy 2 0.9 0.7

Spontaneous abortion - Fetal factors
Aneuploid abortion - Autosomal trisomy
 The most frequently identified chromosomal anomaly associated

with first-trimester abortions
 Most trisomies result from isolated non-disjunction , balanced

structural chromosomal rearrangements are present in one partner
in 2 to 4 percent of couples with a history of recurrent abortions
 Autosomes 13, 16, 18, 21, and 22 – most common

 Monosomy X
 The second frequent chromosomal abnormality

 Usually results in abortion
 Much less frequently in liveborn female infant (Turner syndrome)
 Triploidy
 Associated with hydropic placental (molar) degeneration

 Incomplete (partial) hydatidiform moles may contain triploidy or
trisomy for only chromosome 16
Tetraploid abortuses
 Rarely are liveborn and most often are aborted early in gestation
Euploid abortion
 Abort later in gestational than aneuploid
 Three fourths of aneuploid abortions occurred before8 weeks
 Euploid abortions peak at about 13 weeks
 The incidence of euploid abortions increased dramatically after maternal age exceeded 35
years

B. Chromosomal structural abnormalities
 Identified only since the development of banding

techniques, infrequently cause abortion
Maternal factors
II. Infections
 According to the American College of Obstetricians and
Gynecologists (2001),infection are an uncommon causes
of abortion in human
 Listeria monocytogenes
 Chlamydia trachomatis
 Mycoplasma hominis
 Ureaplasma urealyticum
 Toxoplasma gondii causes abortion in humans remains
inconclusive
Spontaneous abortion – Maternal factors
III. Chronic debilitating diseases
 In early pregnancy, fetuses seldom abort secondary to

chronic wasting disease such as tuberculosis or
carcinomatosis
 Celiac sprue
 Cause both male and female infertility and recurrent
abortions
IV. Endocrine abnormalities

 Hypothyroidism
 Iodine deficiency associated with excessive miscarriages
 Thyroid autoantibodies → incidence of abortion↑
 Diabetes mellitus
 The rates of spontaneous abortion & major congenital
malformations
 Poor glucose control → incidence of abortion↑
 Progesterone deficiency
 Luteal phase defect
 Insufficient progesterone secretion by the corpus luteum or
placenta
 Poor glucose control → incidence of abortion↑
V. Nutrition
 Dietary deficiency of any one nutrients → not important cause
 Drug use and environmental factor

 Tobacco
 ↑ Risk for euploid abortion
 More than 14 cigarettes a day → the risk twofold greater ↑
 Alcohol
 Spontaneous abortion & fetal anomalies → result from frequent alcohol use during
the first 8 weeks of pregnancy
 Drinking twice a week → abortion rates doubled ↑
 Drinking daily → abortion rates tripled ↑
 Caffeine
 At least 5 cups of coffee per day → slightly increased risk of abortion
VI. Drug use and environmental factor

 Radiation
 In sufficient doses → abortifacient
 Contraceptives
 When intrauterine devices fail to prevent pregnancy → abortion ↑
 Environmental toxins
 Anesthetic gases : exact fetal risk of chronic maternal exposure is
unknown
 Arsenic, lead, formaldehyde, benzene, ethylene oxide → abortifacient
 Video display terminal & accompanying electromagnetic fields
short waves & ultrasound do not increase the risk of abortion
VII. Immunological factors – autoimmune factors

 Recurrent pregnancy loss patients : 15%
 Antiphospholipid antibody : most significant
 LCA (lupus anticoagulant), ACA (anticardiolipin Ab)
Reduce Prostacyclin production
→ facilitating thromboxane dominant milieu → thrombosis
 Prostacyclin : produced by vascular endothelial cell
→ potent vasodilator & inhibit platelet aggregation
 Thromboxane A2 : produced by platelets
→ vasoconstrictor & platelet aggregator
 Strong association with
 Decidual vasculopathy , placental infarction, fetal growth restriction
Early-onset preeclampsia, recurrent abortion, fetal death
 Immunological factors – autoimmune factors
 Therapy of antiphopholipid antibody syndrome

: low dose aspirin, prednisone, heparin, intravenous Ig
→ affect both immune & coagulation system
→ counteract the adverse action of antibodies
 Immunological factors – alloimmune factors
 Allogeneity
 Genetic dissimilarities between animals of the same species
 Human fetus is allogenic transplant tolerated by mother
 Several test for diagnosis of alloimmune factors

 Maternal & paternal HLA comparison
 Maternal serum test for blocking antibodies
: blocking antibodies to paternal antigens
: ig G origin
 Maternal serum test for antipaternal antibodies
: cytotoxic antibodies to paternal leukocyte
VIII. Inherited thrombophilia

 Many studies of aggregated thrombophilia
→ excessive recurrent abortions
IX. Laparatomy
 Surgery performed during early pregnancy
→ no evidence of tncreased abortion

 Peritonitis increases the likelihood of abortion
X. Physical trauma
 Major abdominal trauma → abortion↑
XI. Uterine defects – acquired uterine defects

 Uterine leiomyoma : usually do not cause abortion
 Placental implantation over or in contact with myoma
→ placental abruption, abortion, preterm labor ↑
→ location is more important than size
 Uterine synechiae (Asherman syndrome)

 Partial or complete obliteration of the uterine cavity by adherence
of uterine wall
 Cause : destruction of large areas of endometrium by curettage
→ insufficient endometrium to support implantation &
menstruation
→ recurrent abortion, amenorrhea, hypomenorrhea
 Uterine defects – acquired uterine defects
 Diagnosis of uterine synechiae

 Hysterosalpingogram → characteristic multiple filling defects
 Hysteroscopy → most accurate & direct diagnosis
 Treatment of uterine synechiae

 Lysis of adhesions via hysteroscopy
 Prevention of adherence : IUD
 Promotion of endometrial proliferation
: Continuous high-dose estrogen (60-90 days)
 Uterine defects – developmental uterine defects
 Consequence of abnormal mullerian duct formation or fusion

 Spontaneously
 Induced by in utero exposure to DES (diethylstilbestrol)
XII. Incompetent cervix
 Painless dilatation of cervix in the 2nd or early in the 3rd trimester
→ prolapse & ballooning of membranes into vagina

→ rupture of membrane & expulsion of immature fetus
 Unless effectively treated, tends to repeat in each pregnancy
 Diagnosis in nonpregnant women

 Hysterography
 Pull-through techniques of inflated Foley catheter balloons
 Acceptance without resistance at the internal os of specifically sized cervical
dilators
 The use of transvaginal ultrasound in pregnant women

 Cervical length - shortening
 Funneling
 Incompetent cervix – Etiology
 Previous trauma to the cervix

 Dilatation & curettage
 Conization
 Cauterization
 Abnormal cervical development

 Exposure to DES in utero
 Incompetent cervix – Treatment
 The operation is performed to surgically

 Reinforcement of weak cervix by some type of purse string suture
( Cerclage )
 Prophylactic surgery : generally performed between 12 & 16weeks

 Should be delayed until after 14 weeks’ gestation
→ Early abortion due to other factors will be completed
 The more advanced the pregnancy, the more likely the risk that
surgical intervention stimulate preterm labor or membrane rupture
 Usually do not perform after about 23 weeks
 Incompetent cervix – Preoperative evaluation
 Sonography
: Confirm living fetus & exclude major fetal anomalies
 Cervical cytology
 Cultures for gonorrhea, chlamydia, group B streptococci

 Obvious cervical infections → treatment is given
 For at least a week before & after surgery → sexual
intercourse should be restricted
 Incompetent cervix – Cerclage procedures
 Types of operations commonly used
 McDonald
 Modified Shirodkar
→ 85~90% success rate

 Incompetent cervix – Transabdominal cerclage
 Requires laparatomy for

 Placement of cerclage at uterine isthmus level
 Cerclage removal, delivery, or both
 Indications
 Anatomical defects of cervix
 Failed transvaginal cerclage
 Incompetent cervix – Complications
 High incidence when performed much after 20 weeks

 Membranes ruptures
 Chorioamnionitis
 Intrauterine infection
 Urgent removal of suture

 Operation fails
 Signs of imminent abortion or delivery
Spontaneous abortion – Paternal factors
 Little is known in the genesis of spontaneous abortion
 Chromosomal translocations in sperm can lead to abortion

The categories of spontaneous abortion are:

a. Threatened abortion
b. Inevitable abortion
c. Incomplete abortion
d. complete abortion
e. Missed abortion
f. Recurrent spontaneous abortion
g. Septic abortion
THREATENED ABORTION
Definition:
Threatened abortion is defined as vaginal bleeding
occurring in the first 20 weeks of pregnancy without
cervical dilation, passage of tissue or rupture of the
membranes, indicating that spontaneous abortion may
occur. Diagnosis is by clinical criteria and
ultrasonography. Treatment is usually observation for
threatened abortion and, if spontaneous abortion has
occurred or appears unavoidable, uterine evacuation.
THREATENED ABORTION
Definition:
Any bloody vaginal discharge or bleeding during 1st half of pregnancy.
Bleeding is frequently slight, but may persist for days or weeks
Frequency
Extremely common (one out of four or five pregnant women)
Prognosis
Approximately ½ will abort
Risk of preterm delivery, low birth weight, Perinatal death↑
Risk of malformed infant does not appear to be increased
THREATENED ABORTION
Symptoms
Threatened abortion Presents with:

1. cramping/lower abdominal pain
2. light PV bleeding (blood exits from the cervical os even though it
is closed)
Usually bleeding begins first
Cramping abdominal pain follows a few hours to several
days later
Presence of bleeding & pain
→ Poor prognosis for pregnancy continuation
•O/E
-soft uterus that corresponds with dates

-closed cervix
THREATENED ABORTION
Treatment
1. Bed rest & acetaminophen-based analgesia
2. Progesterone (IM) or synthetic progestational agent (PO or IM)

 Lack of evidence of effectiveness
 Often results in no more than a missed abortion
3. D-negative women with threatened abortion

 Probably should receive anti-D immunoglobulin
4. slight bleeding persists for weeks

Vaginal Sonography
Serial serum quantitative hCG
Serum progesterone
→ can help ascertain if the fetus is alive & its location
THREATENED ABORTION
Treatment
Vaginal Sonography
1. Gestational sac(+) & hCG < 1000mIU/ml
→ gestation is not likely to survive
→ If any doubt(+), check the serum hCG level at intervals of 48hrs
→ if not increase more than 65%, almost always hopeless
2. Serum progesterone value < 5 ng/ml

→ dead conceptus
After death of conceptus

Uterus should be emptied
→ examination of all passed tissue whether the abortion is complete
Ectopic pregnancy should be considered if gestational sac or fetus are not

identified
INEVITABLE ABORTION ABORTION
Definition:
Inevitable abortion: is defined as a threatened abortion

with a dilated cervical os (no expulsion of products, but
bleeding and dilation of the cervix) such that a viable
pregnancy is unlikely. Menstrual-like cramps usually
occur.
Inevitable abortion is manifested by prolonged , profuse

bleeding with an open cervical os
Categories of spontaneous abortion
Inevitable abortion
 Gross rupture of membrane, evidenced by leaking amniotic fluid, in the

presence of cervical dilatation, but no tissue passed during 1st half of
pregnancy
 Placenta (in whole or in part) is retained in the uterus

→ Uterine contractions begin promptly or infection develops
 The gush of fluid is accompanied by bleeding, pain, or fever,

abortion should be considered inevitable
INEVITABLE ABORTION ABORTION
Inevitable abortion Presents with:

-Cramping/ lower abdominal pain
-heavy PV bleeding
O/E
-tender uterus corresponds to dates
-dilated cervix
-POC often felt thru the cervical os
INCOMPLETE ABORTION ABORTION
Definition:
Incomplete abortion is characterized by a partial passage
of tissue through the cervix os and Presents with
cramping, bleeding, passage of tissue, and dilated internal
os with tissue in the vagina or endocervical canal. Profuse
bleeding, orthostatic dizziness, syncope, and postural
pulse, and blood pressure changes may occur
Complete or incomplete abortion
 Complete abortion
 Following complete detachment & expulsion of the conceptus
 The internal cervical os closes
 Incomplete abortion
 Expulsion of some but not all of the products of conception during
1st half of pregnancy
 The internal cervical os remains open & allows passage of blood
 The fetus & placenta may remain entirely in utero or may partially
extrude through the dilated os
→ Remove retained tissue without delay
INCOMPLETE ABORTION ABORTION
Incomplete abortion:
Partially expulsion of some but not all POCs before 20 weeks gestation).
Incomplete abortion Presents with:

-painful uterine contractions
-heavy bleeding
O/E
-uterus smaller than dates
-dilated cervix
-partial expulsion of POC
COMPLETE ABORTION ABORTION
Definition:
Complete abortion is characterized by a complete
passage of tissue (Complete expulsion of all POCs before
20 weeks gestation), resulting in resolution of symptoms.
Complete abortion is diagnosis when complete passage of
products of conception has occurred. The uterus is well
contracted and cervical os may be closed.
COMPLETE ABORTION ABORTION
Complete abortion Presents with:

-Hx of heavy PV bleeding followed by expulsion of POC then light
bleeding.
O/E
-uterus smaller than dates
-closed cervix.
MISSED ABORTION ABORTION
Definition:
Missed abortion is the death of the embryo or foetus
before 20 weeks with complete retention of POCs
means without the onset of the labor or passage of
tissue and often without any bleeding; these often
proceed to complete abortions in 1—3 weeks but
occasionally are retained much longer. Sonogram
shows finding of a nonviable pregnancy without
vaginal bleeding, uterine cramping, or cervical
dilation.
Missed abortion
 Retention of dead products of conception in utero for several weeks
 Many women have no symptoms except persistent amenorrhea
 Uterus remain stationary in size, but mammary changes usually

regress → uterus become smaller
 Most terminates spontaneously
 Serious coagulation defect occasionally develop after prolonged

retention of fetus
MISSED ABORTION ABORTION
1. The embryo/fetus dies but doesn’t get expelled

from the uterus.
2. Pt presents with slow progressive bleeding

followed by caesation of pregnancy symptoms.
3. Examination reveals a firm uterus smaller than GA

and a closed cervix.
.
Recurrent abortion
 Definition : Three or more consecutive spontaneous abortions
 Clinical investigation of recurrent miscarriage

 Parental cytogenetic analysis
 Lupus anticoagulant & anticardiolipin antibodies assays
 Postconceptional evaluation
 Serial monitoring of ß–hCG from missed mens period
 ß–hCG>1500mIU/ml → USG
 Maternal serum α-fetoprotein assessment (GA16-18wks)
 Amniocentesis → fetal karyotype
 Prognosis
 Depends on potential underlying etiology & number of prior losses
SEPTIC ABORTION
Definition:
Septic abortion is serious uterine infection during or shortly
before or after an abortion. Septic abortions usually result
from induced abortions done by untrained practitioners using
nonsterile techniques; they are much more common when
induced abortion is illegal. Typical causative organisms
include:
Escherichia coli
 Enterobacter aerogenes
Proteus vulgaris
haemolytic streptococci
staphylococci, and
some anaerobic organisms (e.g., Clostridium perfringens).
SEPTIC ABORTION
Septic abortion is characterized by abortion symptoms along

with fever and sepsis secondary to infection of the uterine
content.
Induced abortion
 The medical or surgical termination of pregnancy before

the time of fetal viability
 Therapeutic abortion
 Termination of pregnancy before of fetal viability for the

purpose of saving the life of the mother.
INDUCED ABORTION ABORTION
1. Interfered pregnancy – usually done when the pregnancy is
unwanted/unplanned or when it endangers the life of the
woman.
2. Can be done surgically or medically depending on the GA,

skills and availability of appropriate equipment.
3. Unsafe abortion is performed either by persons lacking

necessary skills or in an environment lacking minimal medical
standards or both usually ending in septic abortion.
4. Induced abortion is ILLEGAL in many country such as

Somaliland.
Induced abortion
 Indication
 Continuation of pregnancy may threaten the life of women or

seriously impair her health
 Persistent heart disease after cardiac decompensation
 Advanced hypertensive vascular disease
 Invasive carcinoma of the cervix
 Pregnancy resulted from rape or incest
 Continuation of pregnancy is likely to result in the birth of child

with severe physical deformities or mental retardation
Induced abortion
 Elective (voluntary) abortion
 Interruption of pregnancy before viability at the request of the women,

but not for reasons of impaired maternal health or
fetal disease
 Counseling before elective abortion
 Continued pregnancy with its risks & parental responsibilities

 Continued pregnancy with its risks & its responsibilities of arranged
adoption
 The choice of abortion with its risks
Surgical techniques for abortion
 Dilatation and curettage
 Performed first by dilating the cervix & evacuating the product of

conception
 Mechanically scraping out of the contents (sharp curettage)
 Vacuum aspiration (suction curettage)
 Both
 Before 14 weeks, D&C or vacuum aspiration should be performed
 After 16 weeks, dilatation & evacuation (D&E) is performed

 Wide cervical dilatation
 Mechanical destruction & evacuation of fetal parts
 Dilatation and curettage
 Hygroscopic dilators
: swell slowly & dilate cervix → cervical trauma can be minimized
 Laminaria tents
: stem of brown seaweed ( Laminaria digitata or japonica)
→ drawing water from proteoglycan complexes of cervix
→ dissociation allow the cervix to soften & dilate
 Insertion technique : tip rests just at the level of internal os
 Usually after 4-6hours, laminaria dilate the cervix sufficiently to
allow easier mechanical dilation & curettage
 May cause cramping pain
→ easily managed with 60 mg codeine every 3-4 hours
 Technique for dilatation & curettage
 Remove laminaria → Uterus is sounded carefully to
 Identify the status of the internal os
 Confirm uterus size & position
 Further dilation of cervix with Hegar dilator

 Complications : uterine perforation
 2 important determinants
 Skill of the physician
 Position of the uterus (retroverted)
 Small defects by uterine sound or narrow dilator

→ often heal without complication
 Suction & sharp curettage
→ Considerable intra-abdominal damage risk↑
→ Laparotomy to examine abdominal content (safest action)
 Other complications – cervical incompetence or uterine synechiae

 Menstrual aspiration
 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
 Laparatomy
 Abdominal hysterectomy or hysterectomy
 Indications
 Significant uterine disease
 Failure of medical induction during the 2nd trimester

Medical induction of abortion
 Early abortion
 Outpatient medical abortion is an acceptable alternative

to surgical abortion in women with pregnancies of less
than 49 days’ gestation
(ACOG, 2001b)
 Three medications for early medical abortion

 Antiprogestins mifepristone
 Antimetabolite Methotrexate
 Prostaglandin Misoprostol
Medical induction of abortion _ 2 nd
trimester abortion
 Oxytocin
 Successful induction of 2nd trimester abortion is possible with high doses of

oxytocin administered in small volumes of IV fluids
 Satisfactory alternatives to PG E2 for midtrimester abortion
 Laminaria tents inserted the night before

 Chance of successful induction is greatly enhanced
 Prostaglandins
 Used extensively to terminate pregnancies, especially in the 2 nd T

 PG E1, E2, F2α
 Technique
: Can act effectively on the cervix & uterus (86~95% effectiveness)
 Vaginal prostaglandin E2 suppository & prostaglandin E1
(misoprostol)
 As a gel through a catheter into the cervical canal & lowermost uterus
 Injection into the amnionic sac by amniocentesis
 Parenteral injection
 Oral ingestion
 Intra-amnionic hyperosmotic solutions
 20-25% saline or 30-40% urea injected into amnionic sac
→ stimulate uterine contraction & cervical dilatation
 Action mechanism : prostaglandin mediated ?
 Complications of hypertonic saline
 Death
 Hyperosmolar crisis (early into maternal circulation)
 Cardiac failure
 Septic shock
 Peritonitis
 Hemorrhage
 DIC
 Water intoxication
 Hyperosmotic urea : less likely to be toxic
 Antiprogesterone RU 486
 Oral agent used alone in combination with oral PG to effect
abortions in early gestation
 High receptor affinity for progesterone binding site
→ Block progesterone action
 Abortion rate
 Single 600mg dose prior 6 weeks → 85%
 Addition of oral, vaginal or injected PG → over 95%
 If given within 72 hours
 Also highly effective as emergency postcoital contraception
 Progressively less effective after 72 hours
 Side effects
 Nausea, vomiting, & gastrointestinal cramping
 Major risk → hemorrhage is a risk if abortion is incomplete
 Epostane
 3ß-hydroxysteroid dehydrogenase inhibitor

→ blocks the synthesis of endogenous progesterone
 Frequent side effect – nausea
 Hemorrhage is a risk if abortion is incomplete

Consequences of elective abortion
 Maternal mortality
 Legally induced abortion
 Relative safe during the first 2 months of pregnancy

( 0.6/100,000 procedures)
 Doubled for each 2 weeks of delay after 8 weeks’ gestation

 Impact on future pregnancies
 Fertility : not altered by an elective abortion
 Vacuum aspiration for a first pregnancy

: Do not increase the incidence of
 2nd trimester spontaneous abortions
 Preterm delivery
 Ectopic pregnancy
 LBW infants
INDUCED ABORTION ABORTION
Induced abortion, subsequent to an induced abortion, pelvic

pain can occurs secondary to:
a) Incomplete abortion
b) Septic abortion
 Impact on future pregnancies
 Dilatations & curettage for a first pregnancy

: Increased risks for
 Ectopic pregnancy
 2nd trimester spontaneous abortions
 LBW infants
 Multiple elective abortion :

 Not increased the incidence of preterm delivery & LBW infants
 Placenta previa
→ increased following multiple sharp curettage abortion
procedures
 Septic abortion
 Most often associated with criminal abortion
 Metritis is usual outcome, but parametritis, peritonitis, endocarditis,

and septicemia may all occur
 Management
 Prompt evacuation of products of conception
 Broad-spectrum IV antimicrobials
Resumption of ovulation after abortion
 Ovulation may resume as early 2 weeks after an abortion
 Therefore, if pregnancy is to be prevented,

effective contraception should be initiated soon after
abortion
Etiology of Abortion
1. Causes of abortion Genetical/x’ chromosomal malformation of the zygote (e.g. molar
pregnancy)
2. Immunological factors (e.g. anti-phospholipid Ab, antinuclear Ab)
3. Infections (TORCHES, malaria, HIV, genital tract infections)
4. Uterine anomalies (septate uterus, bicornuate uterus, unicornuate uterus, cervical

incompetence)
5. General dxs of the mother (diabetes, HT, cardiac dxs)
6. Endocrine disorders (e.g. luteal phase insufficiency)
7. Others; trauma, drugs, emotional disturbance, etc.
8. In the majority cause is unknown.

MANAGEMENT OF ABORTION
Depends on type of abortion and GA. It becomes an

emergency when it is incomplete, septic, or c severe
hemorrhage.
Threatened abortion
-take proper hx
-do proper PE and make diagnosis
-give simple analgesics, avoid strenuous activities + sexual
intercourse and encourage bed rest
.
MANAGEMENT OF INEVITABLE ABORTION
1. Take proper hx and PE to confirm dx.
2. If GA is less than 12 wks do manual vacuum aspiration of the

uterus (MVA)
3. If GA is > 12 wks await spontaneous expulsion of POC the

MVA.
4. Some times augmentation with Oxytocin is necessary to

speed up the process.
5. Counseling before and after the procedure is very important.

.
MANAGEMENT OF INCOMPLETE
ABORTION
a. Hx and proper PE are mandatory.
b. Some of these pts come in shock 2° severe bleeding.
c. Act fast, put iv line & give NS or Ringers lactate, take blood
for grouping and x-matching & prepare blood for BT.
d. Do MVA if GA is < 12 wks, simple curettage if GA is > 12.

Counseling and reassurance – very important.
.
MANAGEMENT OF COMPLETE ABORTION
A. Take proper hx & PE to confirm dx.
B. Evacuation of the uterus is usually not necessary.
C. Observe for heavy bleeding or LAP
D. Counseling and follow-up.

MANAGEMENT OF MISSED ABORTION
A. Eventually they are all expelled spontaneously.
B. Once the dx has been made evacuation of the uterus must be

done by dilation & curettage.
C. Its important to check bleeding indices as this condition may

complicate to DIC
SEPTIC ABORTION
1. Septic abortion is characterized by abortion symptoms along

with fever and sepsis secondary to infection of the uterine
content.
2. Septic abortion Results from unsafe abortion, prolonged

retention of POC, incomplete or unsterile evacuation of the
uterus.
3. Symptoms include; fever, abdominal pain, foul smelling PV

discharge & PV bleeding.
4. Signs; high temp, high PR, abdominal tenderness, foul

smelling PV discharge, shock, confusion, hypothermia,
jaundiced or oliguric.
MANAGEMENT OF SEPTIC ABORTION
Suspect bowel, uterine or vaginal injury if the pt presents with the
following;
1. -Cramping/abdominal pain.
2. -rebound tenderness.
3. -abdominal distension
4. -rigid (tense and hard) abdomen.
5. -shoulder pain
6. -nausea and vomiting.
MANAGEMENT OF SEPTIC ABORTION
 Treatment consist s of obtaining appropriate cultures., performing
dilatation and evacuation, and instituting intravenous broad spectrum of
antibiotics.
1. Act fast, take hx & do PE.
2. Give IVF depending on the degree of shock.
3. Take blood for group & x-matching, Hb, WBC, platelet count, serum urea
& creatinine, endocervical swab for c/s
4. Give IV broad spectrum antibiotics e.g. cephalosporins and

metronidazole.
5. Evacuate the uterus under GA after initiating antibiotics and resuscitation.
6. Do a laparatomy if injury to internal organs is suspected.

COMPLICATIONS OF ABORTION
1. Severe bleeding-anemia-shock-renal failure

2. Sepsis-septicaemia-PID-infertility-ectopic
pregnancy.
3. Depression-marital disharmony
4. BT may predispose pt to HIV, hepatitis
5. Perforation of pelvic organs-peritonitis.
POSTABORTAL CARE
1. Importance…………15% of pregnancy are aborted
2. Counseling before discharge on what happened, signs of

recovery/complications, resume of menses and intercourse
etc
3. Counsel and provide contraception; couple counseling

encouraged.
4. Follow up visits – assess recovery, feedback on FP.
5. Discuss on histology results

ECTOPIC PREGNANCY
The blastocyst normally implants in the endometrial

lining of the uterine cavity. EP is Any pregnancy where
the fertilized ovum gets implanted & develops in a site
other than normal uterine cavity". It represents a
serious hazard to a woman's health and reproductive
potential, requiring prompt recognition and early
aggressive intervention.
ECTOPIC PREGNANCY
A. Ectopic pregnancy – complication of pregnancy

where fertilized ovum implants outside the uterine
cavity. , usually in the fallopian tubes (90%).
B. Most of ectopic pregnancies are not viable.
C. Heterotopic pregnancy
D. Internal bleeding occurs when the site of
implantation ruptures or tubal abortion occurs.
E. Pts easily die of hemorrhage.
Incidence
According to the American College of Obstetricians and
Gynecologists (2008), 2% of all 1st -trimester pregnancies
in the USA are ectopic, and these account for 6 %of all
pregnancy-related deaths. The risk of death from an extra
uterine pregnancy is greater than that for pregnancy that
either results in a live birth or is intentionally terminated.
Moreover, the chance for a subsequent successful
pregnancy is reduced after an ectopic pregnancy. With
earlier diagnosis, however, both maternal survival and
conservation of reproductive capacity are enhanced.
Incidence
1. There is a 7-to 13-fold increase in the risk for a
subsequent ectopic pregnancy
 Intrauterine pregnancy: 50% to 80%
 Tubal pregnancy: 10% to 25%
Site Percentage
TUBAL 95-96%
Ampulla 70%
Isthmic 12 %
Fimbrial or Infundibulum 11%
Interstitial & Cornual 2-3%
OVARIAN 3%
ABDOMINAL
(primary or secondary) 1%
Secondary:
 Intraperitoneal or
 Extra peritoneal Broad Ligament (rare)
UTERUS
Isthmus 1
Cervical <1%
Cesarean Scar 2%
Table 1. Risk Factors for Ectopic
Pregnancy
INCIDENCE
Increasing ectopic pregnancy rates:
 Prevalence of sexually transmitted tubal infection and damage or
increased due to PID especially those caused by Chlamydia trachomatis
 Ascertainment through earlier diagnosis of some EP otherwise destined

to reabsorb spontaneously
 Popularity of contraception that predisposes failures to be ectopic

Increasing ectopic pregnancy rates(use of IUCD)
 Use of Tubal sterilization techniques that with contraceptive failure

increase the likelihood of ectopic pregnancy
 Use of assisted reproductive techniques
 Use of tubal surgery, including Salpingectomy for tubal pregnancy and

tuboplasty for infertility
INCIDENCE
1. Ranges from 1:25 to 1:250

2. Average range is 1 in 100 normal pregnancies.
3. Late marriages and late child bearing -> 2%
4. (ART) -> 5%.
5. ART Recurrence rate - 15% after 1st, 25% after 2 ectopics
Etiology
 Any factor that causes delayed transport of the fertilized

ovum through the tube.
 Fallopian tube favors implantation in the tubal mucosa

itself thus giving rise to a tubal ectopic pregnancy.
 These factors may be Congenital or Acquired.

Etiology Congenital
Tubal Hypoplasia
Tortuosity
Congenital diverticuli •
Accessory Ostia
Partial stenosis
Elongation
Intramural polyp
Entrap the ovum on its way.
Etiology Acquired
1. Pelvic Inflammatory disease (6-10 times)
 Chlamydia trachomatis is most common
2. Contraceptive Failure
 CuT - 4%
 Progestasart -17%
 Minipills -4-10%
 Norplant -30%
3. Tubal sterilization failure -40%. Depends on sterilization technique

and age of the patient
 Bipolar Cauterization -65%
 Unipolar Cautery -17%
 Silicon rubber band -29%
 Interval Salpingectomy -43%
Etiology Acquired
4. Reversal of sterilization
 Depends on method of sterilization, Site of tubal occlusion,
residual tubal length.
 Reanastomosis of cauterized tube -15%
 Reversal of Pomeroy’s - < 3%
5. Tubal reconstructive surgery (4-5 times)
6. Assisted Reproductive technique

 Ovulation induction, IVF-ET and GIFT (4-7%)
 Risk of heterotopic pregnancy(1%)
7. Previous Ectopic Pregnancy

 7-15% chances of repeat ectopic pregnancy
Other Risk factors
 Age 35-45 yrs
 Previous induced abortion
 Previous pelvic surgeries
 Cigarette smoking
 DES Exposure in Utero
 Infertility
 Salpingitis Isthmica Nodosa
 Genital Tuberculosis
 Fundal Fibroid & Adenomyosis of tube
 Transperitoneal migration of ovum
 Iffy hypothesis – “Theory of reflux” menstrual fluid throw the fertilized
ovum into the tube
 Factors facilitating nidation of ovum in tube:
 Premature degeneration of Zona pellucida
 Increased decidual reaction
 Tubal endometriosis
Risk factors
 IUD
 PID
 previous ectopic pregnancy
 Endometriosis
 tubal ligation
 tubal surgery
 Smoking
 Kartagener sy.(PCD-)
Evolution
Tubal pregnancies rapidly invade the mucosa, feeding from the tubal
vessels, which become enlarged and engorged. The segment of the
affected tube is distended as the pregnancy grows. Possible outcomes
of such abnormal gestations are as follows:
 The pregnancy is unable to survive owing to its poor blood supply, thus resulting
in a tubal abortion and resorption, or it is expelled from the fimbriated end into
the abdominal cavity.
 The pregnancy continues to grow until the over distended tube ruptures, with
resulting profuse intraperitoneal bleeding.
 Isthmic – 6-8 wks, Ampullary – 8-12wks, Interstitial -4 months
 Abortion is common in Ampullary pregnancies, whereas rupture is in

Isthmic.
 In rare instances, a tubal pregnancy will be expelled from the tube and seed onto
sites in the abdominal cavity (e.g. the omentum, the small or large bowel, or the
parietal peritoneum), and gives rise to a viable abdominal pregnancy.
Evolution
1. Acute
2. Subacute (75-80%)
3. Asymptomatic
Signs and symptoms- clinical presetnation occurs about 7 weeks after the last
normal menstrual period
Early signs:
-pain in the lower abdomen
-vaginal bleeding (falling levels of progesterone from the corpus luteum
causes bleeding)
Signs of late ectopic pregnancy:

-low blood pressure
-dizziness
-lower back, abdominal or pelvic pain
-shoulder pain
CLINICAL APPROACH
 Diagnosis can be done by history, detail examination and
judicious use of investigation.
 H/o past PID, tubal surgery, current contraceptive

measures should be asked
 Wide spectrum of clinical presentation from asymptomatic

pt to others with acute abdomen and in shock.
ACUTE ECTOPIC PREGNANCY
 Classical triad is present in 50% of pt with rupture ectopic.
1. PAIN:- most constant feature in 95% pt - variable in severity and
nature
2. AMENORRHOEA:- 60-80% of pt - there may be delayed period or

slight spotting at the time of expected menses.
3. VAGINAL BLEEDING: - scanty dark brown

 Feeling of nausea, vomiting, fainting attack, syncope attack(10%) due to
reflex vasomotor disturbance.
ACUTE ECTOPIC PREGNANCY
 O/E:- patient is restless in agony, looks blanched, pale, sweating with
cold clammy skin. Features of shock, tachycardia, hypotension.
 P/A:- abdomen tense, tender mostly in lower abdomen, shifting dullness,

rigidity may be present.
 P/S:- minimal bleeding may be present
 P/V:- uterus may be bulky, deviated to opposite side, fornix is tender,

excitation pain on movement of cervix. POD may be full, uterus floats
as if in water.
CHRONIC ECTOPIC PREGNANCY
 It can be diagnosed by high clinical suspicion.
 Patient had previous attack of acute pain from which she

has recovered.
 She may have amenorrhea, vaginal bleeding with dull pain

in abdomen, and with bladder and bowel complaints like
dysuria, frequency or retention of urine, rectal tenesmus.
CHRONIC ECTOPIC PREGNANCY
 O/E:- patient look ill, varying degree of pallor, slightly raised
temperature. Features of shock are absent.
 P/A:- Tenderness and muscle guard on the lower abdomen. A mass may
be felt, irregular and tender.
 P/V:- Vaginal mucosa pale, uterus may be normal in size or bulky, ill
defined boggy tender mass may be felt in one of the fornix.
UNRUPTURED ECTOPIC
1. High degree of suspicion & ectopic conscious clinician can
diagnose.
2. Diagnosed accidentally in Laparoscopy or Laparatomy

C/F – delayed period, spotting with discomfort in lower
abdomen.
P/A – tenderness in lower abdomen
P/V – should be done gently uterus is normal size, firm
small tender mass may be felt in the fornix
DIAGNOSIS
 “Pregnancy in the fallopian tube is a black cat on a dark night.
 In recent years, in spite of an increase in the incidence of ectopic

pregnancy there has been a fall in the case fatality rate.
 This is due to the widespread introduction of diagnostic tests and an

increased awareness of the serious nature of this disease.
 This has resulted in early diagnosis and effective treatment.
 Now the rate of tubal rupture is as low as 20%.

DIAGNOSIS
 Patient with acute ectopic can be diagnosed clinically.
 Blood should be drawn for Hb gm%, blood grouping and cross

matching, DC and TWBC, BT, CT.
 Should be catheterized to know urine output.
 Bed side test:-

1. Urine pregnancy test:- positive in 95% cases.
2. ELISA is sensitive to 10-50 mlU/ml of β hCG and can be detected on
24th day after LMP.
DIAGNOSIS
Culdocentesis:- (70-90%)
 Can be done with 16-18 G lumbar puncture needle
through posterior fornix into POD.
 Positive tap is 0.5ml of non clotting blood.
Other Investigations:-
 1. Ultra Sonography
 a) Transvaginal Sonography (TVS):
 Is more sensitive
 It detect intrauterine gestational sac at 4-5wks and at S-β
hCG level as low as 1500
DIAGNOSIS
Endometrial cavity
 A trilaminar endometial pattern seen
 Pseudo-gestational sac
 decidual cyst may be seen
PSEUDOSAC – All pregnancies induce an endometrial decidual reaction,
and sloughing of the decidua can create an intracavitary fluid collection
called a Pseudosac
Early gestational sac Pseudosac

location below the midline echo Along the cavity line
buried into endometrium b/w endometrial layers
shape usually round may change, ovoid
borders double ring layers single layer
Colour flow high avascular

DIAGNOSIS
DECIDUAL CYST It is identified as an anechoic area lying with in the
endometrium but remote from the canal and often at the endometrial-
myometrial border.
Adnexa
 15-30% an extra uterine yolk sac or embryo seen in fallopian tubes
confirms tubal pregnancy. –
 A halo or tubal ring surrounded by a thin hypo-echoic area caused by
subserosal edema can be seen.
Recto-uterine cul-de-sac:
Free peritoneal fluid with an adnexal mass suggestive of ectopic pregnancy
Diagnosis
 Ultrasound - the most reliable method of verification of ectopic pregnancy
 Levels of β-hCG - more often levels are lower than in normal pregnancy
 Laparascopy
 Laparatomy
 Culdocentesis (a less commonly performed test that may be used to look for
internal bleeding)
CLINICAL PRESENTATION OF ECTOPIC
PREGNANCY
1. Short period of amenorrhea (6-8wks). Some may have no hx
of amenorrhea.
2. LAP, fainting attacks, dizziness, palpitation, scanty PV

bleeding, shoulder tip pain.
3. O/E pt presents moderate to severe pallor, low BP, high PR,

cold sweats, tender distended abdomen with guarding and
rebound tenderness, +ve fluid thrill and shifting dullness
MANAGEMENT OF ECTOPIC PREGNANCY
1. IVF – NS or Ringers lactate should be given fast.

2. Take blood for grouping and x-matching
3. Urgent laparatomy to arrest bleeding.
4. Salpingectomy.
5. Auto transfusion or give cross matched blood as
necessary.
6. Correct anemia, give posta-bortal care.
Treatment
 metotrexate (if the mass is less then 3.5 cm in diametar)
 laparascopy, laparatomy (if the mass is greater than 3.5 cm in
diametar, internal bleeding, cardiovascular colapse).
SALPINGOSTOMY SALPINGECTOMY
SLOW LEAKING RUPTURED ECTOPIC
PREGNANCY
1. May be difficult to diagnose as it may resemble
threatened abortion, PID, UTI, twisted ovarian cyst
or appendicitis
2. Symptoms & signs of shock may not be there.
3. Confirm dx by ultrasound and perform laparatomy

urgently.
ADVANCED ABDOMINAL PREGNANCY
RARE BUT IT HAPPENS

REFFER CASE REPORT

ALL THE BEST DEAR

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Pelvic Pain Acute

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FIRST TRIMESTER

 The four major sources of non traumatic bleeding in

Termination of pregnancy, either spontaneously or

Definition vary according to state laws for reporting

Abortion is important as it contributes to approximately 50%

Abortion is characterized by vaginal bleeding and abdominal

Abortion occurring without medical or mechanical means to

Another widely used term is miscarriage

If early, the ovum detaches, stimulating uterine

Gestational sac is opened , fluid surrounding a small

The fetus become so dry and compressed that it resembles

More than 80 percent of abortions occur in the first 12 weeks

At least half result from chromosomal anomalies

 The risk of spontaneous abortion increases with parity as

 The frequency of abortion increases from 12% in women

 If a woman conceives within 3 months following a term

 The exact mechanism responsible for abortion are not apparent

 In the first 3 months of pregnancy

 1000 spontaneous abortions analyzed by Hertig and Sheldon

 Half demonstrated degenerated or absent embryos, that is,

 Approximately 50 to 60% of embryos and early fetuses that are

 Jacobs and Hassold (1980)

 5 % → d/t paternal error

Chromosomal Studies Kajii et al. Eiben et al. Simpson

Normal (euploid): 46,XY and 46,XX 46 51 54

Double or triple trisomy 2 0.9 0.7

Aneuploid abortion - Autosomal trisomy

 The most frequently identified chromosomal anomaly associated

 Most trisomies result from isolated non-disjunction , balanced

 Autosomes 13, 16, 18, 21, and 22 – most common

 The second frequent chromosomal abnormality

 Associated with hydropic placental (molar) degeneration

 Abort later in gestational than aneuploid

 Three fourths of aneuploid abortions occurred before8 weeks

 Euploid abortions peak at about 13 weeks

B. Chromosomal structural abnormalities

 Identified only since the development of banding

III. Chronic debilitating diseases

 In early pregnancy, fetuses seldom abort secondary to

IV. Endocrine abnormalities

 Drug use and environmental factor

VI. Drug use and environmental factor

VII. Immunological factors – autoimmune factors

 Immunological factors – autoimmune factors

 Therapy of antiphopholipid antibody syndrome

 Several test for diagnosis of alloimmune factors

VIII. Inherited thrombophilia

→ excessive recurrent abortions

→ no evidence of tncreased abortion

XI. Uterine defects – acquired uterine defects

 Uterine synechiae (Asherman syndrome)

 Uterine defects – acquired uterine defects

 Diagnosis of uterine synechiae

 Treatment of uterine synechiae

 Uterine defects – developmental uterine defects

 Consequence of abnormal mullerian duct formation or fusion

→ prolapse & ballooning of membranes into vagina

 Diagnosis in nonpregnant women

 The use of transvaginal ultrasound in pregnant women

 Incompetent cervix – Etiology

 Previous trauma to the cervix

 Abnormal cervical development

 Incompetent cervix – Treatment