Threatened Abortion Conservative with bed rest and reassurance till bleeding stops. Sexual intercourse best avoided. Follow up with ULTRASOUND-presence of fetal cardiac activity predicts good outcome in 95%of cases. Hormone therapy -400mg natural progesterone in 2divided doses orally or vaginally on empirical basis. Anti D if mother is Rh negative and pregnancy is beyond 12 weeks.
Inevitable Abortion Immediate evacuation of pregnancy.(If duration of pregnancy less than 12 weeks- suction evacuation and greater than 12 weeks oxytocin infusion.) Shock-resuscitation with i/v fluids and blood transfusion. Prophylactic antibodies and anti-D.
Incomplete Abortion Resuscitation if patient is in shock and evacuation by suction evacuation. If the os is closed PGE1 tablets are kept in vagina for ripening the cervix. Prophylactic antibodies and anti D
Complete abortion Conservative Anti D not indicated if pregnancy is less than 12 weeks and there was no operative intervention.
Missed Abortion Uterus evacuated as soon as possible. A donor should be kept ready. If uterine size is less than 12 weeks of gestation PGE1 tablets kept in vagina results in spontaneous expulsion without the need of surgical intervention. If more than 12 weeks, 6th or 12th hourly PGE1 tablets used vaginally results in spontaneous expulsion or extra amniotic ethacridine acetate. Anti D and antibiotics.
Septic Abortion Police notification if a criminal abortion is suspected. Mild cases-broad spectrum antibiotics are started and uterus evacuated. Severe cases-maintenance of perfusion and ventilation. I/v infusion and CVP line is inserted Blood transfusion Oxygen given by nasal catheter.
Septic Abortion(cont……..) Antibiotics commenced after taking a high vaginal swab. Ampicillin,Gentamycin and Metronidazole/third generation cephalosporin like cefotaxime or cefuroxime with metronidazole or clindamycin. Evacuation of uterus after infection is controlled.
Recurrent Miscarriage Due to cervical incompetenceM anagem is be cervical cerclage if there is a well ent docum ented history otherwise serial follow up is done with transvaginal ultrasound for early signs of incom petence.Cervical cerclage is usually delayed upto 12-14 weeks so that m iscarriage due to other causes can be eliminated.Sonography is done to confirm live fetus and if there is infection,it should be treated and sexual intercourse should be avoided.Contraindications-B leeding,contractions/ ruptured m branes. em
1.McDonald’s CerclagePatient is in lithotomy position and cervix isexposed with Sim’s speculum.The cervical lipsare held with sponge holding forceps and apurse string suture with a non absorbablematerial like black silk is taken all around thecervix.Disadvantage –suture may be below internal os.
2.Modified Shirodkar’scerclage.Small transverse incision is made onanterior lip of cervix at cervicovaginaljunction 2cm above the external os.Bladderis then pushed up and a suture of black silkor mersilene tape is passed from anterior toposterior aspect submucosally usingShirodkar’s or any curve bodied needle.2ends of the suture are pulled and tiedposteriorly.Anterior incision is closed with
3.Transabdominal cerclageDone in cases of repeated failure ofvaginal approach and cervix is inaccessibleDisadvantage-Caesarean sectionIn case of miscarry cerclage has to beremoved at laparotomy.
Post operative care Bed rest for 48 hours Antibiotic cover Avoid sexual intercourse Cerclage is removed at 37 weeks or at the onset of labour ,if not it can result in rupture uterus.
Other cases of recurrentmiscarriage Chromosomal abnormalities-karyotyping of both parents and prenatal diagnosis in the next pregnancy. Uterine factors-hysteroscopic resection in case of a septum or division of the adhesion in Asherman’s syndrome. Myomectomy in case of fibroid. APLA Syndrome-Combination of low dose aspirin and low MW heparin as soon as pregnancy is confirmed.Aspirin preconceptionally. Inherited thrombophilia-Low dose aspirin and heparin.
Induced abortion THE MEDICAL TERMINATION OF PREGNANCY ACT, 1971 (Act No. 34 of 1971) (10th August 1971) An Act to provide for the termination of certain pregnancies by registered Medical Practitioners and for matters connected therewith or incidental thereto. Be it enacted by Parliament in the Twenty-second Year of the Republic of India as follows :- 1. Short title, extent and commencement – This Act may be called the Medical Termination of Pregnancy Act, 1971. It extends to the whole of India except the State of Jammu and Kashmir. It shall come into force on such date as the Central Government may, by notification in the Official Gazette, appoint. 2. Definitions - In this Act, unless the context otherwise requires, - “guardian” means a person having the care of the person of a minor or a lunatic; “lunatic” has the meaning assigned to it in section 3 of the Indian Lunatic Act, 1912 ( 4 of 1912); “minor” means a person who, under the provisions of the Indian Majority Act, 1875 ( 9 of 1875), is to be deemed not to have attained his majority;
(d) “registered medical practitioner” means a medical practitioner who possesses any recognized medical qualification as defined in clause (h) of section 2 of the Indian Medical Council Act, 1956, (102 of 1956), whose name has been entered in a State Medical Register and who has such experience or training in gynaecology and obstetrics as may be prescribed by rules made under this Act. Place where pregnancy may be terminated - No termination of pregnancy shall be made in accordance with this Act at any place other than - a hospital established or maintained by Government, or a place for the time being approved for the purpose of this Act by Government.