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Threatened abortion

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  • Great post. A threatened abortion medically refers to a situation of heavy bleeding within the first 20 weeks of pregnancy. This is also called a threatened miscarriage because, in such a situation, miscarriage is a possible result. Sometimes, there is a prelude to this bleeding in the form of abdominal cramps. According to a medical journal called ‘Healthline’, nearly 20% to 30% of pregnant women experience this bleeding, and among them, about 50% women complete their term. For more information visit https://parentinghealthybabies.com/threatened-abortion-ultimate-guide/
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Threatened abortion

  1. 1. MANAGEMENT OF THREATENED ABORTION Dr. Bushra Hasan Khan JR-1 Department of Pharmacology JNMC, AMU, Aligarh.
  2. 2. Threatened Abortion  A clinical entity where the process of abortion has started, but has not progressed to a state where recovery is impossible.  The clinical diagnosis of threatened abortion is presumed when a bloody vaginal discharge appears through a closed cervical os during the first half of pregnancy.
  3. 3.  Threatened Abortion is the most common complication in the first half of pregnancy.  Its incidence varies between 20-25%.  Miscarriage is 2.6 times as likely  17% of cases are expected to present complications later in pregnancy.
  4. 4. ETIOLOGY  Embryonic abnormalities  Maternal factors  Anatomic factors  Endocrine factors  Infectious factors  Immunologic factors
  5. 5. CLINICAL FEATURES The pregnant patient complains of : • Bleeding per vaginum • Pain
  6. 6. INVESTIGATIONS  Blood  Urine  Pelvic examination  Ultrasonography
  7. 7. Transvaginal Sonography  Well formed gestational sac  Observation of fetal cardiac activity With these there is about 98% chance of continuation of pregnancy. Sonography can usually differentiate between an intrauterine pregnancy (viable or non-viable), a molar pregnancy, or an inevitable abortion.
  8. 8.  Serum Progesterone value 25 ng/ml or more – a viable pregnancy in about 95% cases  Serial serum beta HCG level 20 ng/ml or more – viable pregnancy To assess the level of fetal well being
  9. 9. Adverse Prognostic factors in cases of Threatened Abortion  A large empty gestational sac  Discrepancy : gestational age and crown to rump length  Fetal bradycardia or absence of fetal heart activity  Advanced maternal age  History of recurrent pregnancy loss  Maternal serum Progesterone < 25 ng/ml or low maternal serum hCG
  10. 10. Complications  These fetuses are at increased risk for intrauterine growth retardation, preterm delivery, low birthweight, and perinatal death.  Maternal risks include antepartum hemorrhage, manual removal of the placenta, and cesarean delivery.
  11. 11. Management  Bed rest  Paracetamol  Progesterone therapy  hCG therapy  Tocolytic agents
  12. 12.  “There is insufficient evidence of high quality that supports a policy of bed rest in order to prevent miscarriage in women with confirmed fetal viability and vaginal bleeding in first half of pregnancy”.
  13. 13. Progesterone therapy  Oral micronized Progesterone : 200mg OD or BD.  Vaginal progesterone suppositories : 200mg OD or BD.  Progesterone vaginal gel : 100mg two or three times/day  Intramuscular Progesterone : Injection in oil given as 50mg /day.
  14. 14. • “Use of progestogens is effective in the treatment of threatened miscarriage with no evidence of increased rates of pregnancy- induced hypertension or antepartum haemorrhage as harmful effects to the mother, nor increased occurrence of congenital abnormalities on the newborn”. •“However, the analysis was limited by the small number and the poor methodological quality of eligible studies (four studies) and the small number of the participants (421), which limit the power of the meta-analysis and hence of this conclusion”.
  15. 15.  “The current evidence does not support the routine use of hCG in the treatment of threatened miscarriage”.
  16. 16. Tocolytics  Adrenergic receptor agonists  Ca2+ channel blockers  Oxytocin-receptor antagonist: Atosiban  Nitric oxide donors  Magnesium sulphate  Cycloxygenase inhibitors
  17. 17. Sites of action of tocolytic drugs in the uterine myometrium
  18. 18. Ritodrine  Started as 50 µg/min i.v. infusion  Rate of infusion is increased every 10 minutes till uterine contractions cease or maternal heart rate rises to 120/min.  Contractions can also be kept suppressed by 10 mg i.m. 4-6 hourly followed by 10 mg oral 4-6 hourly.
  19. 19. Side effects & contraindications  Tachycardia, Hypotension, Pulmonary Edema.  Hypergylycemia, Hypokalemia.  Anxiety, Restlessness, Headaches.  Fetal pulmonary edema.  Neonate may develop hypoglycemia and ileus.  Its use is contraindicated if mother is diabetic, having heart disease, or receiving beta blockers.
  20. 20. Ca2+ channel blockers  Relative to Beta2 adrenergic agonists, Nifedipine is more likely to improve fetal outcomes and less likely to cause maternal side effects.  Oral Nifedipine 10 mg repeated once or twice after 20-30 min, followed by 10 mg, 6 hourly has been used.
  21. 21. Nifedipine: side effects  Maternal flushing  Headache, Dizziness, Nausea  Transient hypotension and Tachycardia, Palpitations.  Fetal hypoxia associated with maternal Hypotension.
  22. 22. Oxytocin receptor antagonists  Atosiban : a peptide analogue of Oxytocin  Competitively inhibits the interaction of Oxytocin with its membrane receptor on uterine cellsdecreases the frequency of uterine contractions.  Intravenous use  6.75 mg bolus, followed by 300µg/min infusion for 3 hours. Then 100µg/hour for upto 45 hours.
  23. 23. Nitroglycerine  Nitric oxide is a potent vasodilator and smooth muscle relaxant.  The major adverse effect is maternal hypotension.  Dose; 50-200µg intravenously.  Can consider repeating dose after 1-4 minutes if inadequate response occurs.
  24. 24. Magnesium Sulphate  Administered intravenously ; 4-6 g loading dose, then 2-4 g/hour titrated to uterine response and maternal toxicity.  Two reviews demonstrate magnesium sulphate to be ineffective as a tocolytic.
  25. 25. Side effects of magnesium sulphate  Maternal flushing,  Sweating,  Respiratory depression,  Bradycardia,  Myocardial depression,  Loss of deep tendon reflexes,  Neuromuscular blockade.
  26. 26.  “There is insufficient evidence to support the use of uterine muscle relaxant drugs for women with threatened miscarriage”.  “Any such use should be restricted to the context of randomised trials”.
  27. 27. Cycloxygenase inhibitor  Indomethacin  Use is controversial.
  28. 28. Anti-D Immunoglobulin  The Rh-negative woman is given anti-D immunoglobulin following abortion.  This practice is controversial with threatened abortion because it lacks evidence-based support (American College of Obstetricians and Gynecologists, 1999; Weissman and associates, 2002).

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