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Abortion

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Abortion

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Abortion

  1. 1. ABORTION DR. KETAKI JUNNARE SKN MC & GH
  2. 2. DEFINITION  ABORTION (MISCARRIAGE) EXPULSION OR EXTRACTION FROM ITS MOTHER OF AN EMBRYO OR FETUS WEIGHING 500 GM OR LESS WHEN IT IS NOT CAPABLE OF INDEPENDENT SURVIVAL (APPROXIMATELY 24 WKS)  ABORTUS – EXPELLED EMBRYO
  3. 3. INCIDENCE  10-20 % OF CLINICAL PREGNANCIES
  4. 4. CLASSIFICATION  SPONTANEOUS (SPORADIC/RECURRENT)  THREATENED  INEVITABLE  COMPLETE  INCOMPLETE  MISSED  SEPTIC    INDUCED LEGAL (MTP) ILLEGAL
  5. 5. ETIOLOGY 1.GENETIC - CHROMOSOMAL ABNORMALITIES 50% -1ST TRIMESTER ABORTIONS  AUTOSOMAL TRISOMY (50%) – TRISOMY 16  POLYPLOIDY (22%) -3n, 4n  MONOSOMY (20%) – 45X  STRUCTURAL CHROMOSIMAL REARRANGEMENTS (2-4%) TRASLOCATION DELETION  OTHERS – MOSAIC , DOUBLE TRISOMY
  6. 6. 2. ENDOCRINE (10-15%)    LUTEAL PHASE DEFECT THYROID ABNORMALIYIES DIABETES MELLITUS 3. ANATOMICAL (10-15%)     CERVICAL INCOMPETANCE CONGENITAL MALFORMATIONS OF UTERUS FIBROID INTRAUTERINE ADHESIONS
  7. 7. 4 . INFECTIONS (5%)    VIRAL – CMV , RUBELLA ,VARIOLA VACCINIA PARASITIC – TOXOPLASMA , MALARIA BACTERIAL – UREAPLASMA , CHLAMYDIA , BRUCELLA 5 . IMMUNOLOGICAL DISORDERS (5-10%)   AUTOIMMUNE DISEASES – ANA , APLA (LAC , aCL ) ALLOIMMUNE DISEASE – PATERNAL HLA SHARING WITH MOTHER 6 . MATERNAL MEDICAL ILLNESS   CYNOTIC HEART DISEASE HAEMOGLOBINOPATHIES
  8. 8. 7 . ANTIFETAL ANTIBODIES NK CELLS 8 . BLOOD GROUP INCOMPATIBILITY 9 . INHERITED THROMBOPHILIA 10 . ENVIRONMENTAL FACTORS   CIGARETTE SMOKING ALCOHOL 11 . PREMATURE RUPTURE OF MEMBRANES
  9. 9. CLINICAL FEATURES    h/o AMENORRHOEA PAIN IN ABDOMEN P/V BLEEDING D/D –ABORTION ECTOPIC PREGNANCY VESICULAR MOLE
  10. 10. THREATENED ABORTION  PROCESS OF ABORTION HAS STARTED BUT NOT PROGRESSED TO A STATE FROM WHERE RECOVERY IS IMPOSSIBLE SYMPTOMS    SLIGHT P/V BLEEDING BRIGHT RED IN COLOUR DULL ABDOMINAL PAIN / BACKACHE
  11. 11. SIGNS P/SP – BLEEDING +/- FROM EXT OS P/V – CERVIX CLOSED, UTERUS –SOFT, CORRESPONDING WITH GEST AGE D/D – CERVICAL LESIONS-EROSION POLYP VARICOSE VAINS MALIGNANCY
  12. 12. INVESTIGATIONS    BLOOD –HAEMATOCRIT ABO Rh GROUPING USG – TO CONFIRM INTRAUTERINE PREGNANCY VIABILITY IF ECTOPIC PREGNANCY IS SUSPECTED Sr. PROGESTERONE LEVELS Sr.BhCG LEVELS
  13. 13. TREATMENT &PROGNOSIS    REST MONITORING OF VITALS , VAGINAL BLEEDING PROGESTERONE ROLE DOUBTFUL 60 -70 % CONTINUES >28 WEEKS HIGH RISK OF PRETERM LABOUR , IUGR PLACENTA PREVIA , FETAL ANOMALIES 30% INEVITABLE / MISSED ABORTION
  14. 14. INEVITABLE ABORTION DEFINITION PROCESS OF ABORTION HAS REACHED A STAGE FROM WHERE CONTINUATION OF PREGNANCY IS NOT POSSIBLE SYMPTOMS- VAGINAL BLEEDING PAIN IN ABDOMEN SIGNS – GENERAL CONDITION DEPENDS UPON AMOUNT OF BLOOD LOSS DILATED INTERNAL OS – PRODUCTS FELT THROUGH OS MEMBRANES MAY BE RUPTURED
  15. 15. MANAGEMENT   IMPROVE GENERAL CONDITION IV FLUIDS BLOOD TRANSFUSION IF PT IS IN SHOCK / SEVERE ANAEMIA EVACUATION OF PREGNANCY <12 WEEK – DILATATION & EVACUATION >12 WEEK –T. misoprostol 400 mg 4 hrly 3 doses - OXYTOCIN DRIP 10 U IN NS IF PLACENTA IS RETAINED – EVACUATION UNDER ANAESTHESIA
  16. 16. COMPLETE ABORTION  PRODUCTS OF CONCEPTION HAVE BEEN EXPELLED EN MASS  H/O EXPULSION OF FLESHY MASS FOLLOWED BY SUBSIDANCE OF ABDOMINAL PAIN AND BLEEDING P/V UTERINE SIZE SMALLER THAN PERIOD OF AMENORRHOEA UTERUS FIRM CERVIX CLOSED
  17. 17. MANAGEMENT   ASESS & IMPROVE GENERAL CONDITION ULTRASOUND EXAMINATION TO CONFIRM NO PRODUCTS HAVE BEEN RETAINED
  18. 18. INCOMPLETE ABORTION PRODUCTS OF CONCEPTION HAVE BEEN PARTLY EXPELLED FROM UTERINE CAVITY     CLINICAL FEATURES H/O EXPULSION OF FLESHY MASS ABDOMINAL PAIN PERSISTS P/V BLEEDING PERSISTS P/V EXAMINATION – UTERUS SMALLER THAN PERIOD OF AMENORRHOEA - CERVIX PATULOUS
  19. 19. COMPLICATIONS    PROFUSE BLEEDING SEPSIS PLACENTAL POLYP
  20. 20. MANAGEMENT    CORRECTION OF SHOCK – IV FLUIDS , BLOOD IV ANTIBIOTICS EVACUATION OF UTERUS
  21. 21. MISSED ABORTION SILENT MISCARRIAGE/EARLY FETAL DEMISE FETUS IS DEAD AND RETAINED INSIDE UTERINE CAVITY FOR VARIABLE TIME PATHOLOGY   BEFORE 12 WKS – CLOTTED BLOOD WITH OVUM FORMS CARNEOUS MOLE (FLESHY MOLE) AFTER 12 WKS – FETUS BECOMES MACERATED LIQUOR GETS ABSORBED PLACENTA BECOMES PALE
  22. 22. SYMPTOMS    ABDOMINAL PAIN BROWNISH VAGINAL DISCHARGE SUBSIDENCE OF PREGNANCY CHANGES SIGNS RETROGRESSION OF BREAST CHANGES UTERUS BECOMES SMALLER IN SIZE FETAL HEART SOUND NOT AUDIBLE CERVIX IS FIRM
  23. 23. COMPLICATIONS   INFECTION DIC
  24. 24. INVESTIGATIONS USG – EARLY PREGNANCY – EMPTY SAC  2 nd TRIMESTER – ABSENCE OF FETAL HEART / ABSENCE OF FETAL MOVEMENTS HEMOGRAM COAGULATION PROFILE BT , CT , PT PLATELET COUNT 
  25. 25. SEPTIC ABORTION ASSOCIATED WITH CLINICAL EVIDENCE OF INFECTION OF UTERUS AND ITS CONTENTS
  26. 26. AETIOLOGY MORE ASSOCIATED WITH ILLEGAL ABORTION    LACK OF ASEPSIS INCOMPLETE EVACUATION INJURY TO GENITAL TRACT & OTHER ORGANS LIKE GUT ORGANISMS   ANAEROBES – BACTEROIDES , STREPTOCOCCI , Cl. WELCHI , Cl . TETANI AEROBIC – E. COLI , STAPH , STREPTOCOCCI , KLEBSIELLA , PSEUDOMONAS
  27. 27. CLINICAL FEATURES         FEVER 38 C OR MORE - FOR > 24 HRS ABDOMINAL PAIN VAGINAL DISCHARGE FEBRILE TACHYCARDIA ABDOMINAL TENDERNESS PURULENT VAGINAL DISCHARGE P/V – UTERINE TENDERNESS , CERVIX IS OPEN BOGGY FEEL OF UTERUS
  28. 28. CLINICAL GRADING – LOCALISED TO UTERUS (80%)  GRADE 1  GRADE 2 – PARAMETRIUM , TUBES , OVARIES ,PELVIC PERITONEUM INVOLVED (15%)  GRADE 3 –GENERALISED PERITONITIS / ENDOTOXIC SHOCH / ACUTE RENAL FAILURE (5%)
  29. 29. INVESTIGATIONS  BLOOD – HEMOGLOBIN ,TLC DLC RENAL FUNCTION TESTS COAGULATION PROFILE BLOOD CULTURE  URINE MICROSCOPY  CERVICAL / HIGH VAGINAL SWAB (BEFORE P/SP , P/V) GM STAIN CULTURE , SENSITIVITY
  30. 30. ULTRASONOGRAPHY RETAINED PRODUCTS OF CONCEPTION PYOMETRA FOREIGN BODY FLUID IN PERITONEAL CAVITY
  31. 31. COMPLICATIONS       HAEMORRHAGE INJURY TO UTERUS , BOWEL GENERALISED PERITONITIS ENDOTOXIC SHOCK ACUTE RENAL FAILURE THROMBOPHLEBITIS
  32. 32. LATE COMPLICATIONS    TUBAL BLOCK – INFERTILITY , ECTOPTC PREGNANCY CHRONIC PELVIC PAIN – DYSPAREUNIA EMOTIONAL DEPRESSION
  33. 33. MANAGEMENT      HOSPITALISATION ANTIBIOTCS GM POSITIVE – AMPICILLIN GM NEGATIVE – GENTAMYCIN , CEFTRIAXONE ANAEROBES – METRONIDAZOLE BLOOD TRANSFUSION ANTITETANUS SERUM – 3000 U ANTI GANGRENE SERUM – 8000 U
  34. 34.  EVACUATION OF UTERUS D & E – AFTER 24 HRS OF ANTIBIOTC COVERAGE EMERGENCY ON ADMISSION IF ACTIVE BLEEDIG POSTERIOR COLPOTOMY – TO DRAIN PUS FOR PELVIC ABSCESS . C/F – SPIKY RISE IN FEVER TENESMUS BOGGY MASS FELT IN POST FORNIX
  35. 35. LAPAROTOMY      INDICATIONS INJURY TO UTERUS / BOWEL PRENCE OF FOREIGN BODY IN ABDOMEN COLLECTION OF PUS IN ABDOMEN NOT RESPONDING TO ANTIBIOTICS SEPTIC SHOCK
  36. 36. RECURRENT ABORTION   CONSECUTIVE THREE OR MORE ABORTIONS INCIDENCE – 1%
  37. 37. CAUSES  GENETIC – PARENTAL CHROMOSOMAL ABNORMALITY  ENDOCRINE UNCONTROLLED DIABETES MELLITUS THYROID ANTIBODIES LUTEAL PHASE DEFECT       INHERITED THROMBOPHILIA PROTEIN C RESISTENCE HYPERHOMOCYSTINAEMIA
  38. 38.    IMMUNOLOGICAL AUTOIMMUNITY – ANA , APLA (LA , ACA) ALLOIMMUNITY SHARING OF HLA BETWEEN PARTNERS LACK OF BLOCKING ANTIBODY PRODUCTION INFECTIONS – SYPHILIS , LISTERIOSIS UNEXPLAINED  ANATOMIC ABNORMALITIES OF GENITAL TRACT (10 – 15 %) SECOND TRIMESTER ABORTIONS CONGENITAL ACQUIRED
  39. 39. CONGENITAL   DEFECTIVE MULLERIAN FUSION CERVICAL INCOMPETENCE
  40. 40. ACQUIRED    CERVICAL INCOMPETENCE INTRAUTERINE ADHESIONS FIBROIDS
  41. 41. INVESTIGATIONS          BLOOD GROUPING BLOOD SUGAR LEVEL VDRL THYROID FUNCTION TEST AUTOIMMUNE SCREENING – LA , ACA ENDOCERVICAL SWAB ULTRASOUND –CONGENITAL MALFORMATION, PCOD , FIBROID HYSTEROSALPINGOGRAPHY KARYOTYPING
  42. 42. TREATMENT INTERCONCEPTION PERIOD SURGICAL TREATMENT OF ANOMALIES  METROPLASTY  HYSTEROSCOPIC RESECTION OF INTRAUTERINE SEPTUM SYNECHIE SUBMUCOUS FIBROID   
  43. 43.   TREATMENT OF INFECTIONS CONTROL OF DIABETES , THYROID DISORDERS
  44. 44. DURING PREGNANCY    REASSURANCE TENDER LOVING CARE NATURAL MICRONISED PROGESTERONE 100 mg BD –TO BE CONTINUED TILL 10 - 12 WKS OF GESTATION APLA POSITIVE PATIENTS LOW MOLECULAR WEIGHT HEPARIN ASPIRIN
  45. 45. ENCIRCLAGE   OS TIGHTENING IN CERVICAL INCOMPETANCE METHOD McDONALD METHOD SHIRODKAR TECHNIQUE Wurms technique  TIMING 16 – 18 WKS
  46. 46. Mc donald technique
  47. 47. Wurms technique

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