Causes and management of first and second trimester abortions
anatomical, chromosomal, immunological, hormonal causes and infections. Investigation for detection of cause and possible treatment. Surgical correction of cervical incompetence and medical treatment, progestational drugs
Covers the basic information about abortions that you need to know with in depth discussion of the different types of abortions and their characteristics
Covers the basic information about abortions that you need to know with in depth discussion of the different types of abortions and their characteristics
this slide helps a physician in understanding the basics of miscarriages(definition, types/classification, causes, clinical presentation, investigations and complications. In understanding the basics, this helps a physician to able to treat or manage abortions.
Threatened abortion by dr alka mukherjee dr apurva mukherjee nagpur m.s.alka mukherjee
Threatened abortion is associated with bleeding and/or uterine cramping while the cervix is closed. This stage of abortion may progress to spontaneous incomplete or complete abortion. While this event may be considered a part of the quality control process in human reproduction, it is important to know the possible etiologies and when therapy might prevent pregnancy loss. The World Health Organization estimated that 15% of all clinically recognizable pregnancies and in spontaneous abortion, 50-60% of which are due to chromosomal abnormalities. Apart from the fetal factors, several maternal and probably paternal factors contribute to the causes of spontaneous abortion. The maternal factors that may be responsible for abortion include both local and systemic conditions such as infections, maternal disease states, genital tract abnormalities, endocrine factors and other miscellaneous causes (antiphospholipid antibodies, maternal-fetal histocompatibility, excessive smoking and other environmental toxicants, etc.). This review focuses on the management of threatened abortion, but it should be emphasized that the management to maintain pregnancy is reasonable only in those cases, in which the fetus is not seriously affected. It would not be beneficial to provide treatment that would permit chromosomally and anatomically abnormal embryos to survive to term. Treatment is feasible first of all in cases with maternal factors. Surgical procedures may precede pregnancy (correction of septate uterus, removal of a submucous leiomyomata) or may be performed usually in the second trimester (cervical cerclage). Maternal general diseases (diabetes, hypothyroidism) and infections should be treated accordingly. The most common entity to be treated in this category is luteal phase deficiency. Progesterone is the most important hormone for the maintenance of an early human pregnancy. Besides progesterone administration, human chorionic gonadotropin (hCG) also is the logical endocrine treatment of choice. In the pregnant woman hCG stimulates and optimizes hormonal production in the corpus luteum and may also influence the fetoplacental unit. The contribution of environmental, physical and chemical agents to the incidence of spontaneous abortion is controversial. They may be abortifacient even if they are not teratogenic. Exposure to environmental toxicants should be avoided. Paternal leukocyte immunotherapy has been associated with successful outcome in patients with unexplained repeated spontaneous abortion. This therapeutic approach is considered experimental, as there may be some significant risks. Associating maternal antiphospholipid antibodies with reproductive failure is a rapidly developing field. Administration of corticosteroids with low doses of aspirin has resulted in fetal salvage in women in whom antiphospholipid antibodies are present.
this slide helps a physician in understanding the basics of miscarriages(definition, types/classification, causes, clinical presentation, investigations and complications. In understanding the basics, this helps a physician to able to treat or manage abortions.
Threatened abortion by dr alka mukherjee dr apurva mukherjee nagpur m.s.alka mukherjee
Threatened abortion is associated with bleeding and/or uterine cramping while the cervix is closed. This stage of abortion may progress to spontaneous incomplete or complete abortion. While this event may be considered a part of the quality control process in human reproduction, it is important to know the possible etiologies and when therapy might prevent pregnancy loss. The World Health Organization estimated that 15% of all clinically recognizable pregnancies and in spontaneous abortion, 50-60% of which are due to chromosomal abnormalities. Apart from the fetal factors, several maternal and probably paternal factors contribute to the causes of spontaneous abortion. The maternal factors that may be responsible for abortion include both local and systemic conditions such as infections, maternal disease states, genital tract abnormalities, endocrine factors and other miscellaneous causes (antiphospholipid antibodies, maternal-fetal histocompatibility, excessive smoking and other environmental toxicants, etc.). This review focuses on the management of threatened abortion, but it should be emphasized that the management to maintain pregnancy is reasonable only in those cases, in which the fetus is not seriously affected. It would not be beneficial to provide treatment that would permit chromosomally and anatomically abnormal embryos to survive to term. Treatment is feasible first of all in cases with maternal factors. Surgical procedures may precede pregnancy (correction of septate uterus, removal of a submucous leiomyomata) or may be performed usually in the second trimester (cervical cerclage). Maternal general diseases (diabetes, hypothyroidism) and infections should be treated accordingly. The most common entity to be treated in this category is luteal phase deficiency. Progesterone is the most important hormone for the maintenance of an early human pregnancy. Besides progesterone administration, human chorionic gonadotropin (hCG) also is the logical endocrine treatment of choice. In the pregnant woman hCG stimulates and optimizes hormonal production in the corpus luteum and may also influence the fetoplacental unit. The contribution of environmental, physical and chemical agents to the incidence of spontaneous abortion is controversial. They may be abortifacient even if they are not teratogenic. Exposure to environmental toxicants should be avoided. Paternal leukocyte immunotherapy has been associated with successful outcome in patients with unexplained repeated spontaneous abortion. This therapeutic approach is considered experimental, as there may be some significant risks. Associating maternal antiphospholipid antibodies with reproductive failure is a rapidly developing field. Administration of corticosteroids with low doses of aspirin has resulted in fetal salvage in women in whom antiphospholipid antibodies are present.
OBSTETRICS AND GYNAECOLOGICAL NURSING- HIGH RISK PREGNANCY ABORTION.pptxmagie12
The students will be able to
*define abortion
*Identify the difference between various types of abortion
*Perform medical induction for abortion
*Describe various surgical techniques used for abortion
*Detect the consequences that occur by abortion and provide appropriate care
Abortion or pregnancy loss is accounts to spontaneous events or through legal termination.
The first large scale study on abortions and unintended pregnancies conducted by The Lancet in 2017 said one in three of the 48.1 million pregnancies in India end in an abortion with 15.6 million taking place in 2015.
*Definition
*Types of abortion- Spontaneous, Induced, Complete abortion, Incomplete abortion, Missed abortion, Recurrent abortion, Induced abortion
*Risk factors,
*etiology, mechanism,
* clinical manifestations of each type
*Management – medical & surgical
Nursing management
Abortion is the expulsion or extraction from its mother of an embryo or fetus weighing 500 gm or less when it is not capable of independent survival
-WHO
The 500gm of fetal development is attained
approximately at 22 weeks(154 days of gestation).
The expelled embryo or fetus is called abortus
Abortion is the cause for bleeding in early pregnancy.
Abortion occurring without medical or mechanical means to empty the uterus is referred to as spontaneous.
Another widely used term is miscarriage.
10-20% of cases of all clinical pregnancies end in miscarriage.
About 75%miscarriages –before 16th week
About 80% occur –before 12th week of pregnancy.
Increases with parity
Increased 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
Women conceiving within 3 months following a term birth, have a higher incidence of abortion
Anembryonic Gestational sac
- Positive HCG test as placenta secretes HCG and stops later
Presents in first few weeks of pregnancy
Removal through medical or surgical induction
Uncommon causes of abortion in human
Listeria monocytogenes
Clamydia trachomatis
Mycoplasma hominis
Ureaplasma urealyticum
Toxoplasma gondii
Diabetes mellitus
Celiac sprue
Cause both male and female infertility and recurrent abortions
ENDOCRINE ABNORMALITIES
Hypothyroidism
Thyroid autoantibodies → incidence of abortion is high
Diabetes mellitus
Poor glucose control → incidence of abortion increased
Progesterone deficiency
Luteal phase defect
Insufficient progesterone secretion by the corpus luteum or placenta
DRUG USE AND ENVIRONMENTAL FACTORS
Recurrent pregnancy loss patients : 15%
Antiphospholipid antibody : most significant
LCA (lupus anticoagulant), ACA (anticardiolipin Ab)
ALLOIMMUNE FACTORS
- Inherited thrombophilia
Uterine synechiae (Asherman syndrome)
Partial or complete obliteration of the uterine cavity by adherence of uterine wall
The retention power of the cervix(Internal os) may be impaired functionally and or anatomically in an incompetent cervix
Etiology
Previous trauma during pregnancy
A miscarriage, or spontaneous abortion, is an event that results in the loss of a fetus before 20 weeks of pregnancy. It typically happens during the first trimester, or first three months, of the pregnancy. Miscarriages can happen for a variety of medical reasons, many of which aren't within a person's control.
(May 29th, 2024) Advancements in Intravital Microscopy- Insights for Preclini...Scintica Instrumentation
Intravital microscopy (IVM) is a powerful tool utilized to study cellular behavior over time and space in vivo. Much of our understanding of cell biology has been accomplished using various in vitro and ex vivo methods; however, these studies do not necessarily reflect the natural dynamics of biological processes. Unlike traditional cell culture or fixed tissue imaging, IVM allows for the ultra-fast high-resolution imaging of cellular processes over time and space and were studied in its natural environment. Real-time visualization of biological processes in the context of an intact organism helps maintain physiological relevance and provide insights into the progression of disease, response to treatments or developmental processes.
In this webinar we give an overview of advanced applications of the IVM system in preclinical research. IVIM technology is a provider of all-in-one intravital microscopy systems and solutions optimized for in vivo imaging of live animal models at sub-micron resolution. The system’s unique features and user-friendly software enables researchers to probe fast dynamic biological processes such as immune cell tracking, cell-cell interaction as well as vascularization and tumor metastasis with exceptional detail. This webinar will also give an overview of IVM being utilized in drug development, offering a view into the intricate interaction between drugs/nanoparticles and tissues in vivo and allows for the evaluation of therapeutic intervention in a variety of tissues and organs. This interdisciplinary collaboration continues to drive the advancements of novel therapeutic strategies.
Multi-source connectivity as the driver of solar wind variability in the heli...Sérgio Sacani
The ambient solar wind that flls the heliosphere originates from multiple
sources in the solar corona and is highly structured. It is often described
as high-speed, relatively homogeneous, plasma streams from coronal
holes and slow-speed, highly variable, streams whose source regions are
under debate. A key goal of ESA/NASA’s Solar Orbiter mission is to identify
solar wind sources and understand what drives the complexity seen in the
heliosphere. By combining magnetic feld modelling and spectroscopic
techniques with high-resolution observations and measurements, we show
that the solar wind variability detected in situ by Solar Orbiter in March
2022 is driven by spatio-temporal changes in the magnetic connectivity to
multiple sources in the solar atmosphere. The magnetic feld footpoints
connected to the spacecraft moved from the boundaries of a coronal hole
to one active region (12961) and then across to another region (12957). This
is refected in the in situ measurements, which show the transition from fast
to highly Alfvénic then to slow solar wind that is disrupted by the arrival of
a coronal mass ejection. Our results describe solar wind variability at 0.5 au
but are applicable to near-Earth observatories.
THE IMPORTANCE OF MARTIAN ATMOSPHERE SAMPLE RETURN.Sérgio Sacani
The return of a sample of near-surface atmosphere from Mars would facilitate answers to several first-order science questions surrounding the formation and evolution of the planet. One of the important aspects of terrestrial planet formation in general is the role that primary atmospheres played in influencing the chemistry and structure of the planets and their antecedents. Studies of the martian atmosphere can be used to investigate the role of a primary atmosphere in its history. Atmosphere samples would also inform our understanding of the near-surface chemistry of the planet, and ultimately the prospects for life. High-precision isotopic analyses of constituent gases are needed to address these questions, requiring that the analyses are made on returned samples rather than in situ.
A brief information about the SCOP protein database used in bioinformatics.
The Structural Classification of Proteins (SCOP) database is a comprehensive and authoritative resource for the structural and evolutionary relationships of proteins. It provides a detailed and curated classification of protein structures, grouping them into families, superfamilies, and folds based on their structural and sequence similarities.
Seminar of U.V. Spectroscopy by SAMIR PANDASAMIR PANDA
Spectroscopy is a branch of science dealing the study of interaction of electromagnetic radiation with matter.
Ultraviolet-visible spectroscopy refers to absorption spectroscopy or reflect spectroscopy in the UV-VIS spectral region.
Ultraviolet-visible spectroscopy is an analytical method that can measure the amount of light received by the analyte.
Cancer cell metabolism: special Reference to Lactate PathwayAADYARAJPANDEY1
Normal Cell Metabolism:
Cellular respiration describes the series of steps that cells use to break down sugar and other chemicals to get the energy we need to function.
Energy is stored in the bonds of glucose and when glucose is broken down, much of that energy is released.
Cell utilize energy in the form of ATP.
The first step of respiration is called glycolysis. In a series of steps, glycolysis breaks glucose into two smaller molecules - a chemical called pyruvate. A small amount of ATP is formed during this process.
Most healthy cells continue the breakdown in a second process, called the Kreb's cycle. The Kreb's cycle allows cells to “burn” the pyruvates made in glycolysis to get more ATP.
The last step in the breakdown of glucose is called oxidative phosphorylation (Ox-Phos).
It takes place in specialized cell structures called mitochondria. This process produces a large amount of ATP. Importantly, cells need oxygen to complete oxidative phosphorylation.
If a cell completes only glycolysis, only 2 molecules of ATP are made per glucose. However, if the cell completes the entire respiration process (glycolysis - Kreb's - oxidative phosphorylation), about 36 molecules of ATP are created, giving it much more energy to use.
IN CANCER CELL:
Unlike healthy cells that "burn" the entire molecule of sugar to capture a large amount of energy as ATP, cancer cells are wasteful.
Cancer cells only partially break down sugar molecules. They overuse the first step of respiration, glycolysis. They frequently do not complete the second step, oxidative phosphorylation.
This results in only 2 molecules of ATP per each glucose molecule instead of the 36 or so ATPs healthy cells gain. As a result, cancer cells need to use a lot more sugar molecules to get enough energy to survive.
Unlike healthy cells that "burn" the entire molecule of sugar to capture a large amount of energy as ATP, cancer cells are wasteful.
Cancer cells only partially break down sugar molecules. They overuse the first step of respiration, glycolysis. They frequently do not complete the second step, oxidative phosphorylation.
This results in only 2 molecules of ATP per each glucose molecule instead of the 36 or so ATPs healthy cells gain. As a result, cancer cells need to use a lot more sugar molecules to get enough energy to survive.
introduction to WARBERG PHENOMENA:
WARBURG EFFECT Usually, cancer cells are highly glycolytic (glucose addiction) and take up more glucose than do normal cells from outside.
Otto Heinrich Warburg (; 8 October 1883 – 1 August 1970) In 1931 was awarded the Nobel Prize in Physiology for his "discovery of the nature and mode of action of the respiratory enzyme.
WARNBURG EFFECT : cancer cells under aerobic (well-oxygenated) conditions to metabolize glucose to lactate (aerobic glycolysis) is known as the Warburg effect. Warburg made the observation that tumor slices consume glucose and secrete lactate at a higher rate than normal tissues.
2. Abortion is the expulsion or extraction of an
embryo or fetus weighing 500 g or less from
its mother when it is not capable of
independent survival (i.e. before the period
of viability)
3. Incidence
• 10–20% of all clinical pregnancies
• 75% abortions occur before the 16th week
• Rates vary with maternal age; also high in
women with past miscarriages
6. Fetal Factors
• Genetic
– 50% of early miscarriage is due to chromosomal
abnormalities
– Numerical defects like Trisomy, Polyploidy,
Monosomy
– Structural defects like translocation, deletion,
inversion
• Multiple Pregnancies
• Degeneration of villi
9. • Environmental Factors
– Cigarette smoking
– Alcohol consumption
– Contraceptive agents
• Maternal medical illness
– Cyanotic heart disease
– Hemoglobinopathies
• Unexplained (40-60%) – In majority, the exact
cause is not known.
10. Threatened Abortion
• Condition in which miscarriage has started but
has not progressed to a state from which
recovery is impossible
11. CLINICAL FEATURES:
• The patient, having amenorrhea, complains of:
(1) Slight bleeding per vaginam
(2)Pain: Usually painless; there may be mild
backache or dull pain in lower abdomen
12. • The uterus and cervix feel soft.
• Digital examination reveals closed external os
• Differential diagnosis includes
– cervical ectopy
– polyps or carcinoma
– ectopic pregnancy
– molar pregnancy
• Ultrasound is diagnostic; Pelvic examination is
avoided when USG is available
13.
14. Management & Prognosis
• Rest: Patient should be in bed for few days until
bleeding stops
• Relief of pain: Diazepam 5 mg BD
• 80% of pregnancies with threatened abortions go on
until term
• If a live fetus is seen on USG, pregnancy is likely to
continue in over 95% cases.
• If pregnancy continues, there is increased frequency
of preterm labor, placenta previa & IUGR
15. Inevitable Abortion
It is the clinical type of abortion where the
changes have progressed to a state from
where continuation of pregnancy is
impossible.
16. CLINICAL FEATURES:
• The patient, having the features of threatened
miscarriage, presents with
– vaginal bleeding
– Aggravation of colicky pain in the lower abdomen
• Sometimes, the features may develop quickly
without prior clinical evidence of threatened
miscarriage
• Internal examination reveals dilated internal os
through which the products of conception are felt
17.
18. Management
• 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 oxytocic
drugs
– Blood loss is corrected by IV fluid therapy and blood
transfusion
19. Incomplete abortion
The process of abortion has already taken
place, but the entire products of conception
are not expelled & a part of it is left inside the
uterine cavity
20. Clinical features:
• History of expulsion of a fleshy mass per vaginam;
– 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
Complications:
• The retained products may cause:
(a) bleeding (b) sepsis or (c) placental polyp.
21.
22. MANAGEMENT:
• Evacuation of the retained products of conception (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 by 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 200 μg is used
vaginally every 4 hours
23. Complete Abortion
• When the products of conception are
completely expelled from the uterus, it is
called complete miscarriage.
24. Clinical features
• There is history of expulsion of a fleshy mass per
vaginam followed by
– Subsidence of abdominal pain
– Vaginal bleeeding becomes trace or absent
• Internal examination reveals:
– Uterus smaller than the period of amenorrhea
– Cervical os is closed
– Bleeding is trace.
• Transvaginal sonography confirms that uterus is
empty
25. 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.
26. • CLINICAL FEATURES:
The patient usually presents with features of
threatened miscarriage followed by:
– Subsidence of pregnancy symptoms
– 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
27. Complications
• Retaining the products for long time can lead
to sepsis
• DIC [Disseminated Intravascular Coagulation]
– (very rare) in gestations exceeding 16 weeks
28. Management
Uterus is less than 12 weeks:
• Prostaglandin E1 (Misoprostol) 800 mg is given
vaginally and repeated after 24 hours if needed.
Expulsion usually occurs within 48 hours
• Suction evacuation is done when the medical method
fails
Uterus more than 12 weeks
• 6th or 12th hourly misoprostol tablets given vaginally
• If this fails, extraamniotic instillation of ethacridine
lactate is used
• Antibiotics are given
29. Septic Abortion
• Any abortion associated with clinical
evidences of infection of the uterus and its
contents
• Most common cause – Attempt at induced
abortion by an untrained person without the
use of aseptic precautions
30. Clinical Grading:
• Grade–I: The infection is localized in the uterus.
• Grade–II: The infection spreads beyond the
uterus to the parametrium, tubes and ovaries or
pelvic peritoneum.
• Grade–III: Generalized peritonitis and/or
endotoxic shock or jaundice or acute renal
failure.
Grade-I is the commonest and is usually
associated with spontaneous abortion
31. Clinical Features
• Fever, abdominal pain and vomiting or diarrhoea
• A rising pulse rate of 100–120/min or more is a
significant finding than even pyrexia. It indicates
spread of infection beyond the uterus.
• Examination shows abdominal tenderness,
guarding, rigidity
• Internal examination reveals:
– offensive purulent vaginal discharge
– tender uterus usually with patulous os or a boggy feel
– Soft cervix with open internal os
32. Investigations
• CBC
• Serum urea, creatinine, electrolytes
• High vaginal swab
• Blood culture in suspected septicaemia
• Pelvic USG to detect retained products of
conception
• X-ray abdomen in suspected bowel injury
• X-ray chest if there is difficulty in respiration
33. Complications
Immediate:
• Hemorrhage
• Injury may to uterus & adjacent structures
• Spread of infection leads to:
– Generalized peritonitis
– Endotoxic shock—mostly due to E. Coli
– DIC
– Acute renal failure
– Thrombophlebitis.
• All these lead to increased maternal deaths
34. Management
• Mild cases –
– Broad spectrum antibiotics started
– Uterus is evacuated
• Severe Cases
– Vigorous IV infusion with crystalloid
– Oxygen given by nasal catheter
– Broad spectrum antibiotics – combination of
ampicillin, gentamicin, metronidazole is started
– Uterus is evacuated in 4-6 hrs of commencing therapy.
36. Recurrent Abortion
• Recurrent miscarriage is defined as a
sequence of three or more consecutive
spontaneous abortions
• Seen in ~ 1% of all women
• Risk increases with each successive abortion
• No underlying cause is found for 50% of
recurrent pregnancy loss
37. Etiology
FIRST TRIMESTER ABORTION:
• Genetic factors (3–5%):
Parental chromosomal abnormalities
The most common abnormality is a balanced
translocation.
This leads to unbalanced translocation in the
fetus, causing early miscarriage or a live birth
with congenital malformations
Risk of miscarriage in couples with a balanced
translocation is > 25%.
This is the most common cause for 1st trimester
loss
38. • Endocrine and Metabolic:
– Poorly controlled diabetic patients
– Presence of thyroid autoantibodies
– Luteal phase defect
– Hypersecretion of luteinizing hormone (e.g. in PCOS).
• Infection:
– Infection in the genital tract - (Transplacental fetal
infection)
– Syphilis
• Inherited thrombophilia
– Protein C deficiency, Protein S deficiency, factor V
Leiden mutation, prothrombin gene mutation
39. • Immunological cause:
Autoimmunity – Antiphospholipid antibody
syndrome(15%).
– Antiphospholipid antibodies present in mother
produce adverse fetal outcome
– Diagnosis by presence of lupus
anticoagulant/IgG/IgM anticardiolipin antibodies
Alloimmune factors
– Immune response against paternal antigens in the
fetus
– This is a result of lack of production of blocking
antibodies by the mother.
40. SECOND TRIMESTER MISCARRIAGE:
• Anatomic abnormalities - responsible for 10–
15% of recurrent abortion.
• Causes may be
(a)Congenital - defects in the mullerian duct fusion
(e.g. unicornuate, bicornuate, septate or double
uterus)
(b)Acquired - intrauterine adhesions, uterine
fibroids and endometriosis, cervical incompetence
41. Uterine Causes
• Defects of mullerian fusion
– Double uterus, septate or bicornuate uterus
– About 12% cases of recurrent abortion.
– Implantation on the septum leads to defective
placentation
• Asherman syndrome – Intrauterine adhesions
due to previous curettage – can lead to early
miscarriage
• Transvaginal ultrasound is used for diagnosis;
• Hysteroscopic resection for septum or division of
adhesions in Asherman’s syndrome.
• Submucous fibroids - managed by myomectomy
44. Cervical Insufficiency (Incompetence)
• Painless cervical dilatation with ballooning of
amniotic sac into vagina, followed by rupture
of membrane and expulsion of fetus
• Usually at 16 – 24 weeks
45. Etiology
• Congenital
– Developmental weakness of cervix
– Uterine anomalies
• Acquired (iatrogenic)—common, following:
(i) D&C operation
(ii) Induced abortion by D and E
(iii) vaginal operative delivery through an undilated
cervix
(iv) amputation of the cervix or cone biopsy.
• Multiple gestations, prior preterm birth.
46. Diagnosis
• History - Repeated mid trimester painless
cervical dilatation and escape of liquor amnii
followed by painless expulsion of the products
of conception
• Internal examination:
Interconceptual period:
– Passage of no. 6–8 Hegar dilator beyond the
internal os without any resistance or pain
– Funnelling of internal os seen in
hysterosalpingography
47. During pregnancy
– Clinical digital – Painless cervical shortening and
dilatation
– Sonography: Trans vaginal ultrasound is
performed. Short cervix < 25 mm; Funnelling of
the internal Os > 1 cm.
48. Management
• Surgical management – Cervical circlage
• Ususally at 12-14 weeks
• The procedure reinforces the weak cervix by a
non-absorbable tape, placed around the
cervix at the level of internal os.
51. • Contraindications
– Intrauterine infection
– Ruptured membranes
– History of vaginal bleeding
– Severe uterine irritability
– Cervical dilatation > 4 cm.
• 2 main methods – McDonald and Modified
Shirodkar
• Success rates - 80 – 90%
52. Types of circlage
• History Indicated
– Definite history of 3 previous second trimester losses/
preterm births
• Ultrasound indicated
– Short ended cervix or early funnelling in ultrasound in
a woman with 1 or 2 spontaneous losses
• Examination indicated / Rescue circlage
– Performed after the cervix is found dilated
– Also called emergency circlage
53. Methods
I. McDONALD’S OPERATION
• The non-absorbable suture material (Mersilene) is
placed as a purse string suture, as high as possible
(level of internal os)
• The suture starts at the anterior wall of the cervix.
Taking successive deep bites (4–5 sites) it is carried
around the lateral and posterior walls back to the
anterior wall again where the two ends of the suture
are tied.
• Commonly performed method nowadays.
54.
55. II. Modified Shirokdar Circlage
• A transverse incision is made on the vaginal wall and
the bladder is pushed up to expose the level of the
internal os.
• The non-absorbable suture material—Mersilene tape is
passed submucously with the help of any curved round
bodied needle so as to bring the suture ends to the
posterior.
• The ends of the tapes are tied up posteriorly by a knot.
• The anterior incision is repaired using synthetic
absorbable suture.
56.
57. III. Transabdominal Cerclage
• Rarely done in cases of repeated failure of
vaginal approach
• Cerclage is placed at the level of isthmus
• Delivery by CS
58. • Postoperative care:
– The patient should be in bed for at least 2–3 days
– Progesterone supplementation - Weekly injections
of 17 α hydroxy progesterone caproate 500 mg IM
– Patient is asked to avoid sexual inercourse
• Removal of stitch:
– The stitch should be removed at 37th week, or
earlier if labor pain starts or features of abortion
appear.
– If the stitch is not cut in time, uterine rupture or
cervical tear may occur.
59. • Complications:
– Slipping or cutting through the suture
– Chorioamnionitis
– Rupture of the membranes
– Cervical scarring and dystocia requiring cesarean
delivery.
60. Prognosis of recurrent abortions
• The overall risk of recurrent abortions is
about 25–30% irrespective of the number of
previous spontaneous miscarriage.
• The overall prognosis is good even without
therapy.
• The chance of successful pregnancy is about
70–80% with an effective therapy.