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ABORTION
- 1.
- 3. Fertilization Fertilization • Theprocess of union of male & female gamate • Site-ampullary region Aim of fertilization • Restoration of diploid number chromosome • Determination of sex • Initiation of clevage Fig: Fertilization to implantation
- 18. Period of Viability •Viability is the capability of fetus to survive outside the uterus at the earlier gestational age • Survival depends on Maturity of fetal central nervous system Maturity of lungs • PERIOD OF VIABILITY – varies in different countries WHO – 22weeks and 500gms UK – 24 weeks India – 28 weeks
- 20.
- 21. Definition • Clinically recognisedpregnancy loss before 20th week of gestation • Expulsion or extraction of an embryo or fetus weighing 500gm or less(WHO) • Synonymous with MISCARRIAGE • Latin :aboriri: to miscarry
- 22. Incidence • MC earlypregnancy complication • Frequency decreases with increasing gestational age • Incidence:8-20%(clinically recognised pregnancies) • 80% spontaneous abortion :< 12 wks
- 23. Risk factors • Advancedmaternal age • Previous spontaneous abortion • Medications & substances (smoking) • Mechanisms responsible for abortion: not apparent • Death of fetus precedes spont. expulsion, finding cause involves ascertaining the cause of fetal death
- 24. Maternal age • Mostimportant risk factor in healthy women • 30yrs:9-17% • 35yrs:20% • 40yrs:40% • 45yrs: 80%
- 25. Previous spontaneous abortion •Previous successful pregnancy: 5% risk • 1 miscarriage: 20% • 2 consecutive miscarriages:28% • ≥3 consecutive miscarriages:43%
- 26. Medications or substances •Heavy smoking(>10 cigarettes/day) : vasoconstrictive & antimetabolic effects of tobacco smoke • Moderate to high alcohol consumption(>3 drinks/week) • NSAIDS use(acetaminophen) :abnormal implantation & pregnancy failure due to antiprostaglandin effect
- 27. Other factors • Lowplasma folate levels(≤2.19ng/ml): no specific evidence to support • Extremes of maternal weight: prepregnancy BMI<18.5 OR >25kg/m2 • Maternal fever:100°F(37.8°C), no evidence to support
- 28. Etiology • Fetal • Maternal •unexplained
- 29. Etiology • Foetal factors –Chromosomal abnormalities(50% ), • aneuplodies ,monosomy X,Triploidy • Trisomy 16 : mc autosomal trisomy,lethal • Abnormalities arise de novo – Congenital anomalies – Trauma: invasive prenatal diagnostic procedures
- 31. Aetiology :Maternal factors –Maternal endocrinopathies: hypothyroidism, insulin dependant diabetes – Congenital or acquired uterine abnormalities: interfere with implantation & growth – Maternal diseases: acute maternal infection (listeria, toxo, parvo B19,rubella,CMV) : inconclusive – Radiation in therapeutic doses – Hypercoagulable state(thrombophillias) : RPL
- 32. Clinical presentation • Vaginalbleeding – Scant brown spotting to heavy vaginal bleeding – Amount /pattern does not predict outcome – May be accompanied by passage of fetal tissue • Pelvic pain – Crampy /dull in character – Constant/intermittent • Incidental finding on pelvic ultrasound in asymptomatic patient
- 33. Diagnostic evaluation • History –Period of amenorrhea ,LMP/USG • Physical examination: Complete pelvic examination: – P/S,:source, amount of bleeding, dilated cervix, POC visible at Os/in vagina – P/V: uterine size(consistent with GA) • Pelvic ultrasound
- 34. Pelvic ultrasound • Mostuseful test in diagnostic evaluation of women with suspected spontaneous abortion • Foetal cardiac activity: most important (5.5-6wks) • Foetal heart rate • Size & contour of G.sac • Presence of yolk sac • Best evaluated ,transvaginal approach(TVS)
- 35. Differential diagnosis • Physiologic:placental sign • Ectopic pregnancy • Gestational trophoblastic disease • Cervical/vaginal/uterine pathology • Physical examination • Transvaginal sonography(TVS) • Serial quantitative ßhCG
- 36. Post diagnostic classification •Based upon the location of POC • Degree of cervical dilatation(pelvic exam) • Pelvic ultrasound • Categorization impacts clinical management – Threatened – Inevitable – Incomplete/complete – Missed
- 39. Threatened abortion • Vaginalbleeding has occurred • The cervical os is closed • Managed expectantly: until symptoms resolve or progresses
- 40. Threatened abortion: • Expectant •Progestin treatment: most promising, efficacy not established • Bed rest • Avoid vigorous activity • Avoid heavy lifting • Avoid sexual intercourse
- 41. Threatened abortion : •Counsel about risk of miscarriage • Return to hospital in case of additional vaginal bleeding, pelvic cramping or passage of tissue from vagina • Repeat pelvic USG until a viable pregnancy is confirmed or excluded • Viable pregnancy, resolved symptoms: prenatal care • If symptoms continue: monitor for progression to inevitable, incomplete, or complete abortion
- 42. Inevitable abortion • Vaginalbleeding, typically accompanied by crampy pelvic pain • Dilated cervix( internal os) • Products of conception felt or visualised through the internal os
- 43. Incomplete abortion • Vaginalbleeding and/or pain present • Cervix is dilated • Products of conception partially expelled out • Uterine size less than period of amenorrhea
- 44. Missed abortion • Nonviable intrauterine pregnancy • Cervical os is closed • POC not expelled
- 45. Complete abortion • POCexpelled completely from uterus & cervix • Cervical os is closed • Uterus small in size (GA) • Resolved or minimal vaginal bleeding & pain • Aim of t/t: ensure that bleeding is not excessive & all POC have expelled • Theoretically does not need treatment
- 46. Management • Complete evacuationof uterine contents(POC) • Surgical methods: suction evacuation/suction curettage/dilation & evacuation • Medical methods: Misoprostol,mifepristone • All have similar efficacy
- 48. Abortion : complications •Hemorrhage • Uterine perforation • Retained products of conception • Endometritis • Septic abortion: abortion accompanying intrauterine infection
- 49. Prevention of spont.abortion •Preconception & prenatal counseling • Routine screening & optimal disease control(diabetes, thyroid, thrombophilia) • Correction of uterine structural anomalies(septum, submucosal myoma, intrauterine adhesions) prior to pregnancy • Avoiding exposure to teratogen or infections • Modifiable risk factors
- 50. • Clinically recognisedpregnany losses <20 wks gestation • Most common complication of early pregnancy • Advanced maternal age, previous spontaneous abortion, maternal smoking: risk factors • Mostly due to fetal structural/chromosomal abnormalities
- 51. • Present withmenstrual delay, vaginal bleeding& pelvic pain • D/D: uterine or other genital tract bleeding in viable pregnancy, ectopic,& GTD • Pelvic examination & pelvic ultrasound: key elements for diagnosis • Spontaneous abortion diagnosed based on USG criteria • Categorised as threatened/incomplete/missed
- 52. • Preconceptual &prenatal counseling & care regarding modifiable aetiologies ,risk factors are most imp intervention • Normal menstrual cycle resumes in 4-6 weeks • hCG returns to normal 2-4wks
- 53. Thank you foryour patient listening !
Editor's Notes
- #36 Cyclical bleeding till 12 weeks of pregnancy – this happens until the decidual space is obliterated by fusion of decidua vera and decidua capsularis