Termination of pregnancy before the period of fetal viability is called as Abortion. Mostly they are spontaneous and some times they are iatrogenic.

1. Dr.Suresh Babu Chaduvula
Professor
Dept. of OBGyn, College of Medicine,
KKU, Abha, KSA

2.  1] Abortion
 2] Ectopic Pregnancy
 3] Hydatidiform mole
 4] Implantation bleeding
 5] Local causes – Erosion, Polyp, Varicose
veins rupture, Cervical malignancy

3.  Definition: Termination of pregnancy before
the period of viability or fetus weighing less
than 500 grams.
 Expulsion or Extraction of an embryo or fetus
before viability
 Period of viability: Developing countries – 28
weeks.
 UK, USA – Less than 22 to 24 weeks

4.  10 – 20%
 75 % occur before 16th week
 75 % occur at 8th week

5.  1] Spontaneous
 2] Threatened
 3] Inevitable
 4] Incomplete
 5] Complete
 6] Missed
 7] Septic
 8] Recurrent
 9] Induced – Legal or Illegal [ Criminal ]

6.  1] Genetic factors –
 Chromosomal abnormalities – Autosomal
trisomy – 50 % - Trisomy 16 is common
 Polyploidy – 20 % - Presence of extra haploid
number of chromosomes – 69 or 92
chromosomes – Triploidy is common
 Chromosomal rearrangements – Inversion,
deletion, translocation
 Others - Mosaic

7.  2] Endocrine factors:
 Luteal Phase defect
 Deficient Progesterone
 Hyper & Hypothyroidism
 Uncontrolled Diabetes Mellitus

8.  3] Uterine Anomalies:
 Cervical incompetence
 Bocornuate uterus
 Septate uterus
 4] Sub-mucus Fibroid:
 5] Intra-uterine synechiae: [ Asherman’s
syndrome ]

9.  6] Infections:
 Viral – Rubella, Cytomegalo, varicella,
variola
 Parasitic: Toxoplasmosis, Malaria
 Bacterial: Chlamydia, Ureaplasma, Brucella
 Spirochetes: Treponema pallidum

10.  7]Immunological disorders:
 Antinuclear Antibodies
 Anti phospholipid antibodies like Lupus
anticoagulant and Anti cardiolipin antibodies

11.  8] Medical Disorders:
 Cyanotic heart diseases
 Hemoglobonopathies
 9] Paternal Factors:
 Sperm chromosomal anomaly
 10] Inherited Thrombophilia
 11] Environmental - Smoking, Radiation,
Teratogenic drugs, chemicals, Alcohol
 12] Unexplained – 40- 60%

12.  1] Genetic
 2] Endocrine disorders
 3] Immunological disorders
 4] Infections
 5] Unexplained

13.  1] Cervical Incompetence
 2] Bicornuate uterus
 3] Septate uterus
 4] Uterine synechiae
 5] Submucus fibroid
 6] Maternal Diseases
 7] Unexplained

14.  Clinical features:
 Vaginal bleeding
 Mild lower abdominal pain
 Vitals stable
 Vaginal examination – Cervix is closed and
uterus size will correspond to pregnancy
 Diagnosis – CBC, Ultrasound, Serum
Progesterone and Serum HCG levels
 Treatment – Rest, sedation and synthetic
progesterone and HCG injections?

15.  Clinical features:
 Vaginal Bleeding with passage of products of
gestation
 Pain lower abdomen
 Vitals - disturbed according to the blood loss
 Vaginal examination: Cervix is dilated with
hanging of fetal products and uterus size will be
lesser than amenorrhea
 Diagnosis - Ultrasound
 Treatment – Stabilize vitals and Suction
evacuation / curettage
 After 12 weeks – Under GA and IV oxytocin drip
products are removed by ovum forceps /
Curettage

16.  Clinical features:
 Vaginal Bleeding with passage of products of
gestation
 Pain may be less or absent
 Vitals - disturbed according to the blood loss
 Vaginal examination: Cervix is closed and
uterus size is lesser than amenorrhea
 Diagnosis - Ultrasound
 Treatment – No active intervention

17.  Clinical features:
 Vaginal Bleeding
 Pain lower abdomen
 Vitals - disturbed according to the blood loss
 Vaginal examination: Cervix is dilated with
hanging of fetal products and uterus size will
correspond to amenorrhea
 Diagnosis - Ultrasound
 Treatment – Stabilize vitals and Suction
evacuation / curettage
 After 12 weeks – IV oxytocin drip

18.  Fetus is dead and retained for variable
period [ 4 – 6 weeks ]
 Clinical Features:
 Brownish vaginal dischage
 Subsidence of pregnancy symptoms
 Retrogression of breast changes
 Vaginal examination: Uterus will be less than
amenorrhea and cervix is closed
 Diagnosis – Ultrasound

19.  Complications:
 Disseminated intravascular Coagulation
 Coagulation Profile is essential
 Treatment:
 Dialatation and Curettage – less than 12
weeks
 After 12 weeks – IV Oxytocin drip /
Prostaglandin vaginal pessaries or Gel / IM
injections of PG F2 alfa.

20.  Any abortion associated with evidence of
infection in the uterus and its contents
 Clinical features:
 Temperature – 100.4 degree F for 24 hrs or
more
 Offensive or purulent vaginal discharge
 Lower abdominal pain and tenderness
 This is mostly due to incomplete and illegal
abortions or also following spontaneus
abortion

21.  Peritonitis features may be present
 Vaginal examination – cervix may be closed
or dilated , pus like offensive discharge
 Tender uterus and size of uterus will be
lesser than amenorrhea
 Organisms responsible for sepsis:
 E.coli, Klebsiella, Staph.aureus, Clostridium
welchi and perfringens etc.,
 Complications - Endotoxemic shock, acute
renal failure, DIC, Peritonitis and Gas
gangrene

22.  Investigations:
 Endo cervical swab for culture & sensitivity
 High vaginal swab for culture & Sensitivity
 CBC
 DIC profile if required
 Blood culture
 Urine Culture
 Ultrasound

23.  Treatment:
 IV Antibiotics – for aerobic, anaerobic
organisms – IV Ampicillin, Gentamycina and
Metronidazole
 Anti Gas Gangrene serum
 Treatment of complications
 Surgery – Evacuation of uterus and
Laparotomy if necessary depending on
peritonitis features

24.  Development of gestational sac without any
evidence of fetus or fetal parts
 Diagnosis – Ultrasound
 Treatment – Dilatation and Curettage
 Tissue should be sent for Fetal karyotyping

25.  A sequence of three or more consecutive
abortions before 20 weeks
 Incidence – 1 %
 Causes:
 First Trimester – Genetic, Endocrine and
Metabolic, Infection, Inherited
thrombophilia, Immunological and
unexplained
 Second Trimester – Bicornuate uterus,
Unicornuate uterus, septate uterus, Cervical
incompetence.

30.  Cervix is unable to with hold the fetus faulty
defect in the sphincteric mechanism.
 Retentive power of cervix is impaired
 Causes:
 Congenital
 Iatrogenic – Dilatation and Curettage,
Amputation of the cervix, cone biopsy
 Clinical features: History of recurrent mid
trimester abortions where leaking followed
by painless expulsion of fetus

32.  Diagnosis:
 Ultrasound – Cervical length less than 2.5 cm
and cervical dilatation more than 1.5 cm
with funneling of cervix and bulging of
membranes
 Periodic per speculum examination
 Treatment:
 Cervical Circlage with Merseline tape at 16 –
18 weeks – Mc Donald operation
 Shiridkar’s operation

34.  Medical Termination of Pregnancy
 Indications:
 Failure of contraception
 Rape
 Medical diseases that may deteriorate
mother’s health
 Congenital anomalies

35.  First Trimester
 Surgical :
 Manual Vacuum Aspiration
 Dilatation and Curettage
 Suction and Evacuation
 Medical:
 Prostaglandin preparations
 Mifepristone
 Misoprostol

36.  Second Trimester:
 Intraamnitic instillation of PGF2 alfa or
Hypertonic saline
 Extraamniotic ethacrydine lactate or PGf2
alfa
 Oxytocin Infusion
 Hysterotomy