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Abortion PG Seminar Power point presentation
- 1. Abortion Dr Aksshaya 1st yearPost graduate MS Obstetrics and Gynecology
- 2. Abortion • Termination ofpregnancy < 20 weeks of gestation. • WHO criteria : Termination of pregnancy occurs in fetus weighing < 500g, at the time of termination • Early pregnancy loss : < 12 weeks • Still birth : Pregnancy loss > 20 weeks • Anembryonic pregnancy : Non viable pregnancy with a gestational sac that does not contain a yolk sac/ embryo. AKA blighted ovum.
- 3. Risk factors • Increasedmaternal age ≥ 35 years • Previous history of abortions • Maternal infections like Viral : Rubella, CMV, Variola, Vaccinia or HIV Parascitic : Toxoplasma, Malaria Bacterial : Ureplasma, Chlamyia, Brucella, Spirochetes. • Maternal factors : Uncontrolled diabetes, Thyroid disorders, Obesity, Stress, Pregnancy with IUCD in place, Substance abuse and radiation exposure.
- 4. Classifications of abortions Abortion Recurrent pregnancyloss Isolated spontaneous abortion Induced abortion Spontaneous abortion Illegal Abortion Legal Abortion • Threatened abortion • Inevitable abortion • Complete abortion • Incomplete abortion • Missed abortion • Septic abortion
- 5. Isolated abortions • Canhappen in 1st and 2nd trimester • Most common cause : Chromosomal anamolies Aneuploidy > Trisomy (group trisomy) > Monosomy X (20%) > Trisomy (16%) • Uterine anomalies : Fibroids, adhesions, septae, Cervical incompetence • Trauma • Infections : Chorioamnionitis, maternal infections like TORCH • Thrombophilias
- 6. Isolated abortions (Contd..) •Environmental factors : Cigarette smoking, Contraceptive agents, drugs, chemicals,noxious agents
- 7. Clinical classification ofSpontaneous abortion • Threatened abortion • Inevitable abortion • Complete abortion • Incomplete abortion • Missed abortion • Septic abortion
- 8. Threatened abortion • Clinicalentity where the process of miscarriage has started but has not progressed to a state from which recovery is impossible. • History : Spotting PV +/- Pain abdomen • C/F : Bleeding PV > Pain P/A : Height of the uterus = Period of gestation P/S : Bleeding if any, escapes through os Internal os - Closed (reversible) D/D : Cervical ectopy, polyps or carcinoma, ectopic pregnancy and molar pregnancy USG : Cardiac activity +
- 9. Management : Nodefenitive treatment Emperical treatment : • Avoid heavy weight lifting • Avoid intercourse • Rest for 48 hours Anti D injection to be given to the Rh negative pregnant women with threatened abortion at ≥ 12 weeks(2nd trimester)
- 10. Inevitable abortion • Theprocess of abortion has reached the stage from where it is not reversible • History : Bleeding + pain abdomen • No H/O expulsion of products of conception • P/A : Height of the uterus = POG • Internal os - Open (Not reversible) • USG : Cardiac activity is absent • Management : Complete the process of abortion by Medical/ Surgical methods (MTP) • Anti D injection to be given to the all Rh negative pregnant women with inevitable abortion whether it is < 12 weeks or ≥ 12 weeks due to increased chance of fetomaternal hemorrhage (< 12 weeks - 50 mcg, ≥ 12 weeks - 300 mcg)
- 11. Incomplete abortion • Theprocess of abortion begins and POC starts coming out • 2nd MC type of abortion which leads to shock • History : POC coming out, bleeding, pain abdomen • P/A : Height of the uterus < POG • Internal os : Open + POC coming out • Management : Complete the process of abortion by Medical/ Surgical methods (MTP) • Anti D injection to be given to the all Rh negative pregnant women with incomplete abortion whether it is < 12 weeks or ≥ 12 weeks
- 12. Complete abortion • Theentire process of abortion is completed on its own • History : Initial H/O bleeding, pain abdomen, expulsion of POC with stoppage of bleeding later • P/A : Height of the uterus < POG • Internal os - Closed • USG : Empty uterus • Management : Reassurance • Anti D injection to be given if complete abortion occurs at ≥ 12 weeks
- 13. Missed abortion • Cardiacactivity of the fetus has stopped and patient is unaware about the abortion • No H/O bleeding • P/A : Height of the uterus < POG • Internal os - Closed Anti D injection to be given to the all Rh negative pregnant women with missed abortion whether it is < 12 weeks or ≥ 12 weeks
- 14. Diagnosis of Missedabortion • Mean sac diameter (MSD) ≥ 25mm and no embryo is seen • ≥ 11 days after the sac showing gestational sac with yolk sac but no embryo • ≥ 2 weeks after scan showing gestational sac without yolk sac or embryo • If CRL ≥ 7mm with no cardiac activity • Most common time for abortion : First trimester - more commonly <8 weeks
- 15. Approach to acase of abortion Approach Open No H/O POC coming out POC came out Open Close Close Incomplete abortion Complete abortion Inevitable abortion Height of the uterus < POG Height of the uterus = POG Threatened abortion Missed abortion
- 16. Septic abortion • Anyabortion associated with clinical evidence of infection of uterus and its contents • Criteria : • Rise of temprature of atleast 100.4o F for 24 hours or more • Offensive or purulent vaginal discharge • Other evidence of pelvic infection such as lower abdominal pain and tenderness • Majority of cases, the infection occurs following illegal induced abortion
- 17. Mode of infection •Anaerobic : Bacteriodes,anaerobic streptococcus, clostridium welchii and tetanus • Aerobic : E coli, Klebsiella, Staphylococcus, Pseudomonas, Beta hemolytic strep, MRSA • Mixed infection is more common
- 18. Clinical grading • Grade1 : Infection localized inside the uterus • Grade 2 : Infection spreading beyond Uterus and parametrium, tubes and ovaries or pelvic peritoneum • Grade 3 : Generalised peritonitis and/ or endotoxic shock or jaundice or acute renal failure
- 19. Management General management : •Hospitalization • High vaginal or cervical swab • Vaginal examination • Overall assessment • Investigations
- 20. Grade 1 Drugs : •Antibiotics • Prophylactic antigas gangrene serum of 8,000 units and 3,000 units of anti tetanus serum IM • Analgesics and sedatives • Evacuation of the uterus : Should be performed at a convinent time within 24 hours following antibiotic therapy
- 21. Grade 2 • Antibiotics •Analgesics and ATS • TPR/BP/Urine I/O charting • Look for pain progression, tenderness in lower abdomen. • Evacuation of the uterus : Withheld for atleast 48 hours when the infection is controlled or localised, only exception is excessive bleeding • Posterior colpotomy : Infection in POD, pelvic abscess
- 22. Grade 3 • Alongwith antibiotics and clinical monitoring • Supportive therapy to treat generalised peritonitis by gastric suction • Laparotomy : Uterus should be removed irrespective of parity. Adnexa is to be removed or preserved according to pathology • Even when nothing is found on laparotomy, simple drainage of pus is effective
- 23. Recurrent pregnancy loss •≥ 3 consecutive pregnancy losses at < 20 weeks. • Investigations should begin ≥ 2 abortions • M/C cause : Idiopathic • M/C group among other causes : Endocrinopathies > Uterine causes > Immunological causes > Chromosomal abnormalities
- 24. Endocrinopathies (15- 60%) Uterine causes(10-50%) Immunological causes Chromosomal abnormalities • Hypothyroidism • Hyperthyroidism • Uncontrolled DM • Increased Prolactin levels • Leuteal Phase defect • PCOS • Cervical Incompetence • Uterine malformations • Submucosal fibroid • Asherman’s syndrome APLA syndrome (Anti Phospholipid antibody) Balanced translocations of chromosomes
- 25. Endocrinopathies • Leuteal phasedefect :Decreased progesterone in the 2nd half of the cycle leading to abortion • Overt hypothyroidism or hyperthyroidism associated with increased fetal loss • Uncontrolled diabetes leads to increased miscarriage
- 26. Infections • Viral :Rubella, CMV, Variola, Vaccinia and HIV • Parasites : Toxoplasma, Malaria • Bacterial : Ureplasma, Chlamydia, brucella, Spirochetes • Infections are not reason for Recurrent pregnancy loss • Syphilis follows Kassowitz’s law : As the number of pregnancy losses increases the period of pregnancy at which the loss occurs also increases • 1st pregnancy : Abortion (<20 wks) • 2nd Pregnancy : Stillbirth (>20 wks) • 3rd pregnancy : Preterm labour
- 27. APLA syndrome Antibodies against: • Lupus anticoagulant : Most common • Anti cardiolipin antibody • Beta 2 glycoprotein antibody All these cause thrombosis : Arterial, Venous or placntal
- 28. Placental thrombosis : Completecut off of blood supply < 20 weeks - abortion (RPL) Complete cut off blood supply > 20 weeks - Still birth • Incomplete cut off blood supply - IUGR and PIH in mother
- 29. Diagnosis of APLAsyndrome • Modifies Sapporo criteria/ Sydney Criteria : 1 clinical criteria with 1 lab criteria should be present • Clinical criteria : ≥ 3 pregnancy losses at < 10 weeks with maternal anatomic or hormonal abnormalities and paternal and maternal chromosomal causes excluded ≥ 1 pregnancy loss at > 10 weeks morphologically normal fetus ≥ 1 preterm labour at < 34 weeks due to early onset eclampsia or IUGR morphologically normal neonate Vascular thrombosis Lab criteria : Presence of LAC/ Anti cardiolipin antibody/ Beta 2 glycoprotein : Presence of any of these in medium to high titres on 2 occasions 12 weeks apart
- 30. Management Non pregnant women: Warfarin (Drug of choice) Pregnant women : Low dose Aspirin • Given in all case of APLA syndrome • Started as soon as pregnancy is diagnosed • Ideally should be started before conception Low molecular weight heparin : • Started after confirmation of intrauterine pregnancy • Given only if there is H/O thrombosis or abortions
- 31. Pregnant female withpersistent LAC antibodies • Low dose Aspirin started as antibodies are present • If H/O thrombosis : Low dose aspirin and LMWH • If no H/O thrombosis : Check for pregnancy complications related to APLA syndrome • If complications present along with H/O abortion : Low dose aspirin + LMWH • If complications present along with H/O pre term labour due to PIH/ Uteroplacental insufficiency : Low dose Aspirin
- 32. Uterine anomalies • Canbe either congenital/ acquired • Congenital : M/C due to Mullerian anamolies ( Septate > Bicornuate) • Acquired causes : Cervical incompetence : M/C uterine anamolies causing RPL Submucous fibroid Polyps Adenomyosis Asherman’s syndrome
- 33. Investigations for Uterineanamolies • Pregnant female : TVS • Non pregnant female : Saline infusion sonography • 3D USG : IOC for mullerian anamolies • MRI : Gold standard investigation for mullerian anamolies • Hysteroscopy • Laparoscopy
- 34. Cervical incompetence • Causesmid trimester pregnancy loss • History based diagnosis of cervical incompetence ≥ 2 painless 2nd trimester pregnancy losses • Spontaneous dilation of cervix which is painless leading to expulsion of POC spontaneously • With every subsequent pregnancy, the time of pregnancy loss decreases
- 35. Risk factors • PastH/O surgeries on cervix : Conization/ LEEP (past H/O CIN) or amputation of cervix in fothergill’s surgery for vaginal prolapse • Cervical trauma during labour, instrumental delivery • Congenital abnormality is rare • Mostly Incompetence is a acquired defect
- 36. Diagnosis • H/O pregnantfemale with ≥ 2 painless 2nd trimester pregnancy losses managed with cervical encercalage and progesterone • H/O 1 painless 2nd trimester abortion : TVS done between 18-24 weeks (ideal time) can be done as early as 14 weeks • Principle for diagnosis : As the cervix dilates, length of the cervix shortens
- 37. • Cervical length≤ 2.5 cms with one 2nd trimester pregnancy losses is taken as cervical incompetence Normal length : 3-4 cms • Diameter of internal os : ≥ 2 cm • Shape of cervix becomes U shaped Normal shape of cervix in TVS : T shaped As the cervix shortens, Cx becomes Y shaped , then V shaped and then U shaped. Os is completely dilated
- 38. USG based diagnosis •H/O of one or more 2nd trimester abortions and TVS showing cervical length as ≤ 2.5 cm • Management : Cervical encercalage and progesterone • Diagnosis of cervical incompetence in a non pregnant female : If Hegar dilator no 8 can be passed through the internal os without any resistence from the female
- 39. Management • Surgery :Cervical encercalage (Transvaginal > Transabdominal) • M/C : Transvaginal (McDonalds and Shirodkars Cercalage) • McDonalds cercalage : Attempt is made to reach as close as possible to the internal os Sutures are applied at cervicovaginal junction Purse string sutures with non absorbable suture material 2’O clock --> 10’ O Clock --> 8’ O Clock --> 2 ‘O clock (Anti clockwise direction)
- 40. • Ideal timefor cercalage : 12 - 14 weeks • Can be done up till 24 weeks --> not to be done beyond 24 weeks • In all patient who has undergone cervical cercalage : Supplemental progesterone given up to 36 weeks + 6 days of gestation
- 41. • Shirodkar’s cercalage: The Cervicovaginal junction is out Suture applied at the internal Os Non absorbable sutures used Less failure rate • Transabdominal cercalage : Only done if transvaginal fails A Mersilene tape is placed at the level of isthmus between uterine walls and uterine vessels Done at 11 and 13 weeks following laparotomy
- 42. Cervical encercalage Indications • Ifhistory based or USG based criteria for incompetence is met Contraindications • Absolute : Gross Congenital anomalies, Current pelvic infections, ruptured membranes • Relative : Placenta previa
- 43. Cervical stitch removal •Time to remove : 37 weeks • Cervical stitch should be removed irrespective of period of gestation in case of : • Ruptured membranes • Patient goes in preterm labour • Chorioamnionitis
- 44. As per 2022amedment • MTP can be done upto 24 weeks • If pregnancy due to contraceptive failure can be done upto 20 weeks • Fetal anamoly : 24 weeks, If severe fetal anamolies - No upper limit • Single doctor’s opinion is needed uptil 20 weeks • 2 doctors opinion needed for 20-24 weeks
- 45. Medical Termination ofpregnancy • MTP act : 1971 • Ammendment : 2022 Consent : • Only female’s consent needed • If the female is < 18 years or mentally ill : Gaurdian’s consent Qualifications for MTP : • RMP who has assisted in 25 MTPs (atleast 5 as primary surgeon) • RMP who has done 6 months as house surgeon in OBG • Diploma/Degree in OBG
- 46. Methods of doingMTP 1st trimester : • Medical abortion • Suction evacuation • Manual vaccum aspiration 2nd trimester • Prostaglandins • Oxytocin • Dilatation and evacuation
- 47. Medical abortion Indian guidelinesWHO Upper limit 7 weeks 9 weeks Done As a OPD procedure if 7-9 weeks , IP basis Day 1 T. Mife 200 mg orally T. Mife 200 mg orally Day 3 T. Misoprostol 400 mcg oral/ buccal/PV/Sublingual/PR T. Misoprostol 800 mcg oral/ buccal/PV/Sublingual/PR Day 15 To ensure that the process is complete To ensure that the process is complete
- 48. Suction evacuation • Doneusing Karman’s canula • Number of Karman’s canula corresponds to the size of uterus • Dilatation : Hegar’s dilator • Pressure generated : 600 mmHg End point of suction : • Decreased blood loss • Gripping sensation • Grating sensation • Air bubbles in the cannula
- 49. Dilatation and evacuation •Similar to suction and evacuation till the dilatation of internal os • Sponge holding forceps/ Ovum forceps is used to carry out abortions • Check curettage with blunt curette is done MVA syringe : Used in rural areas where electricity is not available
- 50. References • Williams Obstetrics- 26th edition • DC dutta’s text book of obstetrics - 9th edition • Comprehensive Abortion care by Ministry of health and family welfare - Third editin (2023)
- 51.