Different kinds of abortion

1. ABORTION
Prepared by
Neha kewat
Tutor

2. ABORTION
Interuption of pregnancy Or expulsion of the product of
conception before the fetus is viable is called abortion.
The fetus is generally considered to be viable any time
after the fifth to six month of gestation.

3. Cont..
• 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). This 500 g of fetal development is attained
approximately at 22 weeks of gestation. The
expelled embryo Or fetus is called abortus.

4. CAUSES OF ABORTION
1.Genetic Factors :-
• Autosomal trisomy
• Polyploidy
• Monosomy
• 2. Endocrine and metabolic factors
• 3. Anatomical abnormalities
• 4. Infections
• 5. Immunological disorders :- Both
autoimmune and alloimmune factors can
cause miscarriage.

5. • 6. Blood group incompatibility :- Incompatible ABO
group matching my be responsible for early pregnancy
wastage and often recurrent but Rh incompatibility is a
rare cause of death of the fetus before 28 week. Couple
with group A husband and group O wife have got higher
incidence of abortion.
• 7. Premature rupture of membranes inevitably leads to
abortion.
• 8. Environmental Factors :-
• Cigarette smoking
• Alcohol
• Contraceptive agents - IUD in situ increase the risk
whereas oral pills do not.
• Drugs, chemicals, noxious agents - anesthetic gases,
arsenic, formaldehyde increase the risk.

6. TYPES OF ABORTION :-

7. SPONTANEOUS ABORTION
(MISCARRIAGE) :-
1.Threatened miscarriage :-
It is a clinical entity where the process of miscarriage
has started but has not progressed to a state from
which recovery is impossible.

8. Clinical feature:-
Bleeding per vaginum
Pain :- Bleeding is usually painless but there may be mild
backache or dull pain in lower abdomen. Pain appears usually
following hemorrhage.
Treatment :-
Rest
Drugs :- Relief of pain may be ensured by diazepam 5 mg
tablet twice daily.

9. 2.Inevitable miscarriage :-
It is the clinical type of abortion where the changes
have progressed to a state from where continuation
of pregnancy is impossible.

10. Clinical feature:-
Increased vaginal bleeding
Aggravation of pain in the lower abdomen which may
be colicky in nature
Management :-
Aim :- 1. To acclerate the process of expulsion
2. To maintain strict asepsis.
Active Treatment :-
Before 12 weeks :-
Dilatation and evacuation followed by curettage of
uterine cavity by blunt curette using analgesia or under
general anaesthesia.

11. After 12 weeks :-
The uterine contraction is accelerated by oxytocin drip
40 - 60 drops per minute.
If the fetus is expelled and placenta is retained, it is
removed by ovum forceps
If the placenta is not separated , digital separation
followed by its evacuation is to be done under general
anesthesia.

12. 3. Complete miscarriage :- When the products of
conception are expelled en masse, it is called complete
miscarriage.
Clinical feature :- There is history of expulsion of a fleshy
mass per vaginam followed by :
Subsidence of abdominal pain
Vaginal bleeding become trace or absent
Internal examination reveals :-
Uterus is smaller than the period of amenorrhea and little
firmer

13. Cervical os is closed
Bleeding is trace
Examination of the expelled fleshy mass is found
complete.
MANAGEMENT :-
Transvaginal sonography is useful to see that uterine
cavity is empty, otherwise evacuation of uterine
curettage should be done.

14. 4. Incomplete miscarriage :- when the
entire products of conception are not
expelled, instead a part of it is left inside
the uterine cavity, it is called incomplete
miscarriage.
Clinical Feature :-
Continuation of pain lower abdomen
Persistence of vaginal bleeding

15. Internal examination reveals :-
Uterus smaller than the period of amenorrhea
Patulous cervical os often admitting tip of the finger
Varying amount of bleeding
on examination, the expelled mass is found
incomplete.

16. Management :-
In recent cases :- Evacuation of the retained
products of conception ( ERCP) is done.
She should be resuscitated before any active
treatment is undertaken.
Early abortion :- Dilatation and evacuation under
analgesia or general anaesthesia is to be done.
Late abortion :- The uterus is evacuated under
general anesthesia and the products are removed
by ovum forceps or by blunt curette. In late cases,
dilatation and curettage operation is to be done to
remove the bits of tissues left behind.

17. 5.Missed Miscarriage :- When the fetus is dead and
retained inside the uterus for a variable period, it is
called missed miscarriage or early fetal demise.
Clinical features :-
The patient usually presents with features of
threatened miscarriage followed by:
(1) Persistence of brownish vaginal discharge
(2) Subsidence of pregnancy symptoms
(3) Retrogression of breast changes
(4) Cessation of uterine growth which in fact becomes
smaller in size

18. (5) Non audibility of the fetal heart sound even with
Doppler ultra sound if it had been audible before
(6) Cervix feels firm
(7) Immunological test for pregnancy becomes
negative
(8) Real time ultrasonography reveals an empty sac
early in the pregnancy or the absence of fetal motion
or fetal cardiac movements.

19. Management :-
1. Uterus is less than 12 weeks :-
Expectant management :- Many women expel the
conceptus spontaneously.
Medical management :- Prostaglandin E1 800mg
vaginally in the posterior fornix is given and repeated
after 24 hrs if needed. Expulsion usually occurs within
48 hrs.
Suction evacuation or dilatation and evacuation is
done either as a definitive treatment or it can be
done when the medical method fails.

20. Uterus more than 12 weeks :-
Prostaglandins are more effective than oxytocin in
such cases. The methods used are:
(a)Prostaglandin E, analogue (misoprostol) 200 ug
tablet is inserted into the posterior vaginal fornix
every 4 hours for a maximum of 5 such.
(b)Oxytocin-10-20 units of oxytocin in 500 ml of
normal saline at 30 drops per minute is started. If
fails, escalating dose of oxytocin to the maximum of
200 mIU/min, may be used with monitoring.

21. (c)Many patients need surgical evacuation following
medical treatment. Following medical
treatment,ultrasonography should be done to
document empty uterine cavity. Otherwise evacuation
of the retained products of conception (ERPC) should
be done.
(d)Dilatation and evacuation is done once the cervix
becomes soft with use of PGE, Otherwise cervical
canal is dilated using the mechanical dilators or by
laminaria tent .Evacuation of the uterine cavity is done
thereafter slowly.

22. 6. SEPTIC ABORTION :- Any abortion associated with
clinical evidences of infection of the uterus and its
contents, called septic abortion.
Although clinical criteria vary, abortion is usually
considered septic when there in
(1) rise of temperature of at least 100.4°F (38°C) for
24 hours or more
(2) offensive or purulent vaginal discharge.
(3) other evidences of pelvic infection such as lower
abdominal pain and tenderness.

23. Mode of infection :- The microorganisms involved in the
sepsis are usually those normally present in the vagina
(endogenous).
The microorganisms are:
(a) Anaerobic-Bacteroides group (fragilis), anaerobic
Streptococci,Cl.welchi and tetanus bacillus
(b) Aerobic-Escherichia coli (E. coli), Klebsiella,
Staphylococcus, Pseudomonas and hemolytic
Streptococcus (usually exogenous)

24. . Mixed infection is more common. The increased
association of sepsis in illegal induced abortion is due to
the fact that:
(1) proper antiseptic and asepsis are not taken
(2) incomplete evacuation and
(3) inadvertent injury to the genital organs and adjacent
structures, particularly the bowels

25. Clinical features :-
1.Pyrexia
2.Abdomen pain
3. A rising pulse rate of 100 - 120/ min
4.Variable systemic and abdominal findings depending
upon the spread of infection.
5.Internal examination reveals offensive purulent
vaginal discharge Or a tender uterus.

26. 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.

27. Management :-
Grade I :-
1. Antibiotics
2.Prophylactic anti -gas - gangrene serum of 8000
units and 3000 units of antitetanus serum IM are
given if there is a history of interference.
3. Analgesics and sedatives
4. Blood transfusion is given to improve anemia and
body resistance.

28. Grade II :-
1. Antibiotics
(A).Gram positive aerobes :-
i.Aqueous penicillin G 5 million units IV every 6 hour
ii.Ampicillin 0.5 - 1 gm IV every 6 hours.
(B). Gram negative aerobes :-
i.Gentamicin 1.5 mg/kg IV every 8 hours
ii. Ceftriaxone IG, IV every 12 hours.
(C).For Anaerobes :-
Metronidazole 500 mg IV every 8 hours or
clindamycin 600 mg IV every 6 hours.

29. 2. Blood transfusion
Surgery:
(1) Evacuation of the uterus-Evacuation should be
withheld for at least 48 hours when the infection is
controlled and is localized, the only exception being
excessive bleeding.
(2) Posterior colpotomy When the infection is localized in
the pouch of Douglas pelvic abscess is formed. It is
evidenced by spiky rise of temperature, rectal tenesmus
(frequent loose stool mixed with mucus) and boggy mass
felt through the posterior fornix. Posterior colpotomy and
drainage of the pus relieve the symptoms and improve the

30. GRADE-III
Antibiotics are discussed above. Clinical monitoring is
to be conducted as outlined in Grade-II. Supportive
therapy is directed to treat generalized peritonitis by
gastric suction and intravenous saline infusion.
Management of endotoxic shock or renal failure, if
present, is to be conducted as described in the
chapter 38. Patient may need intensive care unit
management

31. Active Surgery:
Indications are-
(1) Injury to the uterus
(2) Suspected injury to bowel
(3) Presence of foreign body in the abdomen as
evidenced by the sonography or X-ray or felt through
the fornix on bimanual examination
(4) Unresponsive peritonitis suggestive of collection
of pus
(5) Septic shock or oliguria not responding to the
conservative treatment
(6) Uterus too big to be safely evacuated per vaginam.