The document provides guidelines for the management of abortion in various situations: 1. Threatened abortion is to be managed conservatively with bed rest, avoiding intercourse, and following up with ultrasound to check for fetal cardiac activity. Hormone therapy or anti-D immunoglobulin may also be used. 2. For inevitable or incomplete abortions, evacuation of the pregnancy is necessary, along with resuscitation if needed. Prophylactic antibiotics and anti-D immunoglobulin should also be given. 3. Recurrent miscarriage can be managed with cervical cerclage if cervical incompetence is documented, while other causes like genetic issues require their own management approaches.

1. MANAGEMENT OF
ABORTION

2. Threatened Abortion
 Conservative with bed rest and reassurance till
bleeding stops.
 Sexual intercourse best avoided.
 Follow up with ULTRASOUND-presence of fetal
cardiac activity predicts good outcome in 95%of
cases.
 Hormone therapy -400mg natural progesterone
in 2divided doses orally or vaginally on
empirical basis.
 Anti D if mother is Rh negative and pregnancy
is beyond 12 weeks.

3. Inevitable Abortion
 Immediate evacuation of pregnancy.
(If duration of pregnancy less than 12 weeks-
suction evacuation and greater than 12 weeks
oxytocin infusion.)
 Shock-resuscitation with i/v fluids and blood
transfusion.
 Prophylactic antibodies and anti-D.

5. Suction abortion

9. Incomplete Abortion
 Resuscitation if patient is in shock and
evacuation by suction evacuation.
 If the os is closed PGE1 tablets are kept in
vagina for ripening the cervix.
 Prophylactic antibodies and anti D

10. Complete abortion
 Conservative
 Anti D not indicated if pregnancy is less than
12 weeks and there was no operative
intervention.

11. Missed Abortion
 Uterus evacuated as soon as possible. A
donor should be kept ready.
 If uterine size is less than 12 weeks of
gestation PGE1 tablets kept in vagina results
in spontaneous expulsion without the need of
surgical intervention.
 If more than 12 weeks, 6th or 12th hourly PGE1
tablets used vaginally results in spontaneous
expulsion or extra amniotic ethacridine
acetate.
 Anti D and antibiotics.

12. Septic Abortion
 Police notification if a criminal abortion is
suspected.
 Mild cases-broad spectrum antibiotics are
started and uterus evacuated.
 Severe cases-maintenance of perfusion and
ventilation.
 I/v infusion and CVP line is inserted
 Blood transfusion
 Oxygen given by nasal catheter.

13. CVP line

14. Septic Abortion(cont……..)
 Antibiotics commenced after taking a high
vaginal swab.
 Ampicillin,Gentamycin and Metronidazole/third
generation cephalosporin like cefotaxime or
cefuroxime with metronidazole or clindamycin.
 Evacuation of uterus after infection is
controlled.

15. Recurrent Miscarriage
 Due to cervical incompetence
M anagem is be cervical cerclage if there is a well
ent
docum ented history otherwise serial follow up is done
with transvaginal ultrasound for early signs of
incom petence.Cervical cerclage is usually delayed upto
12-14 weeks so that m iscarriage due to other causes can be
eliminated.
Sonography is done to confirm live fetus and if there is
infection,it should be treated and sexual intercourse
should be avoided.
Contraindications-B leeding,contractions/ ruptured
m branes.
em

16. Cerclage

17. 1.McDonald’s Cerclage
Patient is in lithotomy position and cervix is
exposed with Sim’s speculum.The cervical lips
are held with sponge holding forceps and a
purse string suture with a non absorbable
material like black silk is taken all around the
cervix.
Disadvantage –suture may be below internal os.

18. McDonald’s cerclage

20. 2.Modified Shirodkar’s
cerclage.
Small transverse incision is made on
anterior lip of cervix at cervicovaginal
junction 2cm above the external os.Bladder
is then pushed up and a suture of black silk
or mersilene tape is passed from anterior to
posterior aspect submucosally using
Shirodkar’s or any curve bodied needle.2
ends of the suture are pulled and tied
posteriorly.Anterior incision is closed with

21. Shirodkar’s cerclage

22. 3.Transabdominal cerclage
Done in cases of repeated failure of
vaginal approach and cervix is inaccessible
Disadvantage-Caesarean section
In case of miscarry cerclage has to be
removed at laparotomy.

23. Post operative care
 Bed rest for 48 hours
 Antibiotic cover
 Avoid sexual intercourse
 Cerclage is removed at 37 weeks or at the
onset of labour ,if not it can result in rupture
uterus.

24. Other cases of recurrent
miscarriage
 Chromosomal abnormalities-karyotyping of both
parents and prenatal diagnosis in the next
pregnancy.
 Uterine factors-hysteroscopic resection in case of
a septum or division of the adhesion in
Asherman’s syndrome. Myomectomy in case of
fibroid.
 APLA Syndrome-Combination of low dose aspirin
and low MW heparin as soon as pregnancy is
confirmed.Aspirin preconceptionally.
 Inherited thrombophilia-Low dose aspirin and
heparin.

25. Induced abortion
 THE MEDICAL TERMINATION OF PREGNANCY ACT, 1971
 (Act No. 34 of 1971)
 (10th August 1971)

 An Act to provide for the termination of certain pregnancies by registered Medical Practitioners and for matters
connected therewith or incidental thereto.

 Be it enacted by Parliament in the Twenty-second Year of the Republic of India as follows :-

 1. Short title, extent and commencement –

 This Act may be called the Medical Termination of Pregnancy Act, 1971.
 It extends to the whole of India except the State of Jammu and Kashmir.
 It shall come into force on such date as the Central Government may, by notification in the Official Gazette, appoint.

 2. Definitions - In this Act, unless the context otherwise requires, -

 “guardian” means a person having the care of the person of a minor or a lunatic;

 “lunatic” has the meaning assigned to it in section 3 of the Indian Lunatic Act, 1912 ( 4 of 1912);

 “minor” means a person who, under the provisions of the Indian Majority Act, 1875 ( 9 of 1875), is to be deemed not
to have attained his majority;

26.  (d) “registered medical practitioner” means a medical practitioner who possesses any recognized
medical qualification as defined in clause (h) of section 2 of the Indian Medical Council Act, 1956, (102 of
1956), whose name has been entered in a State Medical Register and who has such experience or training in
gynaecology and obstetrics as may be prescribed by rules made under this Act.
Place where pregnancy may be terminated - No termination of pregnancy shall be made in accordance with this Act at
any place other than -
a hospital established or maintained by Government, or
a place for the time being approved for the purpose of this Act by Government.