2. Definition
It is expulsion or removal of the products of conception from the uterus before
viability of the fetus, that is before 20 weeks of pregnancy or if the fetus weigh
less than 500g or it’s length is less than 25cm (crown-heel length).
Viability starts after the twentieth week and means that when the fetus is
expelled from the uterus it can survive under favorable conditions.
5. Causes Abortion
FAULT IN THE EMBRYO
Most cases (80%) occur in the third month (8- 12 weeks) because at this period
the level of progesterone may drop as the corpus luteum is degenerating and
the placenta is not yet completely formed to carry out its function.
6. Cont..
FAULT IN THE MATERNAL ENVIRONMENT
Maternal diseases causing high fever.
Infection
Hormonal deficiencies as in progesterone deficiency in corpus luteum defect,
in hyperthyroidism or hypothyroidism.
Cervical incompetence
Rh-ve pregnancy
7. Cont…
Uterine fibroid causing improper implantation of the placenta.
Physical trauma,
Surgical trauma due to any operation.
Congenital malformations of the uterus like hypoplastic uterus,unicornuate,bicornate
uterus,septate uterus.
8. Cont…
Abortion may be accidental or reccurrent Accidental
1. Chromosomal abnormalities of the fetus
2. Trauma as blow on the abdomen or operative trauma
3. Fever
4. Maternal hypoxia
5. Over distension of the uterus by multiple pregnancy or acute polyhydramnios
6. Abortificient drugs as quinine
7. Psychological disturbances
11. Diagnosis
1. Signs and symptoms of pregnancy
2. Bleeding, which is usually slight or moderate.
3. Pain is absent or heaviness may be felt in the suprapubic region
4. On examination the uterus is found enlarged and the cervix is closed
5. Pregnancy test is positive
6. Ultrasound show a viable fetus
12. Mechanism Of Abortion
Before 8 weeks: Ovum surrounded by the villi with the decidual coverings is
expelled out. Because the external os fails to dilate the entire mass remains in
cervix. Called as “Cervical Abortion”.
8-14 weeks: Expulsion of the fetus commonly occurs leaving behind the
placenta and membranes, so that there will be bleeding.
Beyond 14th week: Expulsion is similar to that of “mini labour”. The fetus is
expelled first followed by expulsion of placenta.
13.
14.
15. Spontaneous Abortion
Definition: It is defined as the involuntary loss of the products of conception
prior to 20 weeks of gestation.
Incidence: 15% of all confirmed pregnancy 80% occur in first trimester
16. Threatened Abortion
Painless vaginal bleeding, that occur at
anytime between implantation and 24
weeks of gestation. POC has
threatened to abort but has not done
so yet.
17. Clinical features:
• Bleeding (minimal, painless)
• Associated with dull aching lower abdominal pain Examination: • Size of uterus
is correspond to period of amenorrhea (POA)
• Closed cervical os
• U/S : well-formed, rounded gestational sac with fetus within it .
19. Inevitable abortion
Bleeding stops, the embryo or fetus is
still alive and pregnancy continue (50%)
2. Bleeding stops, the embryo dies but
is retained in the uterus leading to
missed abortion 3. Bleeding increases,
uterine contractions occur, and cervix
dilates leading to inevitable.
20. Clinical features
History of amenorrhoea
Vaginal bleeding with passages of fresh blood and clots.
Pain due to uterine contraction
Pallor
Cold,clammy extremities
Tachycardia
Hypotension
Cervix soft to firm and bulky,corresponding to the period of gestation.
22. Management
1. Rest in bed until bleeding stops and days afterwards
2. Travelling and sexual intercourse are avoided
3. Analgesics and antibiotics
4. Treatment of the cause
5. Hormones like thyroxine
6. Evacuation of the uterus if indicated
7. Anti-D
23. INCOMPLETE ABORTION
Definition : POC has aborted but not
completely. When the entire products
of conception are not expelled, instead
a part of it is left inside the uterine
cavity, is called incomplete abortion.
24. Clinical Features:
• Vaginal bleeding (heavy, passed out POC as fleshy masses)
• Associated with colicky pain at lower abdomen
• +/- signs of shock
Examination
• Size of uterus is smaller than POA
• Open cervical os
• USG: reveal retained POC in uterine cavity
25. Management:-
• Resuscitate if bleeding is severe, do blood group and cross match
• Give analgesia for pain
• Evacuation retained product of conception
26. COMPLETE ABORTION
Definition : All the POC has completely
aborted. When the products of
conception are completely expelled, it
is called complete abortion.
27. Clinical features:
• History of pain and passage of product
• Followed by absent of pain, minimal bleeding
•Subsidence of pain
•Vaginal bleeding becomes trace or absent
Examination: • Size of uterus is smaller than period of amenorrhoea (POA )
• Closed cervical os
• empty uterine cavity
•Bleeding is trace
28. Management
Blood loss should be assessed and treated.
If there is doubt about complete expulsion of products, uterine curettage
should be done.
Transvaginal sonography is useful to prevent unnecessary surgical procedure.
In case of Rh negative mother anti D gamma globulin should be given.
29. MISSED ABORTION
Definition : When the embryo/fetus is
already died : but still remain in the
uterine cavity for a period of time :
without symptoms of miscarriage
30. Clinical features
• Decreased in pregnancy symptoms
• Vaginal bleeding (absent, minimal)
Examination:
• Size of uterus is smaller than POA
• Closed cervical os
• U/S : crumpled gestational sac : revealed fetal pole but no signs of activity (no
heart activity)
31. Management
Less than 12wks: vaginal evacuation by suction evacuation or slow dilatation of
the cervix by laminaria tent followed by dilatation and evacuation of the uterus
under GA.
If more than 12wks: Induction is done -Oxytocin 10-20U in 500ml NS at
30drops/min.
If fails increase dose to maximum of 200mlU/min
Prostaglandins:-misoprostol tab inserted into the posterior vaginal fornix
IM administration of 15methyl PGF2α (carboprost tromethamine)
32. RECURRENT ABORTION
Definition : Recurrent miscarriage is defined as a sequence of three or more
consecutive spontaneous abortion before 20weeks. Recurrent / Spontaneous
miscarriage
Can be divided into:-
• Uterine abnormality (uterine fibroid)
• Endocrine (DM, thyrotoxicosis, PCOS)
• Autoimmune (SLE)
• Infection (TORCHES) 1st trimester abortion (<12 weeks)
• Cervical incompetence (hx of termination of pregnancy, vigorous dilatation of
cervix, hx of cone biopsy)
• Uterine abnormalities (septate or subseptate uterus) 2nd trimester abortion
(>12 weeks)
33. Cont…
Etiology During 1st trimester
Genetic factors
Endocrine and metabolic
Infection
Inherited Thrombophiliaintra vascular coagulation .(protein C-natural inhi-of
coag)
Immunological cause : Auto & Allo immunity
Unexplained
36. Cont
1.Diagnostic test
a. Blood glucose , VDRL , Thyroid function test, ABO and Rh grouping
b. Autoimmune screening
c. USG
d. Hysterosalpingography
e. Hysteroscopy / Laparoscopy
f. Endocervical swab
37. Treatment During Inter
conceptional Period
To alleviate anxiety and improve psychology
Hysteroscopic resection of uterine septate
Uterine unification operation (metroplasty) for bicornuate uterus.
Genetic counselling if chromosomal abnormality .
Endocrine dysfunction has to be controlled.
Genital tract infections are treated.
38. Septic Abortion
Definition -Any abortion associated with clinical evidences of infection of the
uterus and its contents.
Criteria
• Rise of temperature 100.4*for 24 hrs
• Offensive or purulent vaginal discharge
• Lower abdominal pain and tenderness
39. Cont…
Mode of infection Usually the micro-organisms present in the vagina are
involved in sepsis when the resistance power of the mother becomes low.
of cases the infection occurs following illegal induced abortion.
Reasons for infection
• Proper antiseptic and asepsis are not taken
• Incomplete evacuation
40. Cont…
Clinical features
Pyrexia associated with chills and rigors.
Purulent vaginal discharge
Shock
Pain abdomen
Internal examination reveals: -
Offensive purulent vaginal discharge
Tender uterus
41. Cont…
Clinical grading
Grade I : Infection localised to uterus (commonest)
Grade II : infection spreads beyond the uterus to the tubes and
ovaries.
Grade III : Generalised peritonitis / shock / jaundice or acute renal
failure (associated with illegal induced abortion).
42. Investigations
Routine investigations : -
Cervical or high vaginal swab for culture and sensitivity test.
Blood for haemoglobin, total and differential count, ABO and Rh grouping.
Urine analysis including culture
Special investigations : -
USG abdomen and pelvis
Blood for culture, serum electrolytes, coagulation profile
43. Complications Immediate
Haemorrhage
Injury to uterus and adjacent structures
Spread of infection causes Peritonitis
Acute renal failure
Thrombophlebitis
Remote :-
Chronic pelvic pain, Backache
Dyspareunia
Ectopic pregnancy
Secondary infertility due to tubal blockage
Emotional depression.
45. Management
• Hospitalization
• To control the sepsis
• To remove the source of infection
• To give the supportive therapy
• To bring back the normal homeostatic and cellular metabolism
• To assess the response to treatment
46. Cont…
Specific management Drugs : -
1.Antibiotics Gram positive aerobes
a)Aqueous Penicillin G 5million U IV every 6 hours
(b)Ampicillin 0.5-1gm IV every 6 hours.
2.Gram negative aerobes
(a)Gentamicin 1.5mg/kg IV every 8 hours.
(b)Ceftriaxone 1.5gm IV every 12 hours
47. Cont…
For Anaerobes
(a) Metronidazole 500mg IV every 8hours
(b) Clindamycin 600mg IV every 6hours Grade I
1.Antibiotics
2. Prophylactic anti gas-gangrene Serum of 8000 U and 3000 U of anti tetanus
serum IM are given.
Analgesics and Sedatives
Blood transfusion
Evacuation of the uterus within 24hours following antibiotic therapy
48. Induced abortion
Definition
Deliberate termination of pregnancy before the viability of the fetus is called
induction of abortion
Elective: if performed for a woman’s desires Therapeutic: if performed for reasons of
maintaining health of the mother
MTP ACT -1971 • The continuation of pregnancy would involve seroius risk of life or
grave injury to the physical and mental health of the pregnant women • There is a
substantial risk of the child being born with serious physical and mental
abnormalities so as to be handicapped in life
• When the pregnancy caused by rape ,both in case of major and minor girl and in
mentally imbalance women
1.• Pregnancy result as a result of contraceptive failure
49. Indication
• To safe the life of the mother
Cardiac diseases
Ch.Glomerulonephritis
Malignant hypertension
Hyperemesis gravidarum
Cervical breast malignancy
DM with retinopathy
Epilepsy or psychiatric diaseases with advice of psychiatrist
50. Cont…
Social indications -unplanned pregnancy with low socioeconomic status
-pregnancy caused by rape or failure of contraceptive methods
• Eugenic -Structural-anencephaly ,chromosomal (down syndrome) or genetic
(hemophilia) -Teratogenic drugs(warfarrin)radiation exposure more than 10 rads
early pregnancy
- rubella infection
51. Cont…
First Trimester Abortion
• Early Uterine Evacuation (EUE),
Minisuction Introduced in 1972 by Karman and Potts
• Menstrual Regulation
• Suction Abortion
• Vacuum Curettage
•
52. Cont…
Medical Abortion/medical methods
Mifepristone (RU 486) With misoprostol
Methotrexate with misoprostol
Tamoxifen with misoprostol
Surgical methods
MVA
Suction evacuation
Aspiration of endometrial cavity
53. Cont…
Second Trimester Termination
• Dilatation and evacuation (D&E)
• Intrauterine injection of abortifacients
• Prostaglandin vaginal suppositories
• High dose oxytocin
• Hysterotomy
54. Cont…
Surgical techniques for abortion
• Menstrual aspiration(menstrual regulation ) – Aspiration of endometrial cavity using a flexible
cannula and syringe within 1-3 weeks after failure to menstruate – Several points at early stage of
gestation
• Woman not being pregnant
• Implanted zygote may be missed by the curette
• Failure to recognize an ectopic pregnancy
• Infrequently, a uterus can be perforated
Dilatation and curettage (D&C)
• Removal of pregnancy contents by some mechanical means
• Vacuum most commonly used
• 12-13 weeks is the upper limit of gestational age
• Usually performed in free standing clinics
55. Cont…
Medical Abortion
• Mifepristone (RU486)
Analogue of progestin norethindrone
Strong affinity for the progesterone receptor, acting as an antagonist
A single oral dose given to women 5 weeks or less produces abortion in 85% of
cases
1.Mifepristone protocol
• Women less than 49 days LMP with confirmed β-hCG
• 600mg mifepristone on day 1
• On day three, return for prostaglandin, Misoprostol 400 mcg orally
• Patient remain in clinic four hours, during which time expulsion of pregnancy
occurs
56. Cont…
Prostaglandin,(PGF2a)
hypertonic saline(20%)
hypertonic urea are introduced by amniocentesis
Fetus and placenta are aborted vaginally • Osmotic dilators are used to
decrease time to delivery and decrease complications
High Dose Oxytocin • As effective as PGE2 when used in appropriate doses •
Risk of water intoxication
Surgical method
Hysterotomy • Surgical method to remove pregnancy abdominally (mini-
cesarean section)
D & C
57. Complications
Complications - Immediate
• Complications of local anesthetic
• Cervical shock
• Cervical lacerations
• Uterine perforation
• Hemorrhage
• Post abortal syndrome
Delayed
• Bleeding –Retained products
• Infection
• Continued pregnancy
