Abortion

1. ABORTION
DR. KETAKI JUNNARE
SKN MC & GH

2. DEFINITION

ABORTION (MISCARRIAGE)
EXPULSION OR EXTRACTION FROM ITS
MOTHER OF AN EMBRYO OR FETUS
WEIGHING 500 GM OR LESS WHEN IT IS
NOT CAPABLE OF INDEPENDENT SURVIVAL
(APPROXIMATELY 24 WKS)

ABORTUS – EXPELLED EMBRYO

3. INCIDENCE

10-20 % OF CLINICAL PREGNANCIES

4. CLASSIFICATION

SPONTANEOUS
(SPORADIC/RECURRENT)
 THREATENED
 INEVITABLE
 COMPLETE
 INCOMPLETE
 MISSED
 SEPTIC



INDUCED
LEGAL (MTP)
ILLEGAL

5. ETIOLOGY
1.GENETIC - CHROMOSOMAL ABNORMALITIES
50% -1ST TRIMESTER ABORTIONS
 AUTOSOMAL TRISOMY (50%) – TRISOMY 16
 POLYPLOIDY (22%) -3n, 4n
 MONOSOMY (20%) – 45X
 STRUCTURAL CHROMOSIMAL REARRANGEMENTS
(2-4%) TRASLOCATION DELETION
 OTHERS – MOSAIC , DOUBLE TRISOMY

6. 2. ENDOCRINE (10-15%)



LUTEAL PHASE DEFECT
THYROID ABNORMALIYIES
DIABETES MELLITUS
3. ANATOMICAL (10-15%)




CERVICAL INCOMPETANCE
CONGENITAL MALFORMATIONS OF UTERUS
FIBROID
INTRAUTERINE ADHESIONS

7. 4 . INFECTIONS (5%)



VIRAL – CMV , RUBELLA ,VARIOLA VACCINIA
PARASITIC – TOXOPLASMA , MALARIA
BACTERIAL – UREAPLASMA , CHLAMYDIA , BRUCELLA
5 . IMMUNOLOGICAL DISORDERS (5-10%)


AUTOIMMUNE DISEASES – ANA , APLA (LAC , aCL )
ALLOIMMUNE DISEASE – PATERNAL HLA SHARING WITH
MOTHER
6 . MATERNAL MEDICAL ILLNESS


CYNOTIC HEART DISEASE
HAEMOGLOBINOPATHIES

8. 7 . ANTIFETAL ANTIBODIES
NK CELLS
8 . BLOOD GROUP INCOMPATIBILITY
9 . INHERITED THROMBOPHILIA
10 . ENVIRONMENTAL FACTORS


CIGARETTE SMOKING
ALCOHOL
11 . PREMATURE RUPTURE OF MEMBRANES

9. CLINICAL FEATURES



h/o AMENORRHOEA
PAIN IN ABDOMEN
P/V BLEEDING
D/D –ABORTION
ECTOPIC PREGNANCY
VESICULAR MOLE

10. THREATENED ABORTION

PROCESS OF ABORTION HAS STARTED BUT NOT
PROGRESSED TO A STATE FROM WHERE
RECOVERY IS IMPOSSIBLE
SYMPTOMS



SLIGHT P/V BLEEDING
BRIGHT RED IN COLOUR
DULL ABDOMINAL PAIN / BACKACHE

11. SIGNS
P/SP – BLEEDING +/- FROM EXT OS
P/V – CERVIX CLOSED,
UTERUS –SOFT, CORRESPONDING WITH
GEST AGE
D/D – CERVICAL LESIONS-EROSION
POLYP
VARICOSE VAINS
MALIGNANCY

12. INVESTIGATIONS



BLOOD –HAEMATOCRIT
ABO Rh GROUPING
USG – TO CONFIRM INTRAUTERINE PREGNANCY
VIABILITY
IF ECTOPIC PREGNANCY IS SUSPECTED
Sr. PROGESTERONE LEVELS
Sr.BhCG LEVELS

13. TREATMENT &PROGNOSIS



REST
MONITORING OF VITALS , VAGINAL BLEEDING
PROGESTERONE
ROLE DOUBTFUL
60 -70 %
CONTINUES >28 WEEKS
HIGH RISK OF PRETERM LABOUR , IUGR
PLACENTA
PREVIA , FETAL ANOMALIES
30%
INEVITABLE / MISSED ABORTION

14. INEVITABLE ABORTION
DEFINITION
PROCESS OF ABORTION HAS REACHED A STAGE
FROM WHERE CONTINUATION OF PREGNANCY IS
NOT POSSIBLE
SYMPTOMS- VAGINAL BLEEDING
PAIN IN ABDOMEN
SIGNS – GENERAL CONDITION DEPENDS UPON
AMOUNT OF BLOOD LOSS
DILATED INTERNAL OS – PRODUCTS FELT
THROUGH OS
MEMBRANES MAY BE RUPTURED

15. MANAGEMENT


IMPROVE GENERAL CONDITION
IV FLUIDS
BLOOD TRANSFUSION IF PT IS IN SHOCK / SEVERE
ANAEMIA
EVACUATION OF PREGNANCY
<12 WEEK – DILATATION & EVACUATION
>12 WEEK –T. misoprostol 400 mg 4 hrly 3 doses
- OXYTOCIN DRIP 10 U IN NS
IF PLACENTA IS RETAINED –
EVACUATION UNDER ANAESTHESIA

16. COMPLETE ABORTION

PRODUCTS OF CONCEPTION HAVE BEEN
EXPELLED EN MASS

H/O EXPULSION OF FLESHY MASS FOLLOWED BY
SUBSIDANCE OF ABDOMINAL PAIN AND BLEEDING
P/V
UTERINE SIZE SMALLER THAN PERIOD OF
AMENORRHOEA
UTERUS FIRM
CERVIX CLOSED

17. MANAGEMENT


ASESS & IMPROVE GENERAL CONDITION
ULTRASOUND EXAMINATION TO CONFIRM NO
PRODUCTS HAVE BEEN RETAINED

18. INCOMPLETE ABORTION
PRODUCTS OF CONCEPTION HAVE BEEN PARTLY
EXPELLED FROM UTERINE CAVITY




CLINICAL FEATURES
H/O EXPULSION OF FLESHY MASS
ABDOMINAL PAIN PERSISTS
P/V BLEEDING PERSISTS
P/V EXAMINATION – UTERUS SMALLER THAN
PERIOD OF AMENORRHOEA
- CERVIX PATULOUS

19. COMPLICATIONS



PROFUSE BLEEDING
SEPSIS
PLACENTAL POLYP

20. MANAGEMENT



CORRECTION OF SHOCK – IV FLUIDS , BLOOD
IV ANTIBIOTICS
EVACUATION OF UTERUS

21. MISSED ABORTION
SILENT MISCARRIAGE/EARLY FETAL
DEMISE
FETUS IS DEAD AND RETAINED INSIDE
UTERINE CAVITY FOR VARIABLE TIME
PATHOLOGY


BEFORE 12 WKS – CLOTTED BLOOD WITH OVUM
FORMS CARNEOUS MOLE (FLESHY MOLE)
AFTER 12 WKS – FETUS BECOMES MACERATED
LIQUOR GETS ABSORBED
PLACENTA BECOMES PALE

22. SYMPTOMS



ABDOMINAL PAIN
BROWNISH VAGINAL DISCHARGE
SUBSIDENCE OF PREGNANCY CHANGES
SIGNS
RETROGRESSION OF BREAST CHANGES
UTERUS BECOMES SMALLER IN SIZE
FETAL HEART SOUND NOT AUDIBLE
CERVIX IS FIRM

23. COMPLICATIONS


INFECTION
DIC

24. INVESTIGATIONS
USG –
EARLY PREGNANCY – EMPTY SAC
 2 nd TRIMESTER – ABSENCE OF FETAL HEART /
ABSENCE OF FETAL MOVEMENTS
HEMOGRAM
COAGULATION PROFILE
BT , CT , PT
PLATELET COUNT


25. SEPTIC ABORTION
ASSOCIATED WITH CLINICAL EVIDENCE OF
INFECTION OF UTERUS AND ITS CONTENTS

26. AETIOLOGY
MORE ASSOCIATED WITH ILLEGAL ABORTION



LACK OF ASEPSIS
INCOMPLETE EVACUATION
INJURY TO GENITAL TRACT & OTHER ORGANS LIKE GUT
ORGANISMS


ANAEROBES – BACTEROIDES , STREPTOCOCCI , Cl. WELCHI ,
Cl . TETANI
AEROBIC – E. COLI , STAPH , STREPTOCOCCI , KLEBSIELLA ,
PSEUDOMONAS

27. CLINICAL FEATURES








FEVER 38 C OR MORE - FOR > 24 HRS
ABDOMINAL PAIN
VAGINAL DISCHARGE
FEBRILE
TACHYCARDIA
ABDOMINAL TENDERNESS
PURULENT VAGINAL DISCHARGE
P/V – UTERINE TENDERNESS , CERVIX IS OPEN
BOGGY FEEL OF UTERUS

28. CLINICAL GRADING
– LOCALISED TO UTERUS (80%)

GRADE 1

GRADE 2 – PARAMETRIUM , TUBES , OVARIES ,PELVIC
PERITONEUM INVOLVED (15%)

GRADE 3 –GENERALISED PERITONITIS / ENDOTOXIC SHOCH /
ACUTE RENAL FAILURE (5%)

29. INVESTIGATIONS

BLOOD –
HEMOGLOBIN ,TLC DLC
RENAL FUNCTION TESTS
COAGULATION PROFILE
BLOOD CULTURE

URINE MICROSCOPY

CERVICAL / HIGH VAGINAL SWAB (BEFORE P/SP , P/V)
GM STAIN
CULTURE , SENSITIVITY

30. ULTRASONOGRAPHY
RETAINED PRODUCTS OF CONCEPTION
PYOMETRA
FOREIGN BODY
FLUID IN PERITONEAL CAVITY

31. COMPLICATIONS






HAEMORRHAGE
INJURY TO UTERUS , BOWEL
GENERALISED PERITONITIS
ENDOTOXIC SHOCK
ACUTE RENAL FAILURE
THROMBOPHLEBITIS

32. LATE COMPLICATIONS



TUBAL BLOCK – INFERTILITY , ECTOPTC
PREGNANCY
CHRONIC PELVIC PAIN – DYSPAREUNIA
EMOTIONAL DEPRESSION

33. MANAGEMENT





HOSPITALISATION
ANTIBIOTCS
GM POSITIVE – AMPICILLIN
GM NEGATIVE – GENTAMYCIN , CEFTRIAXONE
ANAEROBES – METRONIDAZOLE
BLOOD TRANSFUSION
ANTITETANUS SERUM – 3000 U
ANTI GANGRENE SERUM – 8000 U

34. 
EVACUATION OF UTERUS
D & E – AFTER 24 HRS OF ANTIBIOTC COVERAGE
EMERGENCY ON ADMISSION IF ACTIVE BLEEDIG
POSTERIOR COLPOTOMY – TO DRAIN PUS
FOR PELVIC ABSCESS . C/F – SPIKY RISE IN FEVER
TENESMUS
BOGGY MASS FELT IN POST FORNIX

35. LAPAROTOMY





INDICATIONS
INJURY TO UTERUS / BOWEL
PRENCE OF FOREIGN BODY IN ABDOMEN
COLLECTION OF PUS IN ABDOMEN NOT
RESPONDING TO ANTIBIOTICS
SEPTIC SHOCK

36. RECURRENT ABORTION


CONSECUTIVE THREE OR MORE ABORTIONS
INCIDENCE – 1%

37. CAUSES

GENETIC – PARENTAL CHROMOSOMAL
ABNORMALITY

ENDOCRINE
UNCONTROLLED DIABETES MELLITUS
THYROID ANTIBODIES
LUTEAL PHASE DEFECT






INHERITED THROMBOPHILIA
PROTEIN C RESISTENCE
HYPERHOMOCYSTINAEMIA

38. 


IMMUNOLOGICAL
AUTOIMMUNITY – ANA , APLA (LA , ACA)
ALLOIMMUNITY
SHARING OF HLA BETWEEN PARTNERS
LACK OF BLOCKING ANTIBODY PRODUCTION
INFECTIONS – SYPHILIS , LISTERIOSIS
UNEXPLAINED

ANATOMIC ABNORMALITIES OF GENITAL TRACT
(10 – 15 %)
SECOND TRIMESTER ABORTIONS
CONGENITAL
ACQUIRED

39. CONGENITAL


DEFECTIVE MULLERIAN FUSION
CERVICAL INCOMPETENCE

40. ACQUIRED



CERVICAL INCOMPETENCE
INTRAUTERINE ADHESIONS
FIBROIDS

41. INVESTIGATIONS









BLOOD GROUPING
BLOOD SUGAR LEVEL
VDRL
THYROID FUNCTION TEST
AUTOIMMUNE SCREENING – LA , ACA
ENDOCERVICAL SWAB
ULTRASOUND –CONGENITAL MALFORMATION,
PCOD , FIBROID
HYSTEROSALPINGOGRAPHY
KARYOTYPING

42. TREATMENT
INTERCONCEPTION PERIOD
SURGICAL TREATMENT OF ANOMALIES

METROPLASTY

HYSTEROSCOPIC RESECTION OF
INTRAUTERINE SEPTUM
SYNECHIE
SUBMUCOUS FIBROID




43. 

TREATMENT OF INFECTIONS
CONTROL OF DIABETES , THYROID DISORDERS

44. DURING PREGNANCY



REASSURANCE
TENDER LOVING CARE
NATURAL MICRONISED PROGESTERONE
100 mg BD –TO BE CONTINUED TILL 10 - 12 WKS OF
GESTATION
APLA POSITIVE PATIENTS
LOW MOLECULAR WEIGHT HEPARIN
ASPIRIN

45. ENCIRCLAGE


OS TIGHTENING IN CERVICAL INCOMPETANCE
METHOD
McDONALD METHOD
SHIRODKAR TECHNIQUE
Wurms technique

TIMING
16 – 18 WKS

46. Mc donald technique

47. Wurms technique