2. ABORTION
Varna mohan
MSc nursing 2nd year
CON, JIPMER

3. INTRODUCTION
 Spontaneous abortion (SAB)- Natural termination of pregnancy before the fetus has reached viability.
 This term is preferred in talking with patients because the word abortion is frequently associated with
induced abortions.
 A fetus of less than 20 weeks of gestation and early and late.
 An early abortion occurs before 12 weeks of gestation, and a midtrimester or late abortion occurs
between 12 and 20 weeks of gestation.

4. The causes of bleeding in early pregnancy are broadly divided into two groups:
Those related to the pregnant state:
This group relates to abortion (95%), ectopic pregnancy, hydatidiform mole and
implantation bleeding.
Those associated with the pregnant state:
The lesions are unrelated to pregnancy—either pre-existing or aggravated during
pregnancy. Cervical lesions such as vascular ectopy (erosion), polyp, ruptured
varicose veins and malignancy are important causes.

6. DEFINITION:
Abortion is the expulsion or extraction from its mother of an embryo or fetus weighing
500 g or less when it is not capable of independent survival (WHO).
 This 500 g of fetal development is attained approximately at 22 weeks (154 days) of
gestation.
 The expelled embryo or fetus is called abortus.
 The word abortion is the recommended terminology for spontaneous miscarriage.

7. INCIDENCE:
10–20% of all clinical pregnancies end in miscarriage
10% are induced or deliberate.
About 75% miscarriages occur before the 16th week and of these about 80% occur
before the 12th week of pregnancy.

8. CLASSIFICATION OR TYPES

9. Etiological factor

10. Genetic
Anatomic
Infection
Endocrine and
metabolic
Immunological
Thrombophilias
Environmental

11. GENETIC FACTORS:
 Majority (50%) of early miscarriages
 Autosomal trisomy (50%)
 Trisomy 16 (30%).
 Polyploidy (22% ).Triploidy is more common than tetraploidy
 Monosomy X (45, X) (20%).
 Structural chromosomal rearrangements 2–4% of abortuses. These include
translocation, deletion, inversion and ring formation.
 Other chromosomal abnormalities like mosaic, double trisomy, etc. are found in about
4% of abortuses.

12. ENDOCRINE AND METABOLIC FACTORS (10–15%):
 Luteal phase defect (LPD)
 Overt hypothyroidism or hyperthyroidism
 Diabetes mellitus

13. ANATOMICALABNORMALITIES (3–38%)
Cervicouterine factors:

14. Causes of fetal loss are:
(i) Reduced intrauterine volume.
(ii)Reduced expansile property of the uterus.
(iii)Reduced placental vascularity when implanted on the septum.
(iv)Increased uterine irritability and contractility.

15. INFECTIONS (5%)
 Late as well as early abortions
 Transplacental fetal infections
 Viral: Rubella, cytomegalovirus, variola, vaccinia or HIV.
 Parasitic: Toxoplasma, malaria.
 Bacterial: Ureaplasma, chlamydia, brucella. Spirochetes hardly cause abortion before 20th week because of
effective thickness of placental barrier.

16. IMMUNOLOGICAL DISORDERS (5–10%)
Antiphospholipid antibody syndrome (APAS
These are: Lupus anticoagulant (LAC), Anticardiolipin antibodies (ACAs) and-
glycoprotein 1 antibodies (GP1).
IMMUNE FACTORS:
Successful pregnancy is the result of predominantly Th2 cytokine response. Women with
recurrent miscarriage have more Th1 response.

17. MATERNAL MEDICAL ILLNESS
Cyanotic heart disease, hemoglobinopathies are associated with early miscarriage.
PREMATURE RUPTURE OF THE MEMBRANES inevitably leads to abortion.

18. Inherited thrombophilia
Protein C resistance (factor V Leiden mutation)
Other conditions are: Protein C deficiency and hyperhomocysteinemia antithrombin III
or prothrombin gene mutation.
THROMBOPHILIAS:

19. ENVIRONMENTAL FACTORS
 Cigarette
 Alcohol consumption
 X-irradiation and antineoplastic drugs. X-ray exposure up to 10 rad is of little risk.
Contraceptive agents—IUD in situ increases the risk whereas oral pills do not.
Drugs, chemicals, noxious agents—anesthetic gases, arsenic, aniline, lead, formaldehyde.
UNEXPLAINED (40–60%)

20. First trimester:
(1) Genetic factors (50%),
(2)Endocrine disorders
(3) Immunological disorders
(4) Infection, and
(5) Unexplained.
Second trimester:
(1) Anatomic abnormalities—
(a) Cervical incompetence
(b) Müllerian fusion defects
(c) Uterine synechiae, and
(d) Uterine fibroid.
(2) Maternal medical illness.
(3) Unexplained.
COMMON CAUSES OF MISCARRIAGE

21. MECHANISM OF MISCARRIAGE:
In the early weeks, death of the ovum occurs first, followed by its expulsion. In the later weeks, maternal environmental factors
are involved leading to expulsion of the fetus which may have signs of life but is too small to survive.
Before 8 weeks:
Between 8 and 14 weeks:
Beyond 14th week:

22. 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.

23. CLINICAL FEATURES

24. Pelvic examination should be done as gently as possible.
(a)Speculum examination reveals—bleeding if any, escapes through
the external os.
(b)Digital examination reveals the closed external os.
 The uterine size corresponds to the period of amenorrhea. The uterus
and cervix feel soft.
 Pelvic examination is avoided when ultrasonography is available.

25. INVESTIGATIONS
Routine investigations include:
(1)Blood—hemoglobin, hematocrit, ABO and Rh grouping.
(2)Urine - the test remains positive for a variable period even after the fetal death.
Ultrasonography (TVS) findings may be:
(1) A well-formed gestation sac, yolk sac with central echoes from the embryo indicating
healthy fetus.
(2) Observation of fetal cardiac motion.
(3) Anembryonic sac

27. TREATMENT
 Rest
 Drugs- diazepam 5 mg tablet twice daily.

28. PROGNISIS
The prognosis is very unpredictable. In isolated spontaneous threatened
miscarriage, the following events may occur:
(1) In about two-thirds, the pregnancy continues beyond 28 weeks.
(2) In the rest, it terminates either as inevitable or missed miscarriage.
 If the pregnancy continues, there is increased frequency of preterm labor,
placenta previa, intrauterine growth restriction of the fetus and fetal
anomalies.

29. INEVITABLE MISCARRIAGE
It is the clinical type of abortion where the changes have progressed to a state from
where continuation of pregnancy is impossible.

30. CLINICAL FEATURES:
The patient, having the features of threatened miscarriage, develops the following manifestations:
(1) Increased vaginal bleeding.
(2) Aggravation of pain in the lower abdomen which may be colicky in nature.
(3) Internal examination reveals dilated internal os of the cervix through which the products of
conception are felt.

31. MANAGEMENT is aimed:
(a) To accelerate the process of expulsion.
(b) To maintain strict asepsis.
General measures:
Excessive bleeding should be promptly controlled by administering Methergine 0.2 mg
if the cervix is dilated and the size of the uterus is less than 12 weeks. The blood loss
is corrected by intravenous (IV) fluid therapy and blood transfusion.

32. Before 12 weeks:
(1) Dilatation and evacuation followed by curettage of the uterine cavity by
blunt curette using analgesia or under general anesthesia.
(2) Alternatively, suction evacuation followed by curettage is done.
Active treatment

33. After 12 weeks:
(1) The uterine contraction is accelerated by oxytocin drip (10 units in 500 mL of normal
saline) 40–60 drops per minute. If the fetus is expelled and the placenta is retained, it is
removed by dilatation and evacuation under general anesthesia.

34. COMPLETE MISCARRIAGE
When the products of conception are expelled en masse, it is called complete
miscarriage.

35. CLINICAL FEATURES:
There is history of expulsion of a fleshy mass per vaginam followed by:
(1) Subsidence of abdominal pain.
(2) Vaginal bleeding becomes trace or absent.
(3) Internal examination reveals:
(a) Uterus is smaller than the period of amenorrhea and a little firmer,
(b) Cervical os is closed and
(c) Bleeding is trace.
(4) Examination of the expelled fleshy mass is found complete.
(5) Ultrasonography (TVS): reveals empty uterine cavity.

36. MANAGEMENT:
Transvaginal sonography is useful to see that uterine cavity is empty, otherwise
evacuation of uterine curettage should be done.
Rh-NEGATIVE WOMEN:
 Protected by antiD gamma globulin 50 μg or 100 μg intramuscularly in cases of
early miscarriage or late miscarriage respectively within 72 hours.
 However, anti-D may not be required in a case with complete miscarriage before 12
weeks of gestation where no instrumentation has been done.

37. INCOMPLETE MISCARRIAGE
DEFINITION:
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.

38. CLINICAL FEATURES:
History of expulsion of a fleshy mass per vaginam followed by:
(1) Continuation of pain in lower abdomen.
(2) Persistence of vaginal bleeding.
(3) Internal examination reveals—
(a) Uterus smaller than the period of amenorrhea,
(b) Patulous cervical os often admitting tip of the finger and
(c) Varying amount of bleeding.
(4) On examination, the expelled mass is found incomplete.
(5) Ultrasonography—reveals echogenic material (products of conception) within the
cavity.

39. COMPLICATIONS:
The retained products may cause:
(a) Profuse bleeding,
(b) Sepsis or
(c) Placental polyp.

40. MANAGEMENT:
In recent cases—evacuation of the retained products of conception (ERPC) is done. She
should be resuscitated before any active treatment is undertaken.
Early abortion: Dilatation and evacuation under analgesia or general anesthesia is to be
done. Evacuation of the uterus may be done using MVA also.

41. 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 (D
and C) operation is to be done to remove the bits of tissues left behind. The removed
materials are subjected to a histological examination.
Medical management
Tablet misoprostol 200 mcg is used vaginally every 4 hours. Compared to surgical
method, complications are less with medical method.

42. 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.

43. PATHOLOGY:
Beyond 12 weeks, the retained fetus becomes macerated or mummified. The liquor amnii gets
absorbed and the placenta becomes pale, thin and may be adherent. Before 12weeks, the
pathological process differs when the ovum is more or less completely surrounded by the
chorionic villi.

44. 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.
(5) Non-audibility of the fetal heart sound even with Doppler ultrasound.
(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 cardiac motion and fetal movements.

45. MANAGEMENT
EXPECTANT
MEDICAL
SURGICAL

46. Uterus is less than 12 weeks:
(i) Expectant management—many women expel the conceptus spontaneously.
(ii)Medical management: Prostaglandin E1 (misoprostol) 800 µg vaginally in the posterior
fornix is given and repeated after 24 hours if needed. Expulsion usually occurs within 48
hours.
(iii)Suction evacuation or dilatation and evacuation is done either as a definitive treatment or it
can be done when the medical method fails.

47. Uterus more than 12 weeks:
Induction is done by the following methods:
Prostaglandins are more effective than oxytocin
Prostaglandin E1 analog (misoprostol) 200 mcg tablet is inserted into the
posterior vaginal fornix every 4 hours for a maximum of 5 such.
Oxytocin—10–20 units of oxytocin in 500 mL of normal saline at 30
drops/min is started. If fails, escalating dose of oxytocin to the maximum of
200 mlU/min may be used with monitoring.

48. May need surgical evacuation following medical treatment.
ultrasonography should be done to document empty uterine cavity.
Evacuation of the retained products of conception (ERPC) should be
done.
Dilatation and evacuation

49. SEPTIC ABORTION
Any abortion associated with clinical evidences of infection of the uterus and its
contents is called septic abortion.
Abortion is usually considered septic when there are:
(1) Rise of temperature of at least 100.4°F (38°C) for 24 hours or more,
(2) Offensive or purulent vaginal discharge and other evidences of pelvic infection such
as lower abdominal pain and tenderness.

50. INCIDENCE:
About 10% of abortions
The majority is associated with incomplete abortion.
Majority of cases, the infection occurs following illegal induced abortion
But infection can occur even after spontaneous abortion.

51. MODE OF INFECTION:
The microorganisms involved are usually those normally present in the vagina (endogenous). The
microorganisms are:
(a) Anaerobic—Bacteroides group (fragilis), anaerobic Streptococci, Clostridium welchii and
tetanus bacillus.
(b) Aerobic—Escherichia coli (E. coli), Klebsiella, Staphylococcus, Pseudomonas and group A
beta-hemolytic Streptococcus (usually exogenous), methicillin resistant Staphylococcus
aureus (MRSA).
Mixed infection is more common.

52. PATHOLOGY:
In the majority (80%), the organisms are of endogenous
origin and the infection is localized to the conceptus .
In about 15%, the infection either produces localized
endomyometritis surrounded by a protective leukocytic
barrier, or spreads to the parametrium, tubes, ovaries or
pelvic peritoneum.
In about 5%, there is generalized peritonitis and/or
endotoxic shock.

53. CLINICAL FEATURES:

54.  Persistent tachycardia ≥ 90 bpm (spreading infection)
 Hypothermia (endotoxic shock) <36°C
 Abdominal or chest pain
 Tachypnea (RR) >20/min
 Impaired mental state
 Diarrhea and/or vomiting
 Renal angle tenderness

55. 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.
Grade I is the most common and is usually associated with spontaneous abortion. Grade III is
almost always associated with illegal induced abortion.

56. INVESTIGATIONS:
Routine investigations include:
(1) Cervical or high vaginal swab is taken prior to internal examination
(2) Blood for hemoglobin estimation, total and differential count of white cells, ABO and Rh
grouping.
(3) Urine analysis including culture.

57. Special investigations—
(1)Ultrasonography of pelvis and abdomen
(2)(2) Blood—
(a) Culture—if associated with spell of chills and rigors;
(b) Serum electrolytes, C-reactive protein (CRP), serum lactate—as an adjunct to
the management protocol of endotoxic shock. Serum lactate greater than or equal to
4 mmol/L indicates tissue hypoperfusion and
(c) Coagulation profile.
(3) Plain X-ray—
(a) Abdomen— in suspected cases of bowel injury,
(b) Chest—for cases with pulmonary complications (atelectasis).

58. COMPLICATIONS
Immediate: illegally induced abortions of grade III type.
Hemorrhage
Injury
Spread of infection leads to:
(a)Generalized
(b)Endotoxic shock—mostly due to E. coli or Cl. welchii infection.
(c) Acute renal failure
(d)Lungs: atelectasis, ARDS.
(e) Thrombophlebitis.

59. PREVENTION:
(1) To boost up family planning acceptance in order to curb the unwanted
pregnancies.
(2) Rigid enforcement of legalized abortion in practice. Education, motivation and
extension of the facilities to get the real benefit out of it.
(3)To take antiseptic and aseptic precautions either during internal examination or
during operation in spontaneous abortion.

60. MANAGEMENT
GENERAL MANAGEMENT
Hospitalization. The patient is kept in isolation.
To take high vaginal or cervical swab .
Vaginal examination is done to note the state of the abortion process and extension of the
infection.
Overall assessment of the case and the patient is leveled in accordance with the clinical
grading.
Investigation protocols.

61. Principles of management are:
(a) To control sepsis.
(b) To remove the source of infection.
(c) To give supportive therapy to bring back the normal homeostatic
and cellular metabolism.
(d) To assess the response of treatment.

62. GRADE I
DRUGS:
1. Antibiotics
2. Prophylactic antigas gangrene serum of 8,000 units and 3,000 units of antitetanus serum
intramuscularly are given if there is a history of interference.
3. Analgesics and sedatives, as required.
 Blood transfusion
 Evacuation of the uterus: As abortion is often incomplete, evacuation should be performed
at a convenient time within 24 hours following antibiotic therapy.
 Excessive bleeding is, of course, an urgent indication for evacuation.

63. GRADE II
Antibiotics are used as discussed. Clinical monitoring is to be conducted as outlined
in grade
GRADE III
DRUGS: Antibiotics
 If Mixed infections, Ideal antibiotic regimens should cover all of them.
 Antimicrobial therapy: A combination of either piperacillin-tazobactam or
carbapenem plus clindamycin (IV) gives broadest range of microbial coverage.
 Emperical therapy is started first and is changed when culture sensitivity report is
available.

64. Piperacillin-tazobactam and carbapenems: Covers most organisms except MRSA, and are
not nephrotoxic. Piperacillin-tazobactam does not cover extended spectrum –lactamase
(ESBL) producers.
Vancomycin or teicoplanin may be added for MRSA resistant to clindamycin.
Clindamycin: Covers most streptococci, staphylococci including MRSA and is not
nephrotoxic.
Gentamycin (3–5 mg/kg—single dose) can be given when renal function is normal.
Co-amoxiclav—does not cover MRSA, Pseudomonas or ESBL-producing organisms.
Metronidazole—covers anaerobes. Analgesic, and ATS are given as in grade I. Blood
transfusion is more often needed than in grade I cases.
 To note pulse, respiration, temperature, urinary output and progress of the pain,
tenderness and mass in lower abdomen, CVP greater than 8 mm Hg.

65. 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
Indications for ICU Management (Plaat-2008)
 Persistent hypotension, persistently raised
serum lactate (≥ 4
mmol/L)
 Pulmonary edema,mechanical ventilation
 Renal failure Renal dialysis
 Impaired consciousness
 Multiorgan failure, hypothermia, acidosis.

66. SUPPORTIVE THERAPY
Gastric suction and intravenous crystalloids infusion. Features of organ dysfunction should be
carefully guarded against.
Active surgery:
 The laparotomy should be done by experienced surgeon with a skilled anesthetist
 Adnexa is to be removed or preserved according to the pathology found.
 Thorough inspection of the gut and omentum for evidence of any injury is mandatory.
 Even when nothing is found on laparotomy, simple drainage of the pus is effective.

67. RECURRENT MISCARRIAGE
DEFINITION:
Recurrent miscarriage is defined as the sequence of two or more spontaneous abortions as
documented by either sonography or on histopathology, before 20 weeks (ASRM-2013). However,
earlier definition (RCOG, ESHRE) states prior three or more miscarriages before 24 weeks of
gestation.

68. INCIDENCE:
This distressing problem is affecting approximately 1% of all women of
reproductive age. The risk increases with each successive abortion reaching
over 30% after three consecutive losses.

69. Genetic
factors
(3–5%)
Endocri
ne and
metabol
ic:
Poorly controlled diabetic
(Presence of thyroid
autoantibodies
Luteal phase defect (LPD)
Polycysti
c ovary
syndrom
e
(PCOS)
Infectio
n
Inherite
d
thromb
ophilia
Immune
factors
(10–
15%)
Auto-
immunity
Unexplaine
d
ETIOLOGY
FIRST TRIMESTER ABORTION

70. SECOND TRIMESTER MISCARRIAGE
 Anatomic abnormalities are responsible for 10–15% of recurrent abortion. The causes may
be congenital or acquired.
 Congenital anomalies - Müllerian duct fusion or resorption (e.g. unicornuate, bicornuate,
septate or double uterus). Congenital cervical incompetence is rare.
 Acquired anomalies are: intrauterine adhesions, uterine fibroids and endometriosis and
cervical incompetence. The pathology of abortion has been discussed.
Defective Müllerian fusion—12% cases of recurrent abortion.

73. OTHER CAUSES OF SECOND TRIMESTER MISCARRIAGE
Chronic maternal illness—such as uncontrolled diabetes with arteriosclerotic changes,
hemoglobinopathies, chronic renal disease. Inflammatory bowel disease, systemic lupus
erythematosus (SLE).
Infection—Syphilis, toxoplasmosis and listeriosis may be responsible in some cases.
Unexplained.

74. INVESTIGATIONS FOR RECURRENT MISCARRIAGE
A thorough medical, surgical and obstetric history with meticulous clinical examination
should be carried out to find out the possible cause or causes as mentioned previously.
Careful history-taking should include—
(i) The nature of previous abortion process.
(ii)Histology of the placenta or karyotyping of the conceptus, if available
(iii)Any chronic illness.

75. Diagnostic tests:
(1) Blood-glucose (fasting and postprandial), VDRL, thyroid function test, ABO and Rh
grouping (husband and wife), toxoplasma antibodies IgG and IgM.
(2) Autoimmune screening—lupus anticoagulant and anticardiolipin antibodies.
(3) Serum LH on D2/D3 of the cycle.
(4) Ultrasonography
(5) Hysterosalpingography
(6) This is supported by hysteroscopy and/or laparoscopy.
(7) Karyotyping (husband and wife).
(8) Endocervical swab to detect chlamydia, mycoplasma and bacterial vaginosis.

76. TREATMENT
INTERCONCEPTIONAL PERIOD
To alleviate anxiety and to improve the psychology
Hysteroscopic resection
Chromosomal anomalies
Women with PCOS.Metformin therapy is helpful.
Endocrine dysfunction: Control of diabetes and thyroid disorders is done
Genital tract infections
culture of cervical and vaginal discharge. Empirical treatment with doxycycline or
erythromycin is cost-effective.

77. DURING PREGNANCY
Reassurance and tender loving care (TLC)
Ultrasound
Rest
Progesterone therapy
natural micronized progesterone 100 mg daily as vaginal suppository.
It is started 2 days after ovulation. Once pregnancy is confirmed, progesterone
supplementation is continued until 10–12 weeks of gestation.
Antiphospholipid antibody syndrome (APS):
low-dose aspirin (50 mg/day) and heparin (5,000 units SC twice daily) up to 34
weeks.

78. MANAGEMENT OF CERVICAL INCOMPETENCE
Cerclage operation: Two types of operation are in current use during pregnancy each
claiming an equal success rate of about 80–90%. The operations are named after Shirodkar
(1955) and McDonald (1963).
Principle: The procedure reinforces the weak cervix by a nonabsorbable tape, placed around
the cervix at the level of internal os.

80. SHIRODKAR (Cerclage for
Incompetent OS)
 The placement of an encircling
“tape” ligature at the level of the
internal cervical os to maintain
the integrity of the cervical
canal.

81. FIRST TRIMESTER TERMINATION OF PREGNANCY (UP TO 12 WEEKS)
MEDICAL METHODS OF FIRST TRIMESTER ABORTION:
Mifepristone (RU-486) and Misoprostol: It is effective up to 63 days and is highly
successful when used within 49 days of gestation.
Methotrexate and Misoprostol—Methotrexate 50 mg/ m2 IM (before 56 days of gestation)
followed by 7 days later misoprostol 800 mcg vaginally is highly effective. Misoprostol may
have to be repeated after 24 hours if it fails.

82. MIDTRIMESTER TERMINATION OF PREGNANCY
MEDICAL METHODS
PROSTAGLANDINS:
Prostaglandins and their analogs
(i) Misoprostol (PGE1 analog)
(ii) Mifepristone and prostaglandins:
(iii) Gemeprost (PGE1 analog)
(iv) Dinoprostone (PGE2 analog)
(v) Prostaglandin F2 (PGF2 ),
OXYTOCIN: High-dose oxytocin as a single agent can be used for second trimester abortion.

83. SURGICAL METHODS
It is difficult to terminate pregnancy in the second trimester with reasonable safety as in first
trimester. The following surgical methods may be employed.
Between 13 and 15 weeks
Dilatation and evacuation in the midtrimester is less commonly done.

84. SURGICAL METHODS OF FIRST TRIMESTER ABORTION
MENSTRUAL REGULATION
 VACUUM ASPIRATION (MVA/EVA)
SUCTION EVACUATION AND/OR CURETTAGE:
DILATATION AND EVACUATION
Rapid method: This can be done as an outdoor procedure with diazepam sedation and
paracervical block anesthesia.
Slow method:
Slow dilatation of the cervix is achieved by inserting laminaria tents (hygroscopic osmotic
dilators) into the cervical canal (synthetic dilators like Dilapan, Lamicel are also used).
This is followed by evacuation of the uterus after 12 hours. Vaginal misoprostol (PGE1) 400
mcg 3 hours before surgery is equally effective for cervical ripening.

85. INTRAUTERINE INSTILLATION OF HYPERTONIC SOLUTION:
Between 16 and 20 weeks:
Extra-amniotic Intra-amniotic
Extra-amniotic: Extra-amniotic instillation of 0.1% ethacridine lactate (estimated amount is
10 mL/week) Isotonic saline is infused extra-amniotically using a transcervical catheter balloon.
Results are similar to that of Foley’s catheter use alone.
Intra-amniotic: Intra-amniotic instillation of hypertonic saline (20%) is less commonly used
now. It is instilled through the abdominal route.
Intra-amniotic instillation of hyperosmotic urea
HYSTEROTOMY: The operation is performed through abdominal route.

86. A Cross-Sectional Study of the Psychosocial Problems Following Abortion
Sameera Kotta, Umashankar Molangur,1 Rajshekhar Bipeta,2 and Radhika Ganesh3
Author information Copyright and License information Disclaimer
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Abstract
Background:
Twenty percent of pregnant women undergo an abortion. Reviews of previous studies on the effects of abortion on mental health
have been inconclusive. Little research has been carried out in this direction in our country.
Aims:
This study aims to study the psychological effects of abortions and the associated sociodemographic and other parameters.
Setting and Design:
It is a cross-sectional study, conducted in five different government hospitals of Hyderabad.

87. Materials and Methods:
After identifying the participants, an interview was conducted. First, sociodemographic and other parameters were
collected by an interviewer. Then, another interviewer conducted the interview using diagnostic tools (Impact of Events
Scale-Revised [IES-R] and Goldberg Health Questionnaire-12 [GHQ-12]). Analysis was carried out using SPSS software.
Results:
Sixty cases of spontaneous abortion, 31 therapeutic and 9 elective abortions, were collected. Overall, on GHQ-12, 57%
women had no distress, 11% had typical distress, while 14% had more than typical distress, 15% had psychological
distress, and 3% of them had severe distress. On IES-R, 16% women had little or no symptoms of posttraumatic stress
disorder PTSD, 57% had several symptoms, while 27% of them were likely to have PTSD.
Conclusions:
Women who underwent elective abortion showed less distress than the other types. Those that underwent a late abortion
were more likely to suffer from psychological distress than those having an early one. The medical history was a
significant factor in determining the mental health outcome of the women who underwent abortion.

88. BIBILIOGRAPHY
 Dutta, D.C. Textbook of Obstetrics. Kolkata, India: New Central Book Agency. 6th
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