IT HELPS MIDWIVES,NURSING STUDENTS TO ACQUIRE KNOWLEDGE REGARDING EARLY DETECTION AND MANAGEMENT OF ABORTION AMONG WOMEN..........

1. Bleeding in early pregnancy
By
Ms.Sumitra.M
Lecturer
OBG department

2. ABORTION
• Abortion is the expulsion or
extraction from its mother of
an embryo or fetus weighing
500gm or less, when it is not
capable of independent survival.

3. INCIDENCE
• 10% are induced legally
• 75% occur before 16th week

4. TYPES
• Spontaneous
 Isolated}
 Recurrent} –
 Threatened abortion
 Inevitable abortion
 Complete abortion
 Incomplete abortion
 Missed abortion
 Septic abortion
• Induced
 Legal
 Illegal

5. ETIOLOGY
• Geneticfactors:polyploidy,monosomy,structura
l chromosomal rearrangements observed in 2-
4% cases.
• Endocrine and metabolic factors (10-
15%):
Luteal phase defect;placentation and
implantation are not supported
adequately
Deficiency of progesterone

6. • Anatomical abnormalities:
 Cervical incompetence-congenital or acquired
 Congenital malformation of the uterus: bicornuate or septate
uterus
• Infections:
 Viral:rubella,cmv,variola,hiv
 Parasitic:toxoplasma,malaria
 Bacteria:ureaplasma,chlamydia,brucella
• Immunological:5-10%
• Autoimmune and alloimmune disorders: Antigen & antibody
reactions

7.  Blood group incompatibility: couple with
group A and group o, have got higher incidence of
abortion.
 PROM: inevitably leads to
 abortion
 Environmental factors:
Cigarette smoking
Alcohol consumption
Contraceptive agents
Drugs ,chemical agents
• Others :increased uterine irritability, fibroids of
uterus, intrauterine adhesions.

8. THREATENED ABORTION
• It is clinical entity where the process of
abortion has started but has not progressed to
a state from which recovery is
impossible.............
• Clinical features:
 Bleeding per vaginum-slight bright red in color
 Pain

10. Investigations:
 BLOOD-For Hb,hematocrit,ABO,Rh typing
 Urine- HCG
 USG-for fetal movements
Treatment:
 Rest
 Drugs: sedation for relief of pain
 General measures: preservation of vulval pads
 To report if bleeding aggravated
Prognosis:

11. ADVICE ON DISCHARGE:
Restriction of activities
Avoid sexual contact
Re-examination after 1 month to asses
the fetal growth.

12. 02.INEVITABLE ABORTION:
• It is clinical type of abortion where the
changes have progressed to a state from
where the recovery is impossible.....
• Clinical features:
Increased vaginal bleeding
Aggravation of pain on lower abdomen
General condition is proportion to blood loss
Dilated internal os of the cervix

13. Management
• General measures:
Excessive bleeding should be controlled by
methargin
Shock should be corrected
Dilatation & evacuation before 12 weeks
Oxytocin infusion after 12 weeks

14. Complete abortion
When the products of conception are
expelled in mass,it is called complete
abortion.
Clinical features:
Expulsion of fleshy mass per vaginum
Vaginal bleeding become trace or
absent

15. • Internal examination:
Uterus is smaller than the period of
amenorrhoea
Cervical os closed
 Management :
Assess & treat effect of blood loss
Uterine curretage
Rh immunization

16. Incomplete abortion
• When the entire products of conceptions are not
expelled,instead a part of it is left remain inside
the cavity,is called incomplete abortion
• Clinical features:
Pain in lower abdomen
Persistence of vaginal bleeding
Internal examination reveals: uterus is smaller
than the period of amenorrhoea
Os opened
bleeding

17. Termination: products left behind may lead to
Profuse bleeding
Sepsis
Placental polyp
Management:
Dilatation and evacuation under GA
 Treat Shock
Oxytocin infusion

18. Missed abortion
• When the fetus is dead and retained
inside the uterus for variable period, it
is called missed abortion or silent
miscarriage or early fetal demise.

19. Clinical features
• Persistence of brownish vaginal discharge
• Subsidence of pregnancy symptoms
• Retrogression of breast changes
• Cessation of uterine growth
• Non audibility of FHS
• Cx feels firm
• HCG negative
• USG reveals empty sac

20. Management
• Uterus is less than 12 weeks:
Vaginal evacuation:D+E under GA
• Uterus is more than 12 weeks:
Oxytocin -10-20 units with 30 drops per minute
Prostaglandins:more effective than oxytocin in
such cases,
Misoprostol 200macrogram tab for 4 hourly
Carboprost tromethamine 250 macro gm 3
hourly.

21. Septic abortion
• Any abortion associated with clinical
evidences of infection of the uterus and its
contents is called septic abortion
Rise of temperature of 100.4 degree F
Offensive discharge
Lower abdominal pain and tenderness

22. • Incidence :10% are septic abortions in hospital
admissions
• Clinical features:
Pyrexia
Pain in abdomen
Tachycardia 100-120/min
Internal examination reveals that, offensive
vaginal discharge
Clinical grading:
Grade 1:infection is localised to uterus
Grade 2: beyond the uterus
Grade 3: generalised peritonitis

23. • Investigations:
Culture &sensitivity test
Blood for investigations
Urine analysis
USG
• Complications:
Immediate :haemorrhage,injury
Spread of infection leads to:generalized
peritonitis,endotoxic shock,ARF,
Thrombophlebitis.

24. • REMOTE COMPLICATIONS:
CHRONIC DEBILITY
CHRONIC PELVIC PAIN
DYSPAREUNIA
 ECTOPIC PREGNANCY
SECONDARY INFERTILITY
• PREVENTION:
 LEGAL ABORTION
 FAMILY PLANNING ACCEPTANCE
 ANTISEPTIC MEASURES

25. MANAGEMENT
• GENERAL MANAGEMENT:
Hospitalization
Culture &sensitivity
Vaginal examination
Investigation protocol
• GRADE 1:
o Antibiotics
o Prophylactic antiserum gas gangrene
o Analgesics and sedatives
o Evacuation of the uterus following 24 hr
of antibiotic therapy

26. • Grade 2:
Antibiotic therapy:for gram positive aerobes
aq.penicillin G 5 millon units for 6 hours,ampicillin
0.5-1gm IV every 6 hours
For gram negative aerobes:gentamycin 1.5 mg
ceftrixone 1 gm
For anerobes:metrogyl 500mg,clindamycin 600mg
Surgery:posterior colpotomy
• Grade 3:
• antibiotics,intensive care management
Laprotomy for hysterectomy

27. Recurrent miscarriage
• Sequence of 3 or more consecutive spontaneous
abortion before 20th weeks is called habitual or
recurrent abortion
• 1%of women in reproductive age group
Etiology:
First trimister abortion:
Genetic factors
Endocrine and metabolic
Infection
Inherited thrombophilia
Immunological causes

28. • Second trimister:
Anatomic abnormalities
Cervical incompetence
• Investigations:
Blood
Autoimmune screening
Serum LH
USG
Culture and sensitivity

29. Treatment
• Interconceptional period:
• Improve psychology
• Counselling the couple
• Genetic counselling
• Control diabetes
• Ovulation induction
• Treat Genital tract infections

30. • DURING PREGNANCY:
Reassurance and TLC
Prenatal diagnosis
USG
• Hormonal treatment for LPD
• Treat medical disorders during
pregnancy
• Surgical management:
Shirodkar’s operation
Mc Donald’s operation

31. Shirodkar’s operation
• Pt is put under light GA
• Lithotomy position
• Place the vaginal speculum for exposure of Cx
• Transverse incision on the below the base of the
bladder and bladder is pushed up to expose the
level of internal os,
• Vertical incision on the posterior cervix
• The non absorbable material is passed posteriorly
with the help of cervical needle
• The ends of suture are tied up by reef knot

33. Mc Donald’s operation
• Also called as cervical stitching
• Bed rest for 2-3 days
• Tocolytics
• Antenatal advice
• Avoid intercourse
• To avoid journey
• Periodic monitoring by USG
• removal of stitch by 38th week prior to
labor

35. Complications
• Slipping of ligature
• Chorioamnionitis
• PROM
• Abortion

36. Induced abortion
• Deliberate termination of pregnancy
before the viability of the foetus is
called induction abortion

37. Medical termination of pregnancy
MTP act has been enforced in the year of April
1972
Provisions of the act have been revised in
1975

38. Indications
• To Save the life of the mother:
Cardiac diseases grade 3 and 4
Chronic glomerulonephritis
Malignant hypertension
Intractable hyperemesis gravidarum
 cervical or breast malignancy
Diabetes with retinopathy
Epilepsy
Psychiatric illness

39. • Social indications:
 To prevent injury to Physical and mental
health of the mother
 rape or Unplanned pregnancy
 Low socio economic status
• Eugenic indications: risk of child being born
with physical and mental abnormalities.
Anencephaly
Down’s syndrome
Haemophilia
Teratogenic drugs affected

40. Recommendations
• One has assisted at least 25 MTP in an authorised
centre and having certificate
• One has got 6 months of house surgeon training in
OBG
• One has got diploma or degree in OBG
• Termination can only performed in hospitals,
established or maintained by the government or places
approved by the government.
• Termination is permitted up to 20 weeks

41. • Pregnancy can only terminated on the written
consent of the women, husband’s consent is not
required.
• Pregnancy in minor girl or lunatic cannot be
terminated without written consent of the
parents or legal guardians.
• The abortion has to be performed confidentially
and to be reported to director of health services
of state in prescribed form.

42. First trimister termination methods
• Manual vaccum aspiration:
It is done up to 7 menstrual weeks with
minimal cervical dilatation
With flexible vaccum cannula(6mm)and 50ml
plastic syringe
Advantages:
It is quicker
Less traumatic
safer

44. Dilatation &curretage
• This is procedure is done in first trimister
• The cervix is dilated with small metal dialtors
and suction cannula is introduced in to the
uterine cavity
• With cannula fitted to a suction machine ,the
products of conception are sucked out
• With the small flushing currette,the uterine
cavity is curetted and suctioned out once again
for any remaining portion of the conceptus
• Prophylactic dose of methergine

45. Dilatation and evacuation
• This is done either as two stage procedure(slow)
or one stage(rapid) method
• For two stage
Achieve the cervical dilation with the help of
laminaria tents, the woman is kept in bed for 12
hours during which time it swell up, after 12
hours the tents are removed and further
dilatated with metal dilators
The products of conception is removed with
ovum forceps.
Methergine adminstration

46. • One stage:
Cervical dilation with metal dilators followed by
evacuation is done with one stage.
• Pharmacological methods:
Mifepristone: a single dose of 600mg oraly for
abortion ,if it fails prostglandin E1 vaginal
pessary to complete abortion process.
Methotrexate:
Intramuscularly
Products of conception expells after 3 to 4
hours.

47. Second trimister termination
• Intrauterine instillation
• Extra uterine instillation
• Prostaglandins
• oxytocin
• Hysterotomy

48. Intra amniotic instillation
• Hyper-tonic saline is instilled through a
polythene tube connected to a drip set in to
amniotic cavity
• An amount of 10 ml multiplied by number of
weeks of gestation is infused at a rate of 10ml
per minute.
• Expulsion of products takes place

49. Extra uterine instillation
• This is done by instillation of ethacrydine
lactate 0.1% solution vaginally above the
internal os.
• Presence of the solution between the
membranes and myometrium results in
stripping of the membrane and cx dilatation
takes place.
• Expulsion of the products of conception
follows.

50. • Prostaglandins
• Oxytocin
• Hysterotomy

52. Thank
youuu.......