abortion.pptx iwqjefnhka ka x ;kj coknaCNADS OI

Early pregnancy and its complication
DEFINITION
Any vaginal bleeding before 22 wks period of gestation is defined as
early pregnancy bleeding

The causes of bleeding in early pregnancy are
broadly divided into two groups:
Those related to the pregnant state
Those associated with the pregnant state

Those related to the pregnant state:
this group relates to abortion(95%), ectopic pregnancy.

Those associated with the pregnant state
• Those related with the pregnant state the lesions of cervical such as
vascular erosion, polyp, ruptured varicose veins and malignancy are
important causes

Examination of pregnant women with
vaginal bleeding
•  General examination
• Pallor, tachycardia and hypotension can be found with very heavy bleeding but this is uncommon
•  Abdominal exmination
•  you need to do an abdominal examination to detect any palpable mass.
•  Any point of tenderness, guarding or rigidity should be elicited.
•  Tenderness and guarding can be present in cases of ectopic pregnancy because of intraperitoneal
bleeding.
•  Molar pregnancy can present with uterine size more than the period of gestation but is now usually
diagnosed on ultrasound scan.

Pelvic examination
• Pelvic examination
• Look for signs of bleeding and assess how much she is bleeding
• If she is wearing a pad, note if the pad is soaked or if her underwear is stained.
• You should note if there is active bleeding with blood
• trickling as this is a sign of a significant bleed

Speculum examination
Gently insert the speculum and see if there is bleeding
• in the vagina.
• Use a sponge on sponge holder to see if there is any fresh bleeding.
• If bleeding is seen you need to identify if it is heavy.
• Check the cervical os:
look to see whether the external os is open or closed.
• look for any products of conception.
Check for any local lesion such as a polyp or cervical erosion

Bimanual Examination
• Two fingers inserted into the vagina until they isolate the cervix.
• The health care professional tests for cervical motions tenderness
• As seen in pelvic inflammatory diseases.
• The examiner presses down on the abdomen with the external hand to
locate the fundus of the uterus and the adnexal stracture.
• If these woman with vaginal infection or vaginismus,she will fell pain.
Woman with imprforated hymen,these examination is impossible.

•  insert index and middle finger of gloved lubricated hand into the
vaginnal
• Palpate the cervix.
• Palpate the uterine body between
vaginal and abdominal hands.
• Attempt to palpate the ovaries with
• hand on lower abdomen, while
• vaginal hand pushes upward.
Palpate for masses or tenderness

abortion
• Abortion is the expulsion or extraction from its mother of an
embryo or fetus weighing 500 gms or less when it is not capable of
independent survival (WHO). This 500 gm of fetal develop is
attained approximately at 20 to 22 weeks (154 days) of gestation.

• The etiology of miscarriage is often complex and obscure. The following factors
(embryonic or parker important:
• Genetic - Chromosomal abnormalities: majority of at least 50% of early abortions
are due to chromosomal abnormality e.g. trisomy, monosomy X (XO) and triploidy
• Maternal Factors -abortions are poorly understood, One example is the well-known influence of maternal age just
described.
• Endocrine and metabolic Deficient Progesterone secretion from corpus luteum or
poor endometrial response to progesterone is cause abortion between 8-12
weeks. Luteal phase defect. Diabetes. Thyroid Disorders
• Anatomic-Various inherited and acquired uterine defects are known to cause both early and late recurrent
miscarriages
• Infection -Some common viral, bacterial, and other infectious agents that invade the normal human can cause
pregnancy loss.
• Brucella abortus, Campylobacter fetus, and Toxoplasma gondii, parvovirus, cytomega- lovirus, or herpes simplex virus
• One possible exception is infection with Chlamydia trachomatis, which was found to be present in 4 percent of
abortuses

• Blood group incompatibility: couple with group ‘A’ husband and group ‘O’ wife
have higher incidences of abortion.
• Premature rupture of membranes
• Parental factor: sperm chromosomal anomaly(translocation)
• Drugs: e.g. quinine, ergots, severe purgatives,
• Environmental causes: cigarette smoking,tobacco, alcohol, arsenic, lead,
formaldehyde, benzene and radiation.
• Trauma: external to the abdomen or during abdominal or pelvic operations.
• Maternal anoxia and malnutrition.
• Overdistension of the uterus: e.g. acute hydramnios.
• Ageing sperm or ovum
• Nervous, psychological conditions and over fati

• Till 8wk the ovum surrounded by the villi with the decidual coverings is
expelled out intact. .
• Sometimes, the external os fails to dilate so that the entire mass is
accommodated in the dilated cervical canal and is called cervical abortion.
• The gestational sac tends to be expelled complete and the decidua is shed
thereafter
• Till 14 The decidua capsularis ruptures and the Embryo is expelled either
entire or after rupture of the amnion
• After 14 weeks: The placenta is completely formed and the process of
abortion is like a miniature labour.

Threatened abortion
• Bleeding of intrauterine origin occurring before the 22 week
pregnancy with or without uterine constraction. Withoutt dilatation
of the cervix ant without explusion.
• It is a clinical entity where the process of miscarriage has started but
has not progress to a state from which recovery is impossible.
• Clinical freatures
• Bleeding per vaginam is usually slight and may be brownish or bright
red in color. On rare the bleeding may be brisk, especially in the late
second trimester. The bleeding usually stops spontaneously

• Pain: Bleeding is usually painless but there may be mild backache or
dull pain in lower abdomen. Pain appears usually following
hemorrhage.
Cervix is closed.
Pregnancy test is positive.
Ultrasonography shows a living foetus

INVESTIGATIONS
• Blood - for hemoglobin,
• haematocrit,
• ABO and Rh grouping.
• and anti-D gamma globulin has to be given in Rh negative non-
immunized women.
Management:
The patient should be in bed until one week after stoppage of bleeding
Folic acid sipplements
Avoid coitus

PROGNOSIS
• The prognosis is very unpredictable whatever method of treatment is
employed either in the hospital or at home.
• In about 2/3 the pregnancy continues beyond 28 weeks. In the rest it
terminates either in inevitable or missed abortion. If pregnancy
continues, there is increased frequency of preterm labor, placenta
previa.

Inevitable abortion
• It is the clinical type of abortion where the changes have
progressed to a state from where continuation of pregnancy is
impossible.
• The patient, having the features of threatened miscarriage, develops the
following manifestations.
• Increased vaginal bleeding and may accomplanied with clots.
• Aggravation of pain in the lower abdomen which may colicky in nature in
the suprapubic region radiating to the back.
• Internal examination reveals internal os of the cervix is dilated and
products of conception may be felt through it.
• Rupture of membranes between 12-28 weeks is a sign of the inevitability of
abortion.

• Excessive bleeding should be promptly controlled by administering
methergin 0.2 mg if the cervix is dilated and the size of the uterus is
less than 12 weeks.
• The shock is corrected by intravenous fluid therapy and blood
transfusion
• 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
OVUM forceps, if lying separated.
• If the placenta is not separated, digital separation followed by its
evacuation is done under G.A.

DEFINITION:complete miscsrrig
• When the products of conception are expelled as an masses, it is
called complete miscarriage.

CLINICAL FEATURES:
• There is history of expulsion of a fleshy mass per vagina followed
Subsidence of abdominal pain.
Vaginal bleeding becomes trace or absent
Internal examinations reveals: (a) Uterus is smaller than the period of
amenorrhea and a little firmer (b) Cervical os is close (c) Bleeding is
trace.
Examination of the expelled fleshy mass is found complete.

MANAGEMENT
• The effect of blood loss, if any, should be assessed and treated. If
there is doubt about complete expulsion of product, uterine
curettage should be done.
• Transvaginal sonography is useful to see that uterine cavity is empty;
other evacuation of uterine curettage should be done.

INCOMPLETE ABORTION
• When there is entire products of conception are not expelled, instead
a part of it is left inside the uterine cavity, it is called incomplete
abortion
• Persistent vaginal bleeding
• Examination reveal: uterus smaller than the period of amenorrhoea,
patulous cervical os. Often admitting one finger, expelled mass is
found incomplete

Managment
• In recent cases – the same principles to be followed like that of the
inevitable. it is emphasized, patient may be in a state of shock due to
blood loss.
• Early abortion: dilatation and evacuation under general anesthesia is
to be done.
• Late abortion: the uterus is evacuated under general anesthesia and
the products are removed by ovum forceps or by blunt curette.

MISSED ABORTION
• When the fetus is dead and retained inside the uterus for a variable
period, it is called missed abortion or silent miscarriage or early fetal
demise.
• Features:
• gradual disappearance of pregnancy Symptoms Signs.
• Brownish vaginal discharge.
• Milk secretion.
• Pregnancy test: negative
• Non audibility of the fetal heart sound even with Doppler ultrasound
if it had been audible before.

Treatment
• Wait 4 weeks for spontaneous expulsion
• evacuate if:
• Spontaneous expulsion does not occur after 4 weeks.
• Infection.
• DIC.
• Manage according to size of
uterus
• Uterus < 12 weeks : dilatation and evacuation.
• Uterus > 12 weeks : try
• Oxytocin or PGs.

Treatment
Induction is done by following methods:
• Oxytocin: to start with 10-20 units of oxytocin in 500 ml of normal
saline at 30 drops/minute.
• Prostaglandins: are more effective than oxytocin in such cases. The
methods used are :
• Prostaglandin E1 analogue( misoprostol) 200 µg tablet is
inserted into the posterior vaginal fornix every 4

SEPTIC ABORTION
• A septic abortion or septic miscarriage is á form miscarriage
that is associated with a serious uterine infection. The infection
carries risk of spreading infection to other parts of the body and
cause septicemia, a grave risk to the life of the
• woman
• Causes
• • A septic abortion can occur when bacteria enters the uterus.
The bacteria may also belong to the vaginal flora. Also, sexually
transmitted infections (STI) such a chlamydia

Symptoms
• High fever, usually above 101 °F
• Chills
• Severe abdominal pain and/or cramping /or strong perineal
pressure
• Beginning miscarriage symptoms (heavy bleeding and or
cramping) that suddenly stops and does not resume
• Prolonged or heavy vaginal bleeding
• Foul-smelling vaginal discharge
• Backache or heavv back pressure

Grade-I: The infection is localized in the uterus.
Grade-II: The infection spreads beyond the uterus to the perimetrium,
tubes and ovaries or pelvic peritoneum.
Grade-III: Generalized peritonitis and/ or end toxic shock or jaundice or
acute renal failure

INVESTIGATION
• Routine investigation include: cervical or high vaginal swab is taken
prior to internal examination from culture.
• Sensitivity of micro organisms to antibiotics
• Smear to gram stain.
• Hemoglobin test
• Urine analysis.
• Ultrasonography pelvis and abdomen to detect intrauterine retained
products of conception

COMPLICATION
• Hemorrhage related to abortion process.
• Injury may occur to the uterus and also to the adjacent structures
Generalized peritonitis.
• Endotoxic shock
• Acute renal failure
• Thrombophlebitis

MANAGEMENT
• - IV fluids: RL, NS
• . Insert urethral catheter
• - . Monitor Input/output
• Blood grouping & Cross matching
• Antibiotics:
• • Preferably cephalosporins, if not available ampicilin and metronidazole
• Gentamycin (for gram -ve organisms) + metronidazole (for anaerobic infection)are given
by intravenous route while awaiting the results of the bacteriological culture.
• Another regimen to cover the different causative organism is clindamycin + gentamycin
Evacuation

• Surgical evacuation of the uterus can be done after 6 hours of
commencing IV therapy but may be earlier in case of severe bleeding
or deteriorating condition in spite of the previous therapy.
• Hysterectomy may be needed in endotoxic shock not responding to
treatment particularly due to gas gangrene

Ectopic pregnancy
• "Any pregnancy where the fertilized ovum gets implanted &
develops in a site other than normal uterine cavity".
• • Ectopic pregnancy is accounted for 2% of all pregnancies, and
is the most common cause of maternal death during the first
trimester (usually week 6-8 of pregnancy )
• It represents a serious hazard to a woman's health and
reproductive potential, requiring prompt recognition and early
aggressive intervention.

Risk factors
• 1-The most important risk factor is previous history of ectopic
pregnancy.
(30% risk of recurrence)
• 2-Pelvic inflammator disease
• Tubal Factors (salpingitis, previous tubal surgery) •
• Zygote Abnormalities (chromosoma
• Any Assisted Reproductive techniques ivf
• History of an pelvic or tubal surgervHistory of any pelvic or tubal
surgery
• Contraceptive methods like Intrauterine device

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