Professor and Head Dept Obstetrics and Gynaecology SKHMC Kulasekharam Abortion Abortion Loss of a pregnancy during the first 20 weeks of pregnancy or if the weight is 500gms or less at a time that the fetus cannot survive ID: 918390
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Slide1
Dr Shanthi Serene Sylum VProfessor and HeadDept. Obstetrics and GynaecologySKHMC Kulasekharam
Abortion
Slide2AbortionLoss of a pregnancy during the first 20 weeks of pregnancy, or if the weight is 500gms or less, at a time that the fetus cannot survive.
Such a loss may be involuntary (a "spontaneous" abortion), or it may be voluntary ("induced" or "elective" abortion).
Miscarriage is the term used for spontaneous abortion, an unexpected 1st trimester pregnancy loss.
Slide3Categories of Abortions
These include:
Threatened
Inevitable
Incomplete
Complete
Septic
Slide4Facts about abortion
Such losses are common, occurring in about one out of every 6 pregnancies.
These losses are unpredictable and unpreventable.
About 2/3 are caused by chromosome abnormalities.
About 30% are caused by placental malformations and are similarly not treatable.
The remaining miscarriages are caused by miscellaneous factors but are not usually associated with:
Minor trauma
Intercourse
Medication
Too much activity
Slide5Following a miscarriage, the chance of having another miscarriage with the next pregnancy is about 1 in 6.
Slide6Habitual abortionHabitual abortion, recurrent miscarriage or recurrent pregnancy loss (RPL) is the occurrence of three or more pregnancies that end in miscarriage of the fetus, usually before 20 weeks of gestation.
RPL affects about 0.34%
of women who conceive.
Slide7CausesAnatomical conditions:
Uterine conditions
Cervical conditions
Chromosomal disorders
Endocrine disorders
Immune factors
Lifestyle factors
Infection
Slide8SpontaneousSpontaneous abortion (also known as miscarriage) is the expulsion of an embryo or fetus due to accidental trauma or natural causes before approximately the 22nd week of gestation; the definition by gestational age varies by country.[
Most miscarriages are due to incorrect replication of chromosomes; they can also be caused by environmental factors
Slide9Induced
A pregnancy can be intentionally aborted in many ways. The manner selected depends chiefly upon the gestational age of the embryo or fetus, which increases in size as the pregnancy progresses.
Specific procedures may also be selected due to legality, regional availability, and doctor-patient preference. Reasons for procuring induced abortions are typically characterized as either therapeutic or elective.
Slide10Induced abortion Therapeutic abortion
when it is performed to:
save the life of the pregnant woman
preserve the woman's physical or mental health
terminate pregnancy that would result in a child born with a congenital disorder that would be fatal or associated with significant morbidity or selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy.
Slide11InducedAn elective abortion:When it is performed at the request of the woman "for reasons other than maternal health or fetal disease.
Slide12Threatened Abortion
A threatened abortion means the woman has experienced symptoms of
bleeding or cramping.
At least one-third of all pregnant women will experience these symptoms.
Half will abort spontaneously.
The other half , bleeding and
crampingwill
disappear and the remainder of the pregnancy will be normal.
These women who go on to deliver their babies at full term can be reassured that the bleeding in the first trimester will have no effect on the baby and that you expect a full-term, normal, healthy baby.
Slide13Threatened abortion (Features)
History
Mild vaginal bleeding.
No abdominal pain or mild abdominal pain
Examination
Good general condition.
T
he cervix is closed
The uterus is usually the correct size for date
U/S
which is essential for the diagnosis
Showed the presence of fetal heart activity
Slide14Threatened abortion (Management)
Reassurance
If fetal heart activity is present,
>
90% of cases will be progressed satisfactorily
Advice
:
Decrease physical activity (
bed rest is of
no
therapeutic value
) avoid intercourse
Hormone
s
i.e. Progesterone &
hCG
Which are used in the first trimester to support pregnancy, (but they are of
no
proven value)
Anti- D:
An adequate dose of anti-D should be given to
al
l
Rh
–
ve,non-immunised
patients
, whose husbands are
Rh
+
ve
ANC as high risk patients
Because those patients are liable to late pregnancy complications such as APH and preterm labour .
Slide15Inevitable abortionA condition in which:Vaginal bleeding has been profuse The cervix has become dilatedAbortion will invetably occur.
Slide16Inevitable and incomplete abortions(Features)
History
Heavy vaginal bleeding.
with no passage of products conception
(inevitable)
with the passage of products of conception
(incomplete abortion)
Severe lower abdominal pain
which follows the bleeding
Slide17Inevitable and incomplete abortions(Features)
Examinations
Poor general condition.
The cervix is dilating and products of conception may be passing trough the os
The uterus may be the correct size for date (
inevitable abortion)
or small for date
(incomplete abortion)
U/S
F
etal heart activity may or may not present in inevitable abortion or retained products of conception ( RPOC ) in incomplete abortion
Slide18Inevitable and incomplete abortions(management)
Resuscitatio
n
large IV line, fluids & blood transfusion
Oxytoxic drugs
Ergometrine 0.5 mg IM + Oxytocin infusion (20-40 units in 500 cc saline)
Evacuation & curettage.
Post-abortion management.
Slide19Complete Abortion
Slide20Complete abortion (Features)
History
Heavy vaginal bleeding
which has been stopped
.
lower abdominal pain which follows the bleeding
which has been stopped
.
Examination
T
he cervix is closed
U/S
showed empty uterine cavity or PROP
Slide21Complete abortion(Management)
- Evacuation & curettage
in the presence of RPOC.
Post-abortion management.
Slide22Missed abortion Retention of products for several weeksNo increase in fundal heightAbsence of FHTRegressions of signs of pregnancy
Loss of wight
Slide23Missed abortion (Features)
Most of missed abortions are diagnosed accidentally during routine U/S in early pregnancy .
In some cases there may be a
history of :
Episodes of mild vaginal bleeding
Regression of early symptoms of pregnancy .
Stop of fetal movements after 20 weeks gestation.
Examination
T
he uterus may be small for date
Slide24Missed abortion (Features)
U/S
(
which is essential for diagnosis
)
diagnosed if
two ultrasound
( T/V or T/A) at least
7days apart
showed an embryo of > 7 weeks gestation ( CRL > 6mm in diameter and gestational sac > 20 mm in diameter ) with no evidence of heart activity .
Slide25Missed abortion (Management)
CBC , blood grouping
Platelets count,
to exclude the risk of DIC
NB :
DIC does not occur before 5 weeks of missed abortion or IUFD and if occurred will be of mild grade
Slide26Missed abortion (Management)
Options of treatment
Conservative treatment:
if left alone
spontaneous expulsion will occur
Surgical evacuation of the uterus;
by D & C:
Indicated in
1
st
trimester
missed abortion
Medical termination of pregnancy
:
by
Misoprostol
(PGE1)
Cytotec
:
Indicated in
1
st
& 2
nd
trimesters
missed abortions.
Cytotec
vaginal ( is the best) or oral tab. 200
μg
, 2 tab/ 3 hrs/ up to 5 doses daily, which can be repeated next day if there is no response in the first day
Subsequent surgical evacuation is needed in cases of RPOC
The main side effects of
cytotec
are nausea, vomiting and fever.
Post-abortion management.
Slide27Anembryonic pregnancy (Blighted ovum)
It is due to an early death and resorption of the embryo with the persistence of the placental tissue
It is diagnosed if
two ultrasound
( T/V or T/A) at least
7 days apart
showed after 7 weeks of gestation i.e. gestational sac > 20mm , an
empty
gestational sac with no fetal echoes seen .
It is treated in a similar way to missed abortion .
Slide28Septic abortion Spontaneous or induced termination of a pregnancy in which the mother's life may be threatened because of the invasion of germs into the endometrium, myometrium, and beyond. The woman requires immediate and intensive careMassive antibiotic therapy
Evacuation of the uterus
Emergency hysterectomy to prevent death from overwhelming infection and septic shock.
Slide29Complications of abortion
Haemorrhage
.
Complication related to surgical evacuation
ie
E&C and D&C
.
Uterine perforation
-
which may lead to rupture uterus
in the subsequent pregnancy.
Cervical tear &
excessive cervical dilatation
–
which may lead to cervical incompetence.
Infection
–
which may lead to infertility &
Asherman's
syndrome.
Excessive curettage
–
which may lead to Adenomyosis
Rh
-
iso
immunisation
if the anti –D is not given or if the dose is inadequate
.
Psychological trauma
.
Slide30Post - abortion managementIn cases of incomplete, inevitable, complete, missed & septic abortions
Support:
from the husband, family& obstetric staff
Anti D
– to all Rh –ve, nonimmunised patients, whose husbands are Rh+ve
Counseling & explanation:
Contraception (Hormonal, IUCD, Barrier)
Should start immediately after abortion
if the patient choose to wait , because
ovulation can occur 14 days after abortion
and so pregnancy can occur before the expected next period .
Slide31Post - abortion management
Counseling & explanation:
When can try again :
Best to wait for 3 months before trying again . This time allow to regulate cycles and to know the LMP, to give folic acid, and to allow the patient to be in the best shape (physically and emotionally) for the next pregnancy
Why has it happened
In the fiIn the majority of cases there is no obvious cause
In the first trimester abortion , the most common cause is fetal chromosomal abnormality
Slide32Post - abortion managementCounseling & explanation:
Can it happen again
As the commonest cause is the fetal chromosomal abnormality which is not a recurrent cause , so the chance of successful pregnancy next time in the absence of obvious cause is very high even after 2 or 3 abortions
Not to feel guilty
as it is extremely unlikely that anything the patient did can cause abortion
No evidence that intercourse in early pregnancy is harmful
No evidence that bed rest will prevent it ..
Slide33Recurrent abortion
Definition
:
Is defined as
3 or more consecutive spontaneous
abortions
It may presented clinically as any of other types of abortions .
Types
:
Primary
: All pregnancies have ended in loss
Secondary :
One pregnancy or more has proceeded to viability(>24 weeks gestation) with all others ending in loss
Incidence
:
occurs in about
1%
of women of reproductive age .
Slide34Recurrent abortionCauses
Idiopathic recurrent abortion, in about
50%,
in which no cause can be found .
The known causes include the followings :
Chromosomal disorders
:
Fetal chromosomal abnormalities & structural abnormalities
Parental balanced translocation
Anatomical disorders:
Cervical incompetence
: →congenital and aquired
Uterine causes:
→ submucous fibroids, uterine anomalies & Asherman’s syndrome
Recurrent abortionCauses
Medical disorders:
Endocrine disorders : diabetes , thyroid disorders , PCOS & corpus
luteum
insufficiency .
Immunological disorders :
Anticardiolipin
syndrome & SLE.
Thrombophilia: congenital deficiency of Protein C&S and antithrombin III, & presence of factor V leiden.
Infections
ToRCH
- CMV may be a cause of recurrent
abortion, but
ToRH
are not causes of recurrent abortion.
Genital tract infection
e.g
Bacterial
vaginosis
Rh
–
isoimmunization
Slide36Recurrent abortionDiagnosis :
History
:
Previous abortions : gestational age and place of abortions & fetal abnormalities.
Medical history : DM , thyroid disorders, PCOS, autoimmune diseases & thrombophilia.
Examination
:
General : weight , thyroid & hair distribution
Pelvic: cervix ( length & dilatation ) and uterine size.
Slide37Recurrent abortion
Diagnosis :
investigations
:
Investigations for medical disorders:
Blood grouping & indirect
Coomb’s
test in
Rh
–
ve
women
Endocrinal screening: Blood sugar , TFT & LH /FSH ratio
Immunological screening: Anti
anticardiolipine
antibodies & lupus inhibitor.
Thrombophilia screening: Protein C & S, antithrombin III levels, factor V leiden, APTT and PT.
Infection screening
High vaginal & cervical swabs
ToRCH
profile ( which scientifically is not necessary )
Slide38Recurrent abortionDiagnosis :
investigations
:
Investigations for anatomical disorders
:
TV/US: fibroids, cervical incompetence & PCOS.
Hystroscopy
or HSG, fibroids, cervical incompetence, uterine anomalies &
Asherman's
syndrome
Investigations for chromosomal disorders:
Parental
karyotyping
: Parental balanced translocation.
Fetal
karyotyping
:
Fetal chromosomal anomalies.
Slide39Recurrent abortionManagement:
in idiopathic recurrent abortion.
With support and good antenatal care , the chance of successful spontaneous pregnancy is about 60-70%
Support
: from husband, family & obstetric staff.
Advice :
stop smoking & alcohol intake, decrease physical activity
Tender loving care
Drug therapy
Progesterone &
hCG
: start from the
luteal
phase & up to 12 weeks.
Low dose aspirin ( 75 mg/day ) start from the diagnosis of pregnancy & up to 37 weeks
LMWH (20-40 mg/day) start from the diagnosis of fetal heart activity & up to 37
ws
Slide40Recurrent abortionManagement:
In the presence of a cause
treatment is directed to control the cause
Endocrine disorders
Control DM and thyroid disorders before pregnancy
Ovulation induction drugs , ovarian drilling or IVF in PCOS.
Progesterone or
hCG
in corpus
luteum
insufficiency .
:
In anti-
cardiolipin
syndrome:
Low dose aspirin ( 75 mg/day ) &
prednisilone
( 20-30 mg / day), starting when pregnancy is diagnosed till 37 weeks.
These drugs are not
teratogenic
.
Slide41Recurrent abortionManagement:
In thrombophilia:
Low dose aspirin ( 75 mg/day) starting when pregnancy is diagnosed and low molecular weight heparin
ie
LMWH ( 20-40 mg/day) starting when fetal heart activity diagnosed & to continue both till 37 weeks .
In uterine disorders
Cervical
cerclage
in cervical incompetence, best time at the 14 weeks of pregnancy.
Myomectomy
in
submucus
fibroid, excision of uterine septum in
septate
&
subseptate
uterus &
adhesolysis
in
Asherman's
syndrome.
Slide42Recurrent abortionManagement:
In infection:
: treatment of the genital tract infection.
In
Rh
isoimmunization
: Repeated intrauterine transfusion
In parental balanced translocation
Explain the risk of fetal chromosomal disorders ( about 30% )
Encourage to try again or adoption.
Slide43DC Dutta’s Textbook of Obstetrics including Perinatology & Contraception Eighth Edition 2015 Edited by Hiralal Konar JAYPEE.
Slide44Thank you