Dr Shanthi Serene Sylum V - PowerPoint Presentation

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Dr Shanthi Serene Sylum VProfessor and HeadDept. Obstetrics and GynaecologySKHMC Kulasekharam

Abortion

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AbortionLoss 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.

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Categories of Abortions

These include:

Threatened

Inevitable

Incomplete

Complete

Septic

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Facts 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

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Following a miscarriage, the chance of having another miscarriage with the next pregnancy is about 1 in 6.

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Habitual 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.

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CausesAnatomical conditions:

Uterine conditions

Cervical conditions

Chromosomal disorders

Endocrine disorders

Immune factors

Lifestyle factors

Infection

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SpontaneousSpontaneous 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

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Induced

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.

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Induced 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.

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InducedAn elective abortion:When it is performed at the request of the woman "for reasons other than maternal health or fetal disease.

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Threatened 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.

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Threatened 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

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Threatened 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 .

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Inevitable abortionA condition in which:Vaginal bleeding has been profuse The cervix has become dilatedAbortion will invetably occur.

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Inevitable 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

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Inevitable 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

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Inevitable 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.

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Complete Abortion

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Complete 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

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Complete abortion(Management)

- Evacuation & curettage

in the presence of RPOC.

Post-abortion management.

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Missed abortion Retention of products for several weeksNo increase in fundal heightAbsence of FHTRegressions of signs of pregnancy

Loss of wight

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Missed 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

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Missed 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 .

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Missed 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

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Missed 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.

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Anembryonic 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 .

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Septic 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.

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 Complications 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

.

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Post - 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 .

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Post - 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

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Post - 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 ..

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Recurrent 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 .

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Recurrent 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

 

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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

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Recurrent 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.

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Recurrent 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 )

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Recurrent 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.

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Recurrent 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

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Recurrent 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

.

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Recurrent 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.

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Recurrent 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.

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DC Dutta’s Textbook of Obstetrics including Perinatology & Contraception Eighth Edition 2015 Edited by Hiralal Konar JAYPEE.

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Thank you