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Abortion- Def, Type, Management

Abortion

Definition : Expulsion or extraction from its mother of an embryo or fetus weighing 500gm or less when it is not capable of independent (WHO).

Incidence : Probably over all incidence 10-20%.

Etiology :

  •   Genetic factors
  •   Infection
  •   Endocrine and metabolic factors
  •   Immunological
  •   Anatomical factors
  •   Others

Type of abortion

  •   Spontaneous
    •   Threatened
    •   Inevitable
    •   Incomplete
    •   Complete
    •   Missed
    •   Septic
  • Induced
    • Legal
    • Illegal (criminal)

 

Threatened Abortion

Definition : It is a clinical entity where the process of abortion has started but has not progressed to a state from which recovery is impossible.

Clinical features :

1.   Bleeding per vagina : The bleeding is usually slight and bright red in colour. On rare occasion, the bleeding may be brisk and sharp, specially in the second trimester, suggestive of low implantation of placenta. The bleeding usually stops spontaneously.

2.   Pain : Usually painless, may be mild backache dull pain in lower abdomen. Pain appears usually following haemorrhage.

 

P/V Examination : Usually not done if necessary should be done as gently as possible.

P/S Examination : Reveals bleeding if any escapes through the external os.

Investigation :

  •   Blood for Hb%, ABO and Rh grouping, anti-D gamma   globulin- if Rh negative.
  •   Urine for Pg test.
  •   Ultrasonography (TVS/ Abdominal) :

 Treatment :

1.   Rest : When active bleeding present.

2.   Drugs : Sedation and relief of pain.

3.   General measure : Pulse, Blood Pressure,

4.   Temperature, P/V bleeding.

 

Inevitable Abortion

Definition : In this type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible.

Clinical Features :

1. Amenorrhoea

2. P/V bleeding

3. Lower abdominal pain : Aggravation of pain colicky in nature.

4. P/V examination /Bleeding Present (+)or (++)  :

P/S: Dilated internal os of the cervix through which the products of   conception are felt.

 

Management :

1. Correction of aneaemia

2. Correction of dehydration

3. To accelerate process of expulsion

4. To maintain strict asepsis (to reduce post abortion omplication).

 

Treatment :

1.  Before 12 weeks : Dilatation, evacuation, curettage Suction evacuation   and curettage Under G/A.

2.  After 12 weeks : Oxytocin drip Prosterglandin tablet.

 

Complete abortion

Definition : When product of conception are expelled completely.

Clinical Features :

1. Amenorrhoea

2. History of expulsion of fleshey mass per vagina.

3. Subsidence abdominal pain.

4. P/V bleeding : Trace or absent

5. P/V examination : Bleeding (+) or absent.

 

Bimanual examination :

1. Uterus is smaller than the period of amenorrhoea and firm.

2. Cervical os closed.

3. Bleeding : Trace or absent.

 

Management :

1. Correction of anaemia if needed.

2. Anti-D gamma globulin-50 microgram or 100 microgram if patient Rh negative, within 72 hours of abortion.

 

Incomplete abortion

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 abortion. Commonest type of abortion amongst hospital incidence.

 

Clinical features :

1. Amenorrhoea History of

2. History of Expulsion of product of conception per vagina.

3. Continues lower abdominal colicky pain.

4. Per vaginal bleeding.(irregular).

5. Internal examination :

a. Uterus smaller than the period of amenorrhoea.

b. Patulous cervical os often admitting tip of the finger.

c. Varying  amount of bleeding.(P/V)

 

Management :

1. Correction  of anemia if necessary.

2. Antibiotics.

3. Dilatation and evacuation under G/A.

4. Histopathological examination of product of conception after       removed.

 

Missed abortion

Definition : Sometimes fetus died in uterus and retained inside for a variable period is called missed abortion.

Clinical features :

1. Amenorrhoea

2. P/V bleeding / Brownish discharge.

3. Subsidence of pregnancy symptoms.

4. Fetal heart sound not audible with doppler.

5. Cervix feels firm.

6. Pregnancy test negative.

7. USG reveals absent fetal heart movement and fetal motion.

 

Complication : Blood coagulation disorders.

 

Management :

Less than 12 weeks-dilatation, evacuation & curettage.

More than 12 weeks-induction by

1. Oxytocin

2. Prostaglandins

 

Abortion Complicated By Infection- Click Here

 

Recurrent (Habitual) Abortion

Definition :

Three consecutive pregnancies ending in spontaneous abortion therefore constitute the criterion for the diagnosis of ‘recurrent abortion’. In practice, however, investigation, if not treatment, may be justified by a woman’s anxiety over having lost 2 pregnancies.

Investigation

1.  Occurrence of previous abortions

2.  Periods of amenorrhoea

3.  subsequent bleeding painful and by home

4.  Curettings contain chorionic villi on histological examination

 

Special tests

Between pregnancies

(1)  Blood count and uninalysis.

(2)  Serological tests for syphilis in wife and husband.

(3)  Determination of the blood groups of wife and husband, with tests for antibodies in the wife.

(4)  Glucose tolerance test.

(5) Estimation of theblood urea level, and renal function tests where indicated.

(6)  Tests of thyroid function.

(7)  Hysterography to determine the shape of the fundus and the competence of the internal os is essential in all cases. Cervical sphincteric action is beststudied during the luteal phase.

(8)  A formiminoglutamic acid (FIGLU) excretion test and blood folate assays.

(9)  Study of the chromosome patterns of wife and husband.

 

During pregnancy

(1) All the above tests except those involving the use of radioactive isotopes and hysterography. Re-assessment of the folate and vitamin B12 status in early pregnancy is particularly important since a defect is commonly found even though it is not demonstrable before conception.

(2) Careful vaginal examination to determine the position of the uterus and the competence of the cervix.

(3) Assays of the urinary excretion of HCG, pregnanediol and oestriol, and of plasma levels of HCS (HPL) and progesterone, the choice depending on the duration of the pregnancy, can give a guide to placental function.

(4) A cervical mucus fern test and vaginal cytology to determine the presence or absence of progesterone dominance. In pregnancy a cornification index of less than 10 is normal.

 

 

Treatment

Treatment of the cause

1. Uterine retroversion can be corrected

2. Uterine fibroids can be removed

3. Torn cervix repaired

4. Utriculoplasty

5. Shirodkar operation : It is generally best to perform this operation between the twelfth and sixteenth weeks of pregnancy removing the ligature 2 weeks before term or at the onset of abortion or labour.

 

Empirical remedies

1.  General measures before pregnancy

a.  Wait 3 months

b.  Improve her physical and mental health

c.  Dietetic errors

d.  Defective folate

e.  Folic acid 5 mg t. d. s.

2.  General treatment during pregnancy

a.  Rest

b.  Psychological support

c.  Sedatives

d.  Diet

3.  Special treatment during pregnancy

a.  Progestogens

i)     Improving placentation

ii)    Rendering uterine contractions non-expulsive

iii)   Raising the tone of the cervical sphincter

 

Results

Whatever treatment they receive, or if they have none at all, 70 per cent women who have lost 3 consecutive pregnancies by way of abortion will have a live child next time.

 

Criminal Abortion

Definition :

Every women, being with child, who, with intent to procure her own miscarriage, shall unlawfully administer to herself any position or other noxious things.

 

Methods Used

1. Strong purgatives and single administrations of oxytocins.

2. Intra-uterine instrumentation : Domestic instruments such as hair   pins, knitting needles and the like are frequently used.

3. Dilatation of the cervix

4. An intra-uterine injection

5. Potassium permanganate

 

Dangers

a.  Haemorrhage

b.  Shock

c.  Anuria

d.  Peritonitis

e.  Septicaemia

f.   Air embolism

g.  Chemical embolism

h.  Intravascular haemolysis

 

Diagnosis

Sings of recent injury to the

a.  Cervix

b.  Uterus

c.  Vagina are found

 

Management

If the initial shock due to intravasation of solutions injected into the uterus does not respond to morphine, infusions, of blood and hydrocortisone given intravenously, exchange transfusion should be considered.

A.  Removal of body of shock antibiotic evacuation of uterus.

B.  Prevention.

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