Abortion

ABORTION :- 

Interuption of pregnancy Or expulsion of the product of conception before the fetus is viable is called abortion. The fetus is generally considered to be viable any time after the fifth to six month of gestation. 

Abortion is the expulsion Or extraction from its mother of an embryo Or fetus weighing 500 gm Or less when  it is not capable of independent survival (WHO). This 500 g of fetal development is attained approximately at 22 weeks of gestation. The expelled embryo Or fetus is called abortus.

CAUSES OF ABORTION :- 

1.Genetic Factors :-

Autosomal trisomy 

Polyploidy

Monosomy 

2. Endocrine and metabolic factors 

3. Anatomical abnormalities 

4. Infections 

5. Immunological disorders :- Both autoimmune and alloimmune factors can cause miscarriage. 

6. Blood group incompatibility :- Incompatible ABO group matching my be responsible for early pregnancy wastage and often recurrent but Rh incompatibility is a rare  cause of death of the fetus before 28 week. Couple with group A husband and group O wife have got higher incidence of abortion. 

7. Premature rupture of membranes inevitably leads to abortion. 

8. Environmental Factors :-

Cigarette smoking 

Alcohol

Contraceptive agents - IUD in situ increase the risk whereas oral pills do not. 

Drugs, chemicals, noxious agents - anesthetic gases, arsenic, formaldehyde increase the risk. 

CLASSIFICATION :- 

SPONTANEOUS ABORTION (MISCARRIAGE) :- 

1.Threatened miscarriage :- It is a clinical entity where the process of miscarriage has started but has not progressed to a state from which recovery is impossible. 

Clinical feature:- 

Bleeding per vaginum

Pain :- Bleeding is usually painless but there may be mild backache or dull pain in lower abdomen. Pain appears usually following hemorrhage. 

Treatment :- 

Rest  

Drugs :- Relief of pain may be ensured by diazepam 5 mg tablet twice daily. 

2. Inevitable miscarriage :- It is the clinical type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible. 

Clinical feature:- 

Increased vaginal bleeding 

Aggravation of pain in the lower abdomen which may be colicky in nature 

Management :- 

Aim :- 1. To acclerate the process of expulsion

           2. To maintain strict asepsis. 

Active Treatment :- 

Before 12 weeks :- 

Dilatation and evacuation followed by curettage of uterine cavity by blunt curette using analgesia or under general anaesthesia. 

Alternatively, suction evacuation followed by curettage is done. 

After 12 weeks :- 

The uterine contraction is accelerated by oxytocin drip 40 - 60 drops per minute. 

If the fetus is expelled and placenta is retained, it is removed by ovum forceps 

If the placenta is not separated , digital separation followed by its evacuation is to be done under general anesthesia. 

3. Complete miscarriage :- When the products of conception are expelled en masse, it is called complete miscarriage. 

Clinical feature :- There is history of expulsion of a fleshy mass per vaginam followed by :

Subsidence of abdominal pain

Vaginal bleeding become trace or absent

Internal examination reveals :- 

Uterus is smaller than the period of amenorrhea and little firmer

Cervical os is closed 

Bleeding is trace s

Examination of the expelled fleshy mass is found complete. 

Management:- 

Transvaginal sonography is useful to see that uterine cavity is empty, otherwise evacuation of uterine curettage should be done. 

4. Incomplete miscarriage :- when the entire products of conception are not expelled, instead a part of it is left inside the uterine cavity, it is called incomplete miscarriage. 

Clinical Feature :- 

Continuation of pain lower abdomen

Persistence of vaginal bleeding

Internal examination reveals :- 

Uterus smaller than the period of amenorrhea

Patulous cervical os often admitting tip of the finger 

Varying amount of bleeding

on examination, the expelled mass is found incomplete. 

Management :- 

In recent cases :- Evacuation of the retained products of conception ( ERCP) is done. 

She should be resuscitated before any active treatment is undertaken. 

Early abortion :- Dilatation and evacuation under analgesia or general anaesthesia 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. In late cases, dilatation and curettage operation is to be done to remove the bits of tissues left behind. 

5.Missed Miscarriage :- When the fetus is dead  and retained inside the uterus for a variable  period, it is called missed miscarriage or early fetal demise. 

Clinical features :- 

The patient usually presents with features of threatened miscarriage followed by:

(1) Persistence of brownish vaginal discharge 

(2) Subsidence of pregnancy symptoms

(3) Retrogression of breast changes

(4) Cessation of uterine growth which in fact becomes smaller in size 

(5) Non audibility of the fetal heart sound even with Doppler ultra sound if it had been audible before

(6) Cervix feels firm 

(7) Immunological test for pregnancy becomes negative 

(8) Real time ultrasonography reveals an empty sac early in the pregnancy or the absence of fetal motion or fetal cardiac movements.

Management :- 

1. Uterus is less than 12 weeks :- 

Expectant management :- Many women expel the conceptus spontaneously. 

Medical management :- Prostaglandin E1 800mg vaginally in the posterior fornix is given and repeated after 24 hrs if needed. Expulsion usually occurs within 48 hrs. 

Suction evacuation or dilatation and evacuation is done either  as a definitive treatment or it can be done when the medical method fails. 

2. Uterus more than 12 weeks :- 

Prostaglandins are more effective than oxytocin in such cases. The methods used are:

(a)Prostaglandin E, analogue (misoprostol) 200 ug tablet is inserted into the posterior vaginal fornix every 4 hours for a maximum of 5 such.

(b)Oxytocin-10-20 units of oxytocin in 500 ml of normal saline at 30 drops per minute is started. If fails, escalating dose of oxytocin to the maximum of 200 mIU/min, may be used with monitoring. 

(c)Many patients need surgical evacuation following medical treatment. Following medical treatment,ultrasonography should be done to document empty uterine cavity. Otherwise evacuation of the retained products of conception (ERPC) should be done.

(d)Dilatation and evacuation is done once the cervix becomes soft with use of PGE, Otherwise cervical canal is dilated using the mechanical dilators or by laminaria tent .Evacuation of the uterine cavity is done thereafter slowly.

6. SEPTIC ABORTION :- Any abortion associated with clinical evidences of infection of the uterus and its contents, called septic abortion. 

Although clinical criteria vary, abortion is usually considered septic when there in

 (1) rise of temperature of at least 100.4°F (38°C) for 24 hours or more

 (2) offensive or purulent vaginal discharge. 

(3) other evidences of pelvic infection such as lower abdominal pain and tenderness.

Mode of infection :- The microorganisms involved in the sepsis are usually those normally present in the vagina (endogenous). 

The microorganisms are: 

(a) Anaerobic-Bacteroides group (fragilis), anaerobic Streptococci,Cl.welchi and tetanus bacillus 

(b) Aerobic-Escherichia coli (E. coli), Klebsiella, Staphylococcus, Pseudomonas and hemolytic Streptococcus (usually exogenous)

. Mixed infection is more common. The increased association of sepsis in illegal induced abortion is due to the fact that: 

(1) proper antiseptic and asepsis are not taken

 (2) incomplete evacuation and 

(3) inadvertent injury to the genital organs and adjacent structures, particularly the bowels

 Clinical features :- 

1.Pyrexia 

2.Abdomen pain

3. A rising pulse rate of 100 - 120/ min

4.Variable systemic and abdominal findings depending upon the spread of infection. 

5.Internal examination reveals offensive purulent vaginal discharge Or a tender uterus. 

Clinical grading :- 

Grade I :- The infection is localized in the uterus. 

Grade II :- The infection spreads beyond the uterus to the parametrium, tubes and ovaries or pelvic peritoneum. 

Grade III :- Generalized peritonitis and / or endotoxic shock or jaundice or acute renal failure. 

Management :- 

Grade I :- 

1. Antibiotics

2.Prophylactic anti -gas - gangrene serum of 8000 units and 3000 units of antitetanus serum IM are given if there is a history of interference. 

3. Analgesics and sedatives

4. Blood transfusion is given to improve anemia and body resistance. 

Grade II :- 

1. Antibiotics

(A).Gram positive aerobes :- 

i.Aqueous penicillin G 5 million units IV every 6 hours 

ii.Ampicillin 0.5 - 1 gm IV every 6 hours. 

(B). Gram negative aerobes :- 

i.Gentamicin 1.5 mg/kg IV every 8 hours 

ii. Ceftriaxone IG, IV every 12 hours. 

(C).For Anaerobes :- 

Metronidazole 500 mg IV every 8 hours or clindamycin 600 mg IV every 6 hours. 

2. Blood transfusion

Surgery:

 (1) Evacuation of the uterus-Evacuation should be withheld for at least 48 hours when the infection is controlled and is localized, the only exception being excessive bleeding. 

(2) Posterior colpotomy When the infection is localized in the pouch of Douglas pelvic abscess is formed. It is evidenced by spiky rise of temperature, rectal tenesmus (frequent loose stool mixed with mucus) and boggy mass felt through the posterior fornix. Posterior colpotomy and drainage of the pus relieve the symptoms and improve the general outlook of the patient.

GRADE-III

Antibiotics are discussed above. Clinical monitoring is to be conducted as outlined in Grade-II. Supportive therapy is directed to treat generalized peritonitis by gastric suction and intravenous saline infusion. Management of endotoxic shock or renal failure, if present, is to be conducted as described in the chapter 38. Patient may need intensive care unit management 

Active Surgery:

Indications are-

(1) Injury to the uterus 

(2) Suspected injury to bowel 

(3) Presence of foreign body in the abdomen as evidenced by the sonography or X-ray or felt through the fornix on bimanual examination 

(4) Unresponsive peritonitis suggestive of collection of pus 

(5) Septic shock or oliguria not responding to the conservative treatment 

(6) Uterus too big to be safely evacuated per vaginam.