ABORTION

Definition

 

Expulsion from the uterus of an embryo or fetus prior the stage of viability, which is 20 weeks gestation (or fetal weight less than 500gm).

 

Classification of Abortion:

 

A.   Spontaneous abortion.                           

B.   Induce abortion.             

C.   Recurrent abortion.

 

Spontaneous abortion:

1.    Threatened

2.    Inevitable

3.    Complete

4.    Incomplete

5.    Missed

 

 

Induced abortion:

1.    Legal

2.    Illegal

3.    Septic

 

Recurrent abortion:

 Habitual.

 

Threatened abortion:

 

A clinical entity where the choriodecidual haemorrhage (the process of abortion) has begun, but not progress to the stage of irreversibility. The cervix is not open and the products of conception are not expelled.

 

Investigation:

1.    Hemoglobin estimation.

2.    Urine for pregnancy test.

 

Clinical feature:

1.    History of amenorrhoea more than 6weeks.

2.    Bleeding which is fresh and scanty.

3.    Mild uterine cramps and back ache (sometimes painless bleeding).

4.    Signs of early pregnancy.

5.    Cervix soft with os closed.

6.    Uterus soft.

 

 

Obstetrical management:

 

1.    Hospitalization and complete bed rest until bleeding stop.

2.    Hormonal supportive therapy up to 14-16 weeks.

3.    Haematinics, laxative and sedatives if required.

 

 

Inevitable abortion:

 

In this type of abortion, the process of abortion has begun and progressed to such as extent that expulsion of products of conception seems inevitable. 

 

Clinical features:

1.    History of amenorrhoea.

2.    Vaginal bleeding with passes of fresh blood and clot.

3.    Pain due to uterine contractions cervical dilation.

4.    Pallor. - Cold, clammy extremities.

5.    Tachycardia.

6.    Hypotension.

7.    Cervix soft to firm and bulky, corresponding to the period of gestation.

 

Investigation:

 

1.    Blood group and cross matching.

2.    Haemoglobin.

3.    WBC, TC&DC. - USG.

 

Management:

 

1.    Resuscitation with IV fluids and blood if patients is in shock.

2.    Dilatation and suction curettage to evacuate uterus.

3.    Antibiotics.

4.    Tetanus toxoid and anti-D for Rh-negative mother.

 

Complete abortion:

 

Complete abortion the product of conception are expelled complete from the uterus and the uterine cavity is empty.

 

Clinical features:

   History of –

1.    Variable period of amenorrhoea.

2.    Lower abdominal pain and vaginal bleeding with passes of a fleshy mass.

3.    Decrease in bleeding and pain following expulsion of products of conceptions.

4.    Vaginal bleeding minimal.

5.    Uterus is smaller than the period of gestation on internal Examination.

6.    Cervical or is closed.

7.    Expelled mass may be intact.

 

Investigation: 

Ultrasonography-Uterine cavity found empty.    

 

 

Management:

1.    Sedative.

2.    Resuscitation with IV fluids and blood if patients is in shock.

3.    Antibiotics.

4.    Tetanus toxoid and anti-D for Rh-negative mothers.

5.    Rarely curetage may be necessary if bleeding continues, Ultrasonography reveals products in the uterine cavity.

 

Incomplete abortion:

 The uterine products of conception are not expelled completely and a part of its left inside the uterine cavity.

 

Clinical features:

   History of – 

·       Variable period of amenorrhoea.

·       Vaginal bleeding continues or recurrent. 

·       Passes of flashy mass per vagina. 

·       Lower abdominal pain with colicky nature.

 

On vaginal examination:

1.    Uterus smaller than the period of amaenorrhoea.

2.    Internal os open and uterus soft.

3.    Expelled mass may found incomplete.

  

Investigation:

1.    Blood group and cross matching.

2.    Hemoglobin.

3.    WBC, TC&DC.

4.    USG.

 

 Management:

·       Resuscitation with IV fluids and blood if patients is in shock.

 

In recent cases-

·       Dilatation and curettage of empty the uterus using blunt curette under general anesthesia. 

 

In old case-

·       Suction curettage under antibiotic cover.

·       Tetanus toxoid.

·       Anti-D to Rh-negative mothers.

·       Haematinics to correct anemia

Missed abortion:

 

In missed abortion the fetus is dead retained inside the uterus for a variable period of time.

 

Clinical feature:

 History of-

  Variable period of amenorrhea followed by vaginal bleeding or brushing discharge and spotting.  Subside of pregnancy symptoms.

 

On examination-

·       Uterine size smaller than the period of amenorrhea.

·       Cervix soft with internal or closed.

·       Retrogression of breast changes.

 

Investigation:

·       Pregnancy test becomes negative.

·       Ultrasonography.

·       Immunological test for pregnancy-negative.

·       BT, CT.

 

Management:

 Uterus less than 12 weeks-

·       Dilatation and suction evacuation.

 Uterus more than 12 weeks-

·       Ripening of the c4ervix with prostaglandin gel and then 12 hourly injection of prostidin.

 Post abortion-

·       Examine expelled product to ensure completeness 

·       Tetanus toxoid and anti-D where as indicated.

·       Antibiotics and haematinics as prescribed.

 

    Induced abortion:

 Medical termination of pregnancy (MTP).

 

Medical termination of pregnancy is deliberate (planned) termination of pregnancy prior to viability of the fetus. India abortion laws were liberalized in 1971.The act came into force in 1972.

 

A.   Medical methods using:

1.    Mefipriston with misoprostol.

2.    Methotrexate with misoprostol.

3.    Tamoxifen with misoprostol.

 

B.   Surgical methods:

1.    Dilatation and evacuation.

2.    Hysterectomy.

 

Septic Abortion:

 

A type of abortion associate with sepsis of the products of conception. There is increase association of sepsis in illegal induced abortion because of- 

1.    Improper antiseptic and aseptic measures.

2.    Incomplete abortion and

3.    Inadvertent (fragment) injury to the genital organs and adjacent (closest) organs.

 

Investigation:

1.    Complete blood count and urinalysis.

2.    Blood urea, creatinine, serum electrolytes.

3.    Blood culture when septicemia is suspected.

4.    Pelvic ultrasonography

5.    X-Ray chest.

 

Management:

1.    Shock is to be treated aggressively.

2.    Catheterization & maintain urine output chart.

3.    Antibiotic.

4.    Evacuation of uterine product under anesthesia.

 In severe cases-

1.    Blood transfusion.

2.    Oxygen therapy. 

3.    Prophylactically anti-tetanus Toxoid. 

4.    Analgesic and sedative as required.

 

Illegal Abortion /Criminal Abortion (Unsafe Abortion):

 This is define as the procedure of termination of unwanted pregnancy either by person lacking the necessary skills or in an environment lacking the minimal standard or both.

 

Recurrent Abortion/Habitual Abortion:

 Spontaneous or recurrent Abortion occurring consecutively on three or more occasions is called recurrent or habitual abortion. It may be primary or secondary, It occurs after the birth of a viable baby.