Abortion PG Seminar Power point presentation

Abortion

1. Abortion Dr Aksshaya 1st year Post graduate MS Obstetrics and Gynecology

2. Abortion Termination of pregnancy < 20 weeks of gestation. WHO criteria : Termination of pregnancy occurs in fetus weighing < 500g, at the time of termination Early pregnancy loss : < 12 weeks Still birth : Pregnancy loss > 20 weeks Anembryonic pregnancy : Non viable pregnancy with a gestational sac that does not contain a yolk sac/ embryo. AKA blighted ovum.

3. Risk factors Increased maternal age ≥ 35 years Previous history of abortions Maternal infections like Viral : Rubella, CMV, Variola, Vaccinia or HIV Parascitic : Toxoplasma, Malaria Bacterial : Ureplasma, Chlamyia, Brucella, Spirochetes. Maternal factors : Uncontrolled diabetes, Thyroid disorders, Obesity, Stress, Pregnancy with IUCD in place, Substance abuse and radiation exposure.

4. Classifications of abortions Abortion Recurrent pregnancy loss Isolated spontaneous abortion Induced abortion Spontaneous abortion Illegal Abortion Legal Abortion Threatened abortion Inevitable abortion Complete abortion Incomplete abortion Missed abortion Septic abortion

5. Isolated abortions Can happen in 1 st and 2 nd trimester Most common cause : Chromosomal anamolies Aneuploidy > Trisomy (group trisomy) > Monosomy X (20%) > Trisomy (16%) Uterine anomalies : Fibroids, adhesions, septae, Cervical incompetence Trauma Infections : Chorioamnionitis, maternal infections like TORCH Thrombophilias

6. Isolated abortions (Contd..) Environmental factors : Cigarette smoking, Contraceptive agents, drugs, chemicals,noxious agents

7. Clinical classification of Spontaneous abortion Threatened abortion Inevitable abortion Complete abortion Incomplete abortion Missed abortion Septic abortion

8. Threatened abortion Clinical entity where the process of miscarriage has started but has not progressed to a state from which recovery is impossible. History : Spotting PV +/- Pain abdomen C/F : Bleeding PV > Pain P/A : Height of the uterus = Period of gestation P/S : Bleeding if any, escapes through os Internal os - Closed (reversible) D/D : Cervical ectopy , polyps or carcinoma, ectopic pregnancy and molar pregnancy USG : Cardiac activity +

9. Management : No defenitive treatment Emperical treatment : Avoid heavy weight lifting Avoid intercourse Rest for 48 hours Anti D injection to be given to the Rh negative pregnant women with threatened abortion at ≥ 12 weeks(2nd trimester)

10. Inevitable abortion The process of abortion has reached the stage from where it is not reversible History : Bleeding + pain abdomen No H/O expulsion of products of conception P/A : Height of the uterus = POG Internal os - Open (Not reversible) USG : Cardiac activity is absent Management : Complete the process of abortion by Medical/ Surgical methods (MTP) Anti D injection to be given to the all Rh negative pregnant women with inevitable abortion whether it is < 12 weeks or ≥ 12 weeks due to increased chance of fetomaternal hemorrhage (< 12 weeks - 50 mcg, ≥ 12 weeks - 300 mcg)

11. Incomplete abortion The process of abortion begins and POC starts coming out 2nd MC type of abortion which leads to shock History : POC coming out, bleeding, pain abdomen P/A : Height of the uterus < POG Internal os : Open + POC coming out Management : Complete the process of abortion by Medical/ Surgical methods (MTP) Anti D injection to be given to the all Rh negative pregnant women with incomplete abortion whether it is < 12 weeks or ≥ 12 weeks

12. Complete abortion The entire process of abortion is completed on its own History : Initial H/O bleeding, pain abdomen, expulsion of POC with stoppage of bleeding later P/A : Height of the uterus < POG Internal os - Closed USG : Empty uterus Management : Reassurance Anti D injection to be given if complete abortion occurs at ≥ 12 weeks

13. Missed abortion Cardiac activity of the fetus has stopped and patient is unaware about the abortion No H/O bleeding P/A : Height of the uterus < POG Internal os - Closed Anti D injection to be given to the all Rh negative pregnant women with missed abortion whether it is < 12 weeks or ≥ 12 weeks

14. Diagnosis of Missed abortion Mean sac diameter (MSD) ≥ 25mm and no embryo is seen ≥ 11 days after the sac showing gestational sac with yolk sac but no embryo ≥ 2 weeks after scan showing gestational sac without yolk sac or embryo If CRL ≥ 7mm with no cardiac activity Most common time for abortion : First trimester - more commonly <8 weeks

15. Approach to a case of abortion Approach Open No H/O POC coming out POC came out Open Close Close Incomplete abortion Complete abortion Inevitable abortion Height of the uterus < POG Height of the uterus = POG Threatened abortion Missed abortion

16. Septic abortion Any abortion associated with clinical evidence of infection of uterus and its contents Criteria : Rise of temprature of atleast 100.4 o F for 24 hours or more Offensive or purulent vaginal discharge Other evidence of pelvic infection such as lower abdominal pain and tenderness Majority of cases, the infection occurs following illegal induced abortion

17. Mode of infection Anaerobic : Bacteriodes,anaerobic streptococcus, clostridium welchii and tetanus Aerobic : E coli, Klebsiella, Staphylococcus, Pseudomonas, Beta hemolytic strep, MRSA Mixed infection is more common

18. Clinical grading Grade 1 : Infection localized inside the uterus Grade 2 : Infection spreading beyond Uterus and parametrium, tubes and ovaries or pelvic peritoneum Grade 3 : Generalised peritonitis and/ or endotoxic shock or jaundice or acute renal failure

19. Management General management : Hospitalization High vaginal or cervical swab Vaginal examination Overall assessment Investigations

20. Grade 1 Drugs : Antibiotics Prophylactic antigas gangrene serum of 8,000 units and 3,000 units of anti tetanus serum IM Analgesics and sedatives Evacuation of the uterus : Should be performed at a convinent time within 24 hours following antibiotic therapy

21. Grade 2 Antibiotics Analgesics and ATS TPR/BP/Urine I/O charting Look for pain progression, tenderness in lower abdomen. Evacuation of the uterus : Withheld for atleast 48 hours when the infection is controlled or localised, only exception is excessive bleeding Posterior colpotomy : Infection in POD, pelvic abscess

22. Grade 3 Along with antibiotics and clinical monitoring Supportive therapy to treat generalised peritonitis by gastric suction Laparotomy : Uterus should be removed irrespective of parity. Adnexa is to be removed or preserved according to pathology Even when nothing is found on laparotomy , simple drainage of pus is effective

23. Recurrent pregnancy loss ≥ 3 consecutive pregnancy losses at < 20 weeks. Investigations should begin ≥ 2 abortions M/C cause : Idiopathic M/C group among other causes : Endocrinopathies > Uterine causes > Immunological causes > Chromosomal abnormalities

24. Endocrinopathies (15-60%) Uterine causes (10-50%) Immunological causes Chromosomal abnormalities Hypothyroidism Hyperthyroidism Uncontrolled DM Increased Prolactin levels Leuteal Phase defect PCOS Cervical Incompetence Uterine malformations Submucosal fibroid Asherman’s syndrome APLA syndrome (Anti Phospholipid antibody) Balanced translocations of chromosomes

25. Endocrinopathies Leuteal phase defect : Decreased progesterone in the 2nd half of the cycle leading to abortion Overt hypothyroidism or hyperthyroidism associated with increased fetal loss Uncontrolled diabetes leads to increased miscarriage

26. Infections Viral : Rubella, CMV, Variola , Vaccinia and HIV Parasites : Toxoplasma , Malaria Bacterial : Ureplasma , Chlamydia, brucella , Spirochetes Infections are not reason for Recurrent pregnancy loss Syphilis follows Kassowitz’s law : As the number of pregnancy losses increases the period of pregnancy at which the loss occurs also increases 1st pregnancy : Abortion (<20 wks) 2nd Pregnancy : Stillbirth (>20 wks) 3rd pregnancy : Preterm labour

27. APLA syndrome Antibodies against : Lupus anticoagulant : Most common Anti cardiolipin antibody Beta 2 glycoprotein antibody All these cause thrombosis : Arterial, Venous or placntal

28. Placental thrombosis : Complete cut off of blood supply < 20 weeks - abortion (RPL) Complete cut off blood supply > 20 weeks - Still birth Incomplete cut off blood supply - IUGR and PIH in mother

29. Diagnosis of APLA syndrome Modifies Sapporo criteria/ Sydney Criteria : 1 clinical criteria with 1 lab criteria should be present Clinical criteria : ≥ 3 pregnancy losses at < 10 weeks with maternal anatomic or hormonal abnormalities and paternal and maternal chromosomal causes excluded ≥ 1 pregnancy loss at > 10 weeks morphologically normal fetus ≥ 1 preterm labour at < 34 weeks due to early onset eclampsia or IUGR morphologically normal neonate Vascular thrombosis Lab criteria : Presence of LAC/ Anti cardiolipin antibody/ Beta 2 glycoprotein : Presence of any of these in medium to high titres on 2 occasions 12 weeks apart

30. Management Non pregnant women : Warfarin (Drug of choice) Pregnant women : Low dose Aspirin Given in all case of APLA syndrome Started as soon as pregnancy is diagnosed Ideally should be started before conception Low molecular weight heparin : Started after confirmation of intrauterine pregnancy Given only if there is H/O thrombosis or abortions

31. Pregnant female with persistent LAC antibodies Low dose Aspirin started as antibodies are present If H/O thrombosis : Low dose aspirin and LMWH If no H/O thrombosis : Check for pregnancy complications related to APLA syndrome If complications present along with H/O abortion : Low dose aspirin + LMWH If complications present along with H/O pre term labour due to PIH/ Uteroplacental insufficiency : Low dose Aspirin

32. Uterine anomalies Can be either congenital/ acquired Congenital : M/C due to Mullerian anamolies ( Septate > Bicornuate) Acquired causes : Cervical incompetence : M/C uterine anamolies causing RPL Submucous fibroid Polyps Adenomyosis Asherman’s syndrome

33. Investigations for Uterine anamolies Pregnant female : TVS Non pregnant female : Saline infusion sonography 3D USG : IOC for mullerian anamolies MRI : Gold standard investigation for mullerian anamolies Hysteroscopy Laparoscopy

34. Cervical incompetence Causes mid trimester pregnancy loss History based diagnosis of cervical incompetence ≥ 2 painless 2nd trimester pregnancy losses Spontaneous dilation of cervix which is painless leading to expulsion of POC spontaneously With every subsequent pregnancy, the time of pregnancy loss decreases

35. Risk factors Past H/O surgeries on cervix : Conization/ LEEP (past H/O CIN) or amputation of cervix in fothergill’s surgery for vaginal prolapse Cervical trauma during labour, instrumental delivery Congenital abnormality is rare Mostly Incompetence is a acquired defect

36. Diagnosis H/O pregnant female with ≥ 2 painless 2nd trimester pregnancy losses managed with cervical encercalage and progesterone H/O 1 painless 2nd trimester abortion : TVS done between 18-24 weeks (ideal time) can be done as early as 14 weeks Principle for diagnosis : As the cervix dilates, length of the cervix shortens

37. Cervical length ≤ 2.5 cms with one 2nd trimester pregnancy losses is taken as cervical incompetence Normal length : 3-4 cms Diameter of internal os : ≥ 2 cm Shape of cervix becomes U shaped Normal shape of cervix in TVS : T shaped As the cervix shortens, Cx becomes Y shaped , then V shaped and then U shaped. Os is completely dilated

38. USG based diagnosis H/O of one or more 2nd trimester abortions and TVS showing cervical length as ≤ 2.5 cm Management : Cervical encercalage and progesterone Diagnosis of cervical incompetence in a non pregnant female : If Hegar dilator no 8 can be passed through the internal os without any resistence from the female

39. Management Surgery : Cervical encercalage (Transvaginal > Transabdominal) M/C : Transvaginal (McDonalds and Shirodkars Cercalage) McDonalds cercalage : Attempt is made to reach as close as possible to the internal os Sutures are applied at cervicovaginal junction Purse string sutures with non absorbable suture material 2’O clock --> 10’ O Clock --> 8’ O Clock --> 2 ‘O clock (Anti clockwise direction)

40. Ideal time for cercalage : 12 - 14 weeks Can be done up till 24 weeks --> not to be done beyond 24 weeks In all patient who has undergone cervical cercalage : Supplemental progesterone given up to 36 weeks + 6 days of gestation

41. Shirodkar’s cercalage : The Cervicovaginal junction is out Suture applied at the internal Os Non absorbable sutures used Less failure rate Transabdominal cercalage : Only done if transvaginal fails A Mersilene tape is placed at the level of isthmus between uterine walls and uterine vessels Done at 11 and 13 weeks following laparotomy

42. Cervical encercalage Indications If history based or USG based criteria for incompetence is met Contraindications Absolute : Gross Congenital anomalies, Current pelvic infections, ruptured membranes Relative : Placenta previa

43. Cervical stitch removal Time to remove : 37 weeks Cervical stitch should be removed irrespective of period of gestation in case of : Ruptured membranes Patient goes in preterm labour Chorioamnionitis

44. As per 2022 amedment MTP can be done upto 24 weeks If pregnancy due to contraceptive failure can be done upto 20 weeks Fetal anamoly : 24 weeks, If severe fetal anamolies - No upper limit Single doctor’s opinion is needed uptil 20 weeks 2 doctors opinion needed for 20-24 weeks

45. Medical Termination of pregnancy MTP act : 1971 Ammendment : 2022 Consent : Only female’s consent needed If the female is < 18 years or mentally ill : Gaurdian’s consent Qualifications for MTP : RMP who has assisted in 25 MTPs (atleast 5 as primary surgeon) RMP who has done 6 months as house surgeon in OBG Diploma/Degree in OBG

46. Methods of doing MTP 1st trimester : Medical abortion Suction evacuation Manual vaccum aspiration 2nd trimester Prostaglandins Oxytocin Dilatation and evacuation

47. Medical abortion Indian guidelines WHO Upper limit 7 weeks 9 weeks Done As a OPD procedure if 7-9 weeks , IP basis Day 1 T. Mife 200 mg orally T. Mife 200 mg orally Day 3 T. Misoprostol 400 mcg oral/ buccal/PV/Sublingual/PR T. Misoprostol 800 mcg oral/ buccal/PV/Sublingual/PR Day 15 To ensure that the process is complete To ensure that the process is complete

48. Suction evacuation Done using Karman’s canula Number of Karman’s canula corresponds to the size of uterus Dilatation : Hegar’s dilator Pressure generated : 600 mmHg End point of suction : Decreased blood loss Gripping sensation Grating sensation Air bubbles in the cannula

49. Dilatation and evacuation Similar to suction and evacuation till the dilatation of internal os Sponge holding forceps/ Ovum forceps is used to carry out abortions Check curettage with blunt curette is done MVA syringe : Used in rural areas where electricity is not available

50. References Williams Obstetrics - 26th edition DC dutta’s text book of obstetrics - 9th edition Comprehensive Abortion care by Ministry of health and family welfare - Third editin (2023)

51. THANK YOU