Abortion-spontaneous miscarriage

Spontaneous miscarriage definition types management
Recurrent miscarriage types
Cervical incontinence and management
Cerclage types
Indication
Apla
Threatened abortion, complete abortion, septic abortion

1. ABORTION

2. Abortion is the expulsion (or extraction from its mother) of an embryo or fetus weighing 500 g or less when it is not capable of independent survival (WHO). The current cut off for fetal viability is 22 weeks by the WHO. DEFINITION

3. 15% of all clinically recognized pregnancies. 80% of this occur in the first trimester . Rates vary with maternal age. High in elderly and in women with previous miscarriage INCIDENCE

4. 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 presentation : Vaginal bleeding Usually painless , may have abdominal cramps and back ache Examination : Cervix soft with closed internal os . Size of uterus corresponds to period of amenorrhoea THREATENED ABORTION

5. Differential diagnosis Ectopic gestation ( serial serum beta HCG ) Hydatidiform mole Missed abortion Ultrasonography is diagnostic Management The patient should be in bed for few days until bleeding stops. Coitus is avoided during this period Relief of pain may be ensured by diazepam 5 mg tablet twice daily Anti-D for Rh negative mother.(beyond 12 weeks) There is some evidence that treatment with progesterone improves the outcome.(controversial) should be followed up with repeat sonography at 3–4 weeks’ time Ultrasonography (TVS) findings may be: (1) A well-formed gestation ring with central echoes from the embryo indicating healthy fetus (2) Observation of fetal cardiac motion. With this there is 98% chance of continuation of pregnancy. (3) A blighted ovum is evidenced by loss of definition of the gestation sac, smaller mean gestational sac diameter, absent fetal echoes and absent fetal cardiac movements

6. Prognosis and outcome The prognosis is very unpredictable. 80% willl go on to term. In the rest, it terminates either as inevitable or missed miscarriage If the pregnancy continues, there is increased frequency of preterm labor , placenta previa , intrauterine growth restriction of the fetus and fetal anomalies .

7. It is the clinical type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible. Clinical presentation : Vaginal bleeding, profuse Associated with severe pain, colicky in nature Examination : Internal examination reveals dilated internal os of the cervix through which the products of conception are felt . INEVITABLE ABORTION

8. Management The blood loss should corrected by intravenous (IV) fluid therapy and blood transfusion. Before 12 weeks: suction evacuation followed by curettage is done. After 12 weeks: The uterine contraction is accelerated by oxytocin drip (10 units in 500 mL of normal saline) 40–60 drops per minute to hasten expulsion. Anti-D is given to Rh negative mother.

9. When the process of abortion has already taken place but entire products of conception are not expelled, instead a part of it is left inside the uterine cavity , it is called incomplete miscarriage. This is the commonest type met amongst women Incomplete abortion

10. CLINICAL FEATURES: History of expulsion of a fleshy mass per vaginam pain in lower abdomen. Persistence of vaginal bleeding. EXAMINATION uterus smaller than the period of amenorrhea internal os is open on examination, the expelled mass is found incomplete Ultrasonography —reveals echogenic material (products of conception) within the cavity. COMPLICATIONS: The retained products may cause: profuse bleeding sepsis or placental polyp.

11. MANAGEMENT: Resuscitation Early abortion: evacuation of uterus by suction evacuation Late abortion: dilatation and curettage The removed materials are subjected to a histological examination . In stable patients with closed os , Tablet misoprostol 200 µg is used vaginally every 4 hours anti-D gamma globulin 50 μg or 100 μg intramuscularly

12. when the products of conception are expelled en masse , it is called complete miscarriage. CLINICAL FEATURES: There is history of expulsion of a fleshy mass per vaginam followed by: Subsidence of abdominal pain. Vaginal bleeding becomes trace or absent. EXAMINATION Uterus is smaller than the period of amenorrhea and a little firmer. Cervical os is closed Examination of the expelled fleshy mass is found complete. Ultrasonography (TVS): reveals empty uterine cavity. Management is usually conservative. Complete abortion

13. In this the fetus is dead and retained inside the uterus for a variable period. CLINICAL FEATURES: Spotting or bleeding Persistence of brownish vaginal discharge. Subsidence of pregnancy symptoms. EXAMINATION Uterine size smaller Nonaudibility of the fetal heart sound Cervix feels firm and os is closed immunological test for pregnancy becomes negative. Missed abortion

14. ULTRASONOGRAPHY Missed abortion is diagnosed when there is a crown rump length of 15 mm without a fetal heart. Anembryonic pregnancy (blighted ovum) is considered when there is a gestational sac more than 16mm in diameter without a fetal node. COMPLICATIONS Sepsis DIC ( thromboplastin like substance from dead fetus ) Psycological trauma

15. Uterus less than 12 weeks: Medical management: Prostaglandin E1 ( misoprostol ) 800 µg vaginally in the posterior fornix is given and repeated after 24 hours if needed. Expulsion usually occurs within 48 hours. Suction evacuation or dilatation and evacuation is done either as a definitive treatment or it can be done when the medical method fails. MANAGEMENT

16. Uterus more than 12 weeks: Induction is done by the following methods: Prostaglandin E1 analog ( misoprostol ) 200 µg tablet is inserted into the posterior vaginal fornix every 6 hours for a maximum of 5 such. If it fails extra-amniotic instilliation of ethacridine lactate can be done Following medical treatment, ultrasonography should be done to document empty uterine cavity. Otherwise evacuation of the retained products of conception (ERPC) should be done.

17. Any abortion associated with clinical evidences of infection of the uterus and its contents is called septic abortion. Abortion is usually considered septic when there are: (1) rise of temperature of at least 100.4°F (38°C) for 24 hours or more, (2) offensive or purulent vaginal discharge and (3) other evidences of pelvic infection such as lower abdominal pain and tenderness. in the majority of cases, the infection occurs following illegal induced abortion but infection can occur even after spontaneous abortion SEPTIC ABORTION

18. CLINICAL FEATURES History of unsafe termination Fever Abdominal pain and vomiting or diarrhoea Purulent discharge and bleeding per vaginum Hypotension Tachycardia Abdominal tenderness Cervix may be soft and os open Tenderness in the fornicess A soft boggy mass may be felt

19. 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.

20. Complete blood count High vaginal swab for culture and sensitivity Blood urea, creatinine , and electrolyte Blood culture if septicemia is suspected Ultrasonography of pelvis and abdomen to detect intrauterine retained products of conception. Plain X-ray— (a) Abdomen—in suspected cases of bowel injury (b) Chest—for cases with pulmonary complications ( atelectasis ). Investigation

21. Police notification in criminal abortion Maintenance of perfusion and ventilation is of prime concern. Crystalloids are used to restore circulation and if necessary blood transfusion is given monitoring of pulse, respiration, temperature, urinary output and progress of the pain, tenderness and mass in lower abdomen, CVP . Broad spectrum antibiotics : combination of ampicillin , gentamicin , and metronidazole or cefotaxime / sefuroxime along with metronidazole / clindamycin . Once infection is controlled evacuation of uterus is done. If pelvic abscess has formed, it can be drained by posterior colpotomy . Management

22. Indication For Exploratory Laprotomy Uterine perforation with suspected injury to the bowel No response to evacuation and medical therapy Generalised peritonitis with intraabdominal abscessess

23. RECURRENT MISCARRIAGE

24. It is defined as three or more spontaneous abortion. Affects 1% of women Can be primary ( no successful pregnancy) or secondary ( repetitive loss following a live birth) As number of miscarriages increase , the prevelance of maternal cause increases and that of chromosomal abnormality decreases.

25. IMMUNOLOGICAL CAUSE

26. Autoimmune cause. 15% of recurrent miscarriage Antiphospholipid antibodies are: lupus anticoagulant, anticardiolipin antibodies and anti b glycoprotein-I. Antiphospholipid Antibody Syndrome

27. Causes of miscarriage are release of local inflammatory mediators (cytokines) through complement pathway, spiral artery and placental intervillous thrombosis Management Diagnosis is by detection of lupus anticoagulant, or IgM / IgG anticardiolipin antibodies or b2 glycoprotein-I. Lupus anticoagulant can be detected by APTT or dilute Russel viper venom test. treated with low-dose aspirin (50 mg/day) and heparin (5,000 units SC twice daily) may have to be continued till postpartum.

28. immune response directed against foreign or non self antigens. Mother mounts an immune response against the paternal antigen in the fetus . Normal pregnancy is due T helper-2 cytokines response but women with recurrent miscarriage have T helper-1 type response Alloimmune Factors

29. ANATOMIC ABNORMALITIES

30. Uterine anomalies like bicornuate uterus and septate uterus Miscarriage due to reduced size of uterine cavity and decreased blood supply causing defective implantation and placentation Asherman syndrome – intrauterine adhesions due to previous curettage Submucous fibroid UTERINE CAUSE

31. Transvaginal ultrasound in secretory phase is very useful 3 D ultrasound and MRI are confirmatory Hysteroscopic resection in case of septum or divison of adhesions in Asherman’s syndrome Myomectomy in submucous fibroid

32. Cervical insufficency in charctericed by painless cervical dilation in the second or early third trimester with ballooning of the amniotic sac into the vagina, followed by rupture of membrane and expulsion of a live fetus . Usually at 16 – 24 week CERVICAL INCOMPETENCE

33. COMPETENT CERVIX INCOMPETENT CERVIX

34. Aetiology

35. History : Repeated mid trimester painless cervical dilatation (without apparent cause) and escape of liquor amnii followed by painless expulsion of the products of conception Interconceptional period: Passage number 6–8 Hegar dilator beyond the internal os without any resistance and pain Premenstrual hysterocervicography shows funnel-shaped shadow DIAGNOSIS

36. FUNNELLING HEGAR DILATOR

37. During pregnancy Transvaginal Sonography : cervix length < 25 mm (nor 35-40); internal os diameter > 20 mm (nor <20mm) at 14 weeks is suggestive of cervical insufficency . funnelling of os can also be seen

38. Surgical – cervical cerclage The procedure reinforces the weak cervix by a nonabsorbable tape, placed around the cervix at the level of internal os . 12-14 weeks Two types of operation are in current use : Shirodkar (1955) and McDonald (1963) Management

39. CERCLAGE

40. History indicated: definite history with three previous second trimester losses or preterm births. Ultrasound indicated: shortened cervix or early funnelling seen in transvaginal sonography Rescue or Examination indicated: when the cervix is dilated and there is bulging of the membranes Types of Cerclage

41. light general anesthesia lithotomy position Exposure of the cervix by a posterior Sims vaginal speculum. The lips of the cervix are pulled down by sponge holding forceps or Allis tissue forceps. The nonabsorbable suture ( Mersilene ) material is placed as a purse-string suture as high as possible (level of internal os ) . The suture starts at the anterior wall of the cervix. Taking successive deep bites (4–5 sites), it is carried around the lateral and posterior walls back to the anterior wall again where the two ends of the suture are tied. McDonald Cerclage

42. McDonald Cerclage

43. A transverse incision is made anteriorly at cervicovaginal junction and the bladder is pushed up to expose the level of the internal os . A vertical incision is made posteriorly on the cervicovaginal junction. The nonabsorbable suture material— Mersilene tape is passed submucously with the help of shirodkar needle so as to bring the suture ends through the posterior incision. The ends of the tapes are tied up posteriorly by a reef knot. The anterior and posterior incisions are repaired by interrupted stitches using chromic catgut. MODIFIED SHIRODKAR’S OPERATION

44. MODIFIED SHIRODKAR’S OPERATION

45. A Mersilene tape is placed at the level of the isthmus This is done between 11 weeks and 13 weeks following laparotomy . Disadvantages are: ( i ) Increased complications during operation. (ii) Subsequent CS for delivery Indications are—cases where cervix is hypoplastic or where prior vaginal cerclage has failed. Transabdominal Cerclage

46. Postoperative care: The patient should be in bed for at least 2–3 days. antibiotic cover avoid intercourse Weekly injections of 17α-hydroxyprogesterone caproate 500 mg IM. Isoxsuprine ( tocolytics ) 10 mg tablet may be given thrice daily to avoid uterine irritability. The stitch should be removed at 37th week or earlier if labor pain starts or features of abortion appear. If the stitch is not cut in time , uterine rupture or cervical tear may occur.

47. Contraindications : intrauterine infection , bleeding , contractions or rupture membrane , cervical diltation more than 4cm Fetal death or defect Complications : Rupture of membrane Chorioamnonitis and infection Rupture of uterus Necrosis of cervix

48. A thorough medical, surgical and obstetric history taking should be done Blood-glucose (fasting and postprandial), thyroid function test, ABO and Rh grouping (husband and wife), Autoimmune screening—lupus anticoagulant and anticardiolipin antibodies Ultrasonography —to detect congenital malformation of uterus, polycystic ovaries and uterine fibroid. Hysterosalpingography in the secretory phase to detect—cervical incompetence, uterine synechiae and uterine malformation Karyotyping (husband and wife). Endocervical swab to detect chlamydia , mycoplasma and bacterial vaginosis VDRL, INVESTIGATIONS FOR RECURRENT MISCARRIAGE

49. Deliberate termination of pregnancy either by medical or by surgical method before the viability of the fetus is called induction of abortion . Termination is permitted up to 20 weeks of pregnancy. MEDICAL TERMINATION OF PREGNANCY (MTP)

50. 200 mg of mifepristone orally is given on day 1. On day 3, misoprostol (PGE1) 400 µg orally or 800 µg vaginally is given. Expulsion occurs in 4-6 hrs. Menstrual regulation   Suction evacuation and/or curettage   Dilatation and evacuation First trimester

51. Misoprostol (PGE1 analog): 400–800 µg of misoprostol given vaginally at an interval of 3–4 hours is most effective as the bioavailability is high . OXYTOCIN: High-dose oxytocin as a single agent can be used for second trimester abortion Intrauterine instillation of hypertonic solution (Between 16 weeks and 20 week ) Hysterotomy MIDTRIMESTER TERMINATION OF PREGNANCY