Mid Trimester Abortion - A Case Study.pptx

This presentation describes a real clinical case of mid-trimester abortion (spontaneous fetal demise / pregnancy loss during the second trimester) with the objective of exploring both modern medical (biomedical) and Ayurvedic perspectives on possible causation, and proposing integrative management strategies.

1. By Dr Sagar D Dherange (JR II) & Dr Radhika A Patil (JR II) Dept. of srpt Yam kodoli, kolhapur Mid Trimester Abortion A Case Study

2. Case Scenario A 28 yr old married female, registered ANC in our hospital brought by her relative to OBGY ward with c/o B/L leg pain & increased frequency of micturation since 2-3 hrs. patient herself gave history of passage of clots & bleeding ? through per vaginum in minimal amount No H/O pain in abdo No H/O hardening of uterus No H/O leaking per vaginum No H/O loose stools/bowel complaints No H/O Nausea/ Vomitting /Fever

3. History of P resent I llness Patient was alright till afternoon 3 pm, then she developed severe B/L leg pain . For the same complaint she taken tab Paracetamol 500 mg orally & some rest with doctor’s opinion After 1 hr of rest & taking Paracetamol pain doesn’t subside & she noticed bleeding through per vaginum & passage of reddish sticky discharge After this patient came to OBGY ward with her relative by travelling through AUTO Rikshaw of 5 minutes ride for ½ km journey.

4. History of Past I llness Patient is registered ANC of our hospital Primi 17.2 wks GA with Twins Gestation (DCDA) Patient is K/C/O hypothyroidism on Tb Thyroxin 62.5 mcg once a day since 1 yr No K/C/O DM/HTN/PTB/BA/Epilepsy Surgical history- H/o Appendicectomy 3 yrs back No H/O any other Major Medical /Surgical illness

5. Marital History Marital status 5 yrs No contaceptive measures in practiced (history of 2 nd marriage of her husbannd ) No H/O consanguinity No H/O inherited disorders in both the families

6. Menstrual History Duration – 4-5 days Interval – 45-50 days & Irregular Flow – scanty , spotting to 1 pad/day Associated with moderate amount of dysmenorrhoea on & off & passage of clots Patient had taken 3 cycles of OCP (Tab Ovral L)for regularization of menses 2 yrs back Afterward she was taking Syp . M2tone for regularization of menses

7. Obstetric History Patient was having Primary infertility with PCOS with Hypothyroidism Patient has taken treatment for conception from our hospital itself since August 2021 Preconception Folic acid Suppliments started (5mg/day) Patient has been treated for with ovulation Induction for 2 cycles (tab Letrozole & Inj HCG) along with Tab Ovabless LMP – 05/10/2022 EDD- 12/07/2022

8. Obstetric History History of 1 st trimester Patient missed period on 05/11/2022 ,she waited for a week & done UPT at home on 10/11/2022 & found positive Patient reported to the hospital with photograph of positive UPT with c/o Nausea & vomiting . Patient has been advised for routine ANC Profile checkup & Dating Scan Dating scan was done at our hospital showing Twins live intrauterine pregnancy Diamniotic Dichorionic with SGA 6 wks & 6.2 wks with FHS 117bpm & 113 bpm with cervical length 31mm

9. Anc investigation 29/11/2022 Blood group – O Positive HB- 13.6 HIV – NR HbsAg – Negative VDRL – NR BSL R - 84.71 TSH- 4.1 22/12/2022 FT3- 2.72 FT4- 0.85 UltraTSH - 1.651

10. Obstetric History History of 1 st trimester Due to raised TSH, the dose of Thyroxin increased to 62.5 mcg per day Patient has been prescribed for Folic Acid Suppliments & doxylamine succinate Along with these, taking consideration of Precious Pregnancy, Twins Pregnancy, Lower ranged FHR Micronised Progesterone added 100mg twice a day Afterward patient has been admitted for emesis gravidarum & treated with ondensetron,granisetron,IV Fluids,Inj . Pantaprazole & Inj.ondensetron

11. Obstetric History History of 1 st trimester After 7 wks of GA patient has been treated with INJ proluton 500 mg IM weekly Tab Ecosprin 75 mg once a day started for microcirculation The dose of micronised progesteron increased to 400 mg twice a day At 12 wks , NT Scan has been done NT was 1.2 & 1.1 FHR were 152 bpm & 162 bpm for respective fetuses. Cervical length measured 37mm

12. Obstetric History History of 2nd trimester By starting of 12 wks iron calcium supplements along with protein powder added to prescription At 14 wks, patient again admitted for emesis gravidarum & treated with Inj. Antiemetics & IV Fluids The dose of micronized progesterone lowered to 400 mcg once a day due to recurrent nausea & vomiting at 14 wks Inj proluton 500 mcg IM continued till 16 wks Dadimadi ghrita added to the prescription & advised protein enrich diet

13. Other history Personal history- no addiction of Tobacco/ Masheri /Alcohol/Smoking Family history – not significant Dietary history – mixed type(pure vegetarian since conception due to religious assumptions) Allergy history- no history suggestive of any allergic/hypersensitivity reaction Drug history- taking Iron, Calcium ,Protein powder, Tab Ecosprin 75mg OD, Cap Susten 400mg OD, Tab Vomikind 4mg SOS

14. On examination Height – 148 cms Weight – 46 kg BMI- 21 GC- Fair Temp – Afebrile BP- 100/70 mmhg Pulse – 72/min S /E – NAD P/A – UT R elaxed 18 wks sized FHS F1-116bpm & F2- 130 BPM P/S & P/V examination avoided & patient sent for EM OBST USG

15. USG suggestive of Internal Os open Final Diagnosis- Primi Twins Gestation (DCDA) 17.2 wks Hypothyroidism in Threatened Abortion

16. MANAGEMENT After Noting USG , Internal OS- open Patient has been posted for Cervical Encircalge at 7pm Attempt for Rescue Encircalge done But Procedure cancelled due to Tense Bulging Membrane with Effaced & 5-6cm Dilated Cervix Patient has been observed for 1 Hr inside OT due to Spinal Anaesthesia

17. MANAGEMENT Pt Shifted to ward at 8.15 pm Head low position with IV fluids given Spontaneous Rupture of Membrane occurred at 9.45 pm followed by expulsion of 1st Fetus- Male Fetus of 164 gms with Placenta in toto Pt Shifted to Labour room with maintained Supine position on stretcher Inj Pitocin 30 (20+10) IU given in RL drip Spontaneous Rupture of Second amniotic sac occurred at 10.20 pm followed by delivery of Male Fetus of 154 gms along with Placenta in toto Uterine cavity cleaned No active bleeding Pt Shifted to ward with maintaining Supine position on stretcher & Kept NBM for observation

18. What could be the cause…? Cervical incompetence Multiple gestation Hypothyroidism Infection Maternal & fetal stress Acute & subclinical choirioamnionitis Extrauterine infections Fetal inflammatory response syndrome Abnormal P lacentation – severe placental insufficiency Bleeding in choriodecidual interface Uterine abnormalities Uterine overdistension Abnormalities of cervix Unknown

19. What could be done….? Cervical encirclage Prophylactic cerclage at 14 wks or at least 2 wks earlier than the lowest period of previous wastage as early as 10 wks In short cervical length < 25 mm ,with or without funneling of internal os Under light general anasthesia Materials used- Prolene 2 0, Mersiline Tape Can be done- Vaginally or Trans Abdominal

20. Methods of cervical encirclage Shirodkar’s technique McDonald’s technique

21. Post op of cervical encirclage Bed rest Progesterone support- 500 mg IM Hydroxyprogesterone IM Tocolytics - Isoxsuprine 10 mg Thrice daily Avoid Intercourse Avoid Rough Journey Report in case of vaginal bleeding or abdominal pain

22. Removal of stitch A t 37 th wk or earlier if labour pains starts If stitch not removed on time chances of uterine rupture & cervical tear It should be removed in OT; if head is floating then chances of cord prolapse

23. Rescue encirclage

24. T ocolysis

25. Corticosteroids

26. Antibiotics

27. Delivery

28. Summary- Causes of Mid trimester Abortion Anatomical Abnormalities Congenital- mullerian Analmolies Acquired- Intrauterine Adhesion , Uterine Fibroids, Endometriosis, Cervical Incompetence Chronic maternal illness- uncontrolled diabetes with atherosclerotic changes, haemoglobinopathies, chronic renal disease, inflammatory bowel disease, systemic lupus erythematosus Infection Syphiliis,toxoplasmosis,listeriosis Unexplained

29. Summary- Management of Mid trimester Abortion In uterine anomalies – Hysteroscopic resection of septa Hysteroscopic adhesiolysis Uterine unification surgery( Metroplasty ) Endocrine dysfuction Control of DM & Thyroid disorders Control of genital tract infection Progesterone therapy- immunomodulatory role of progesterone APLA- Tab E cosprin Cervical encirclage Unexplained- Rest & Tendor Loving Care

30. REFERENCES D C Dutta - Textbook of obstetrics Williams obstetrics High Risk Pregnancy & Delivery – Fernando Arias, Shirish N Daftary , Amarnath G Bhide Rescue cervical cerclage – Prevention of a previable Birth - a case study by Divya Pandey , Neha Pruthi Tandon NCBI

31. THANK YOU