Threatened abortion

1. MANAGEMENT OF THREATENED ABORTION Dr. Bushra Hasan Khan JR-1 Department of Pharmacology JNMC, AMU, Aligarh.

2. Threatened Abortion A clinical entity where the process of abortion has started, but has not progressed to a state where recovery is impossible. The clinical diagnosis of threatened abortion is presumed when a bloody vaginal discharge appears through a closed cervical os during the first half of pregnancy.

3. Threatened Abortion is the most common complication in the first half of pregnancy. Its incidence varies between 20-25%. Miscarriage is 2.6 times as likely 17 % of cases are expected to present complications later in pregnancy.

4. ETIOLOGY Embryonic abnormalities Maternal factors Anatomic factors Endocrine factors Infectious factors Immunologic factors

5. CLINICAL FEATURES The pregnant patient complains of : Bleeding per vaginum Pain

6. INVESTIGATIONS Blood Urine Pelvic examination Ultrasonography

7. Transvaginal S onography Well formed gestational sac Observation of fetal cardiac activity With these there is about 98% chance of continuation of pregnancy . Sonography can usually differentiate between an intrauterine pregnancy (viable or non-viable ), a molar pregnancy, or an inevitable abortion.

8. Serum Progesterone value 25 ng /ml or more – a viable pregnancy in about 95% cases Serial serum beta HCG level 20 ng /ml or more – viable pregnancy To assess the level of fetal well being

9. Adverse Prognostic factors in cases of Threatened Abortion A large empty gestational sac Discrepancy : gestational age and crown to rump length Fetal bradycardia or absence of fetal heart activity Advanced maternal age History of recurrent pregnancy loss Maternal serum Progesterone < 25 ng /ml or low maternal serum hCG

10. Complications T hese fetuses are at increased risk for intrauterine growth retardation, preterm delivery, low birthweight , and perinatal death. Maternal risks include antepartum hemorrhage, manual removal of the placenta, and cesarean delivery.

11. Management Bed rest Paracetamol Progesterone therapy h CG therapy Tocolytic agents

12. “There is insufficient evidence of high quality that supports a policy of bed rest in order to prevent miscarriage in women with confirmed fetal viability and vaginal bleeding in first half of pregnancy”.

13. Progesterone therapy Oral micronized Progesterone : 200mg OD or BD. Vaginal progesterone suppositories : 200mg OD or BD. Progesterone vaginal gel : 100mg two or three times/day Intramuscular Progesterone : I njection in oil given as 50mg /day.

14. “Use of progestogens is effective in the treatment of threatened miscarriage with no evidence of increased rates of pregnancy-induced hypertension or antepartum haemorrhage as harmful effects to the mother, nor increased occurrence of congenital abnormalities on the newborn”. “However , the analysis was limited by the small number and the poor methodological quality of eligible studies (four studies) and the small number of the participants (421), which limit the power of the meta-analysis and hence of this conclusion”.

15. “The current evidence does not support the routine use of hCG in the treatment of threatened miscarriage”.

16. Tocolytics Adrenergic receptor agonists Ca 2+ channel blockers Oxytocin -receptor antagonist: Atosiban Nitric oxide donors Magnesium sulphate Cycloxygenase inhibitors

17. Sites of action of tocolytic drugs in the uterine myometrium

18. Ritodrine Started as 50 µg/min i.v . infusion Rate of infusion is increased every 10 minutes till uterine contractions cease or maternal heart rate rises to 120/min. Contractions can also be kept suppressed by 10 mg i.m . 4-6 hourly followed by 10 mg oral 4-6 hourly.

19. Side effects & contraindications Tachycardia , Hypotension, Pulmonary Edema. Hypergylycemia , Hypokalemia . Anxiety, Restlessness, Headaches. Fetal pulmonary edema. Neonate may develop hypoglycemia and ileus . Its use is contraindicated if mother is diabetic, having heart disease, or receiving beta blockers.

20. Ca 2+ channel blockers Relative to Beta 2 adrenergic agonists, Nifedipine is more likely to improve fetal outcomes and less likely to cause maternal side effects . Oral Nifedipine 10 mg repeated once or twice after 20-30 min, followed by 10 mg, 6 hourly has been used.

21. Nifedipine : side effects Maternal flushing Headache , Dizziness, Nausea Transient hypotension and Tachycardia , Palpitations. Fetal hypoxia associated with maternal Hypotension.

22. Oxytocin receptor antagonists Atosiban : a peptide analogue of Oxytocin Competitively inhibits the interaction of Oxytocin with its membrane receptor on uterine cells  decreases the frequency of uterine contractions . Intravenous use 6.75 mg bolus, followed by 300µg/min infusion for 3 hours. Then 100µg/hour for upto 45 hours.

23. Nitroglycerine Nitric oxide is a potent vasodilator and smooth muscle relaxant. The major adverse effect is maternal hypotension. Dose; 50-200µg intravenously. Can consider repeating dose after 1-4 minutes if inadequate response occurs.

24. Magnesium Sulphate Administered intravenously ; 4-6 g loading dose , then 2-4 g/hour titrated to uterine response and maternal toxicity . Two reviews demonstrate magnesium sulphate to be ineffective as a tocolytic .

25. Side effects of magnesium sulphate Maternal flushing, Sweating, Respiratory depression, Bradycardia , Myocardial depression, Loss of deep tendon reflexes, Neuromuscular blockade.

26. “There is insufficient evidence to support the use of uterine muscle relaxant drugs for women with  threatened miscarriage”. “Any such use should be restricted to the context of randomised trials”.

27. Cycloxygenase inhibitor Indomethacin Use is controversial.

28. Anti-D Immunoglobulin The Rh-negative woman is given anti-D immunoglobulin following abortion. This practice is controversial with threatened abortion because it lacks evidence-based support (American College of Obstetricians and Gynecologists, 1999; Weissman and associates, 2002).