ABORTION

Introduction:
Any bleeding in pregnancy through
vagina is abnormal. Miscarriage is lay
peoples terminology for abortions.

 Definition:
Abortion is the process of
partial or complete seperation of the
products of conception from the
uterine wall with or without partial or
complete expulsion from the uterine
cavity before the age of viability i.e
28 weeks

Classification
Abortion

Spontaneous

Isolated
(sporadic)

Threatened

Recurrent

Inevitable complete Incomplete

Induced

Legal

Missed

Illegal
(criminal)

septic

Incidence
75% abortion occur before the 16th
week of these about 75% occur
before the 8th week of pregnancy.

Etiology
The causes of miscarriage in most
instances remain unknown but may
include the following:
a)Fetal causes:
- 50% due to chromosomal
abnormalities of the conception.
- Genetic and structural abnormalities.

b) Maternal causes:
-The risk increases with advancing
maternal age.
- Structural abnormalities of the
genital tract: These include
retrovertion of uterus,bicornuate
uterus and fibroids.

- Infections:
Such as rubella,listeria,chlamydia
-Maternal diseases: Management and control of
medical conditions such as diabetes,renal disease
and thyroid dysfunction etc.
- Enviornmental factors:Exessive consumption of
alcohol & coffee along with cigrette
smoking,passive exposure to cigrette smoking or
exposur to radiations.
- Immununological factors: Rh- incompatibility

1) Spontaneous Abortion
It is defined as the involuntary loss of
products of conception prior to 24 weeks
of gestation
Types:
1) Threatened abortion:
It is an abortion or a clinical entity
where the process of abortion has
started but has not progressed to a
state from which recovery is impossible.

Cont..
s/s:
- The blood loss may be scanty with or
without accompanying backache and
cramping like pain.
- The cervix remain closed.
- The uterus soft with no tenderness
when palpated.
The outcome of a threatened abortion
Could be either stoppage of bleeding

Cont
& continuance of pregnancy to term or
Continuance of bleeding and uterine
contraction to expel the products of
conception.
Management:
- General & systemic examination may reveal
the causes of threatened abortion.
- Investigation include hemoglobin.ABO
grouping and Rh, VDRL,urine routiene &
blood glucose and thyroid function tests(if
thyroid dysfunction is suspected)

Cont
- Plasma progesterone estimation is done to
rule outcorpuslteum insufficiency.
- The patient is admitted and given complete
bed rest.
- Phenobarbitone 30 mg or diazepam 5mg
tablete twice daily to ensure sleep & relief
of pain.
- If any specific cause is found,it is treated
accordingly.

2) Inevitable abortion
It is clinical type of abortion where the
changes have progressed to a state from
where continuation of pregnancy is
impossible.
S/S:
- Increased vaginal bleeding
- Aggravation of pain in the lower abdomen
which may be colicky in nature.
- The general condition of patient is
proportionate to blood loss.

Cont

Internal examination reveals dilated

internal 0s of the cervix through which
products of conception are felt.
Management:
To take a appropriate measures to look
after the general condition.
To accelrate the process of expultion.
To maintain strict asepsis as in the
conduction of labour.

Cont..
General measures:
Exessive bleeding should be promptly
controlled by administering
methergin 0.2mg if the cervix is
dilated and the size of uterus is less
than 12 weeks.
The shock is corrected by
intravenous fluid therapy and blood
transfusion.

Cont..
Active treatment:
1) Before 12 weeks: Dilatation and
evacuation followed by curretage of the
uterine cavity by blunt curette under
G.A.
2) -After 12 weeks: Accelrate the uterine
contraction by oxytocin drip(10 units in
500ml of normal sline) 40-60 drops/min.
- If bleeding is profuse with cervix closed
evacuation of the uterus may be done by
abdominal hystrotomy.

3) Incomplete abortion
Definition:
When the entire products of conception are not
expelled instead a part of it is left inside the
uterine cavity is called incomplete abortion.
S/S:
History of expulsion of a fleshy mass per vagina is
followed by:
Continuation of pain lower abdomen.
Continious or recurrent vaginal bleeding.
Internal examination reveals: Uterus smaller than
the period od amenorrhoea

Cont.

Management:
In recent cases:
Same principle are to be followed in as inevitable
should before any active treatment is undertaken.
Early abortion:
Dilatation and evacuation under general
anesthesia is to be done.
Late abortion:
-Intra-uterine swab is sent for bacterial culture
and senstivity test
- Antibiotics prescribed for three days.

4) Complete abortion
Definition:
When the product of conception are expelled
enmasse is called complete abortion.
s/s:
There is a history of expulssion of a fleshy mass
per vagina followed by:
Subsidence of abdominal pain
Vaginal bleeding becomes trace or absent.
Internal examination reveals:
-Uterus is smaller than period of ammnorhoea & a
little firmer.

Cont.
Cervical Os is closed
Bleeding is traced.
Examination of fleshy mass is found intact.
Management:
-The effect of blood loss,if any should be
assessed and treated.
-If doubt for for complete expulsion of the
products uterine curettage should be done.
-Transvaginal sonography to prevent surgical
procedure.

5) Missed abortion
Definition:
When the fetus is dead and retained inside the
uterus for a variable period.is called missed
abortion/silent miscarriage/early fetal demix.
s/s:
The pt. presents features of threatened abortion
followed by:
- Persistent of brownish vaginal discharge.
- Subsidence of pregnancy symptoms.
- Retrogression of breast changes.
- Ceasation of uterine growth which infact becomes
smaller in size.

Cont
No FHS.
Cervix feels firm.
Real time sonography reveals absence of
fetal motoion,fetal heart sound.
Complications:
- Infection
- Blood coagulation disorders
- During labour retained placenta and PPH.

CONT
Management:
Uterus is less than 12 weeks: Vaginal
evacuation can be carried out without
delay. This can be effectively done
by suction evacuation or slow
dilatation of the cervix,of uterus
under general anesthesia.

Cont..
Uterus more than 12 weeks:
Induction is done by the following methods:
Oxytocin -to start with 10 20 units in 500 ml of
NS at 30 drops/min.
b) Prostaglandins: are more effective than oxytocins
in such cases the methods are
-Prostaglandin E,analogue(misoprostol) 200 mew gm
tablet is inserted into the posterior vaginal fornix
every 4 hrly.
-I/M administration of 15 methyl carboprost tro
methamine 250 mew gm at 3 hrly interval

Habitual abortion
Definition:
When spontaneous abortion occurs
consecutively for 3 or more occasions,is
called as habitual abortion.This may be
primary or secondary following birth of
viable pregnacy or MTP
S/S:
- Painless dilatation of the cervix occurs as
pregnancy progresses,results in cervical
incompetence.
- Bulging amniotic sac is visible herniating
through cervical canal under vaginal
speculum examination.

Cont
- As the intrauterine pressure increases the
membranes may rupture, resulting in
miscarriage.
- Abortion due to incompetent Os occurs
after 10 weeks usually at same gestational
age.
Management:
- The pt. is given complete bed rest from
before the time of occurrence of the
earliest abortion to after the time of
occurrence of the latest abortion.

Cont
- Specific treatment is given for any
cause identified.

7) Septic abortion
Definition:
Any abortion associated with clinical
evidence of infection of the uterus and its
contents is called septic abortion.
Although clinical criteria vary,abortion is
usually considered septic when there are:
-Rise of temp. of at least 100.4 degree F for
24 hrs. or more.
-Offensive or prulent vaginal discharge
-Other evidences of pelvic infection such as
lower abdominal pain and tenderness

Cont
S/S:
Depending upon the severity and the
extent of infection,the clinical
picture varies widely.
- History of illegal termination by an
unauthorised person is mostly
concealed.
- Pyrexia associated with chills and
rigors,suggests septicemia.

Cont
- Pain abdomen by varying degrees is
almost a constant feature.
-Tachycardia i.e 100-120/min or more
indicate the spread of infection
beyond the uterus
- Internal examination reveals
offensive purulent vaginal discharge
or a tender uterus usually with a
boggy feel of uterus.

Cont
Clinical grading:
Grade 1: The infection is localized in uterus.
Grade 2: The infection spreads beyond the
uterus to the parametrium,tubes and
ovaries or pelvic peritonium.
Grade 3: Generalized peritonitis & endotoxic
shock or jaundice or acute renal failure.

Cont.

Management:
- Hospitalisation is essential for all cases of
septic abortion.
- The patient is kept under isolation.
- To take high vaginal or cervical swab for
culture,drug sensitivity test and gram
stains.
- Vaginal examination is done to note the
state of the abortion process and
extention of the infection. If the products
are found loosely lying in the cervix,it is
removed by the ovum forceps.

Bibliography
Jacob Annama.A comprehensive text book of
midwifery.1st ed.Jaypee brothers medical
publishers.2005.
Dawn S.C.Textbook of obstetrics,neonatology,
reproductive and child health education.16th ed.
Dawn books.2004
Dutta D.C. Textbook of obstetrics.6th ed. New
central book agency.2004.
Fraser M.D. Cooper A.M. Myles textbook for
midwives 14th ed. Churchill livingstone.2003.