GULF WELFARE TRUST

Introduction

VISION:

Gulf Welfare trust is providing exclusive primary healthcare services and quality primary education to
the under privileged class.

MISSION:

o Providing primary healthcare facilities to children and their parents of deprived communities.
o Providing effective treatment of common diseases.
o Diagnose children from infectious and contagious diseases.
o Accurate diagnosis for symptoms of coronary diseases in their early stages.
o Creating awareness for children’s good health.
o Providing quality I.T. Based education.

CORE VALUES:

o Individual attention to every poor patient.

o We do care for their best health and will ensure their healthy life.
o Our every action is beneficial for under privileged children and women.
o We ensure prevention from complications & an early diagnosis of serious ailments.

OBJECTIVE:

o Perfect smile for every under privilege face, a gift forever.

The need for Gulf Welfare trust in slums and poor localities.

It is evident that Pakistan is far behind in providing primary health and education facilities to its entire
population due to which it has a very low literacy rate and high mortality ratio. Children comprising 45%
of our population have low literacy rate. Due to high inflation rate in Pakistan, the under privileged
people give preference to food and shelter first, and education is their second priority. Another reason
for low literacy rate in children is lack of facilities for primary education by the government.

It is obvious that no nation can progress until their children are given proper health and education, as
they are the future founders and pillars of any nation. It is a fact that due to huge population, Pakistan
government alone cannot fulfill the responsibilities of providing health and educational facilities to the
entire population. It will be unwise to rely entirely on government for health and education for all.

To fill this vacuum, there are many non-governmental organizations and social welfare institutes that
are already working to provide primary healthcare and educational facilities to the under privileged
classes. Gulf welfare trust was established to provide primary health and educational facilities to the
lower class livings in poor residential areas in Pakistan.

Once Quaid-e-Azam said for Education for Children: “Education does not merely mean academic
education and even that of a very poor type. What we have to do is to mobilize our people and build up
the character of our future generation”.

Gulf welfare trust with the support of well wishers, the Vision has now become a reality. We are
diagnosing, treating and medicating more than 8500 diseases daily of the patients visiting all our 44
established and mobile healthcare centers where 142 health and education activates are conducted.
The healthcare activities include free consultation and tests that include Ultrasound Facility for Mothers
& Child Healthcare and quality Medications (to date in a short span of 6 years a total number of over 7.2
Million diseases of patients have been treated with Medications). The schools are laying special
emphasis on Computer training and English Language Skills besides providing basic education to all the
residents of these deprived areas mostly Katchi Abadis.
History

HARDWORK OF CHEF OF PAST 13 YEARS:

Gulf welfare trust was registered in August 2002 as an NGO. The objective of the Foundation was to
build Primary Health Care centers across Pakistan which could provide free medical help to children and
women. Studies have proved that many life threatening diseases could be treated easily at extremely
low cost at a Primary Health Care Centre if detected early and if left undetected or untreated at the
initial stages, could lead to Kidney failure, Terminal Cancer, Blindness, Heart Disease etc.

To date, Gulf welfare trust has provided free medical aid to more than 11 Million patients with the help
of 44 Primary Healthcare Centers & Mobile Medical Vans. Besides this, Gulf welfare trust with the help
of valued philanthropists has recently installed 202 water hand pumps in the villages of Sindh and
Baluchistan. This has resulted in significant reduction in water borne diseases like typhoid etc. Gulf
welfare trust has also spent over Rs. 20 million to help the flood victims during 2010 & 2011 and
established a Medical Camp Hospital at Tharparkar.

Along with health services, we have also built primary and secondary schools which are providing quality
education to the under privileged children of Pakistan. We have also launched a new program of IQRA
Scholarship which provides financial aid to students for their higher education.
Health Services

Health activities and Services offered by Gulf

welfare trust
Gulf welfare trust is catering to fulfil the needs of health & education of the suffering communities.

Gulf welfare trust on its medical side is running 44 Primary Mother & Child Healthcare (prenatal,
antenatal & postnatal) Centers all over Pakistan through Base Centers and Mobile Medical Vans.

We follow our slogan and theme: “To detect, diagnose & treat the diseases before they become
incurable” Our slogan is based on the WHO definition of Primary Healthcare, which states:

“The ultimate goal of PHC is better health for all”

Primary healthcare (PHC)

PHC means the healthcare that is provided by the healthcare professionals at the first contact of the
patient with the healthcare system. Basic level of healthcare that includes programs directed at the
promotion of health, early diagnose & prevention of the diseases.

These services include at least 8 basic elements:

1. Food supply and proper nutrition

2. Health Education

3. Provision of essential drugs

4. Immunization

5. MCHC (Mother & Child Healthcare)

6. Treatment of common diseases & injuries

7. Adequate supply of safe water and basic sanitation

8. Communicable disease control

Under Primary Healthcare, following activities and services are being offered by CHAEF for suffering
communities by providing:

o Health education through promotion and prevention measures.

o Curative measures by diagnosing and treating the patients.
o Rehabilitation services for chronic and terminal diseases at their door steps.
We have base centers which are well equipped with:

o All necessary medicines (list attached) o Trained Paramedical Staff

o Registered Medical Officers

o Centers remain open 6 days a week in prime time when the household ladies can visit the
centers easily
o Centers are centrally located for that community and easily approachable without involving the
transport.

Mother & Child Healthcare

Pakistan is one of the countries with high maternal and infant mortality rates. Women especially suffer
even at primary care level due to lack of properly trained and skilled healthcare workers in the
community. Pregnancy and Child birth is such a magical time in a women’s life…yet fall of questions for
many.

To over come this issue of MCH, CHAEF is catering the needs of most vulnerable and least serviced
population of the community “The women & child” through MCH Centers along with PHC.

Children may be saved at birth and in infancy from death and their mothers from death during childbirth
by providing good healthcare at MCH in their vicinity by a primary healthcare provider.
CHAEF is providing services of prenatal, antenatal and postnatal care less delivery. Under the following
protocol:

o Free pregnancy confirmation either by Urine for pregnancy test or by ultrasound.

o When confirmed complete follow up throughout pregnancy till arrangement for delivery
nearby Zakat funded hospital (list attached)

During antenatal period patients have 3 to 4 ultrasounds as follows: –

o Confirmation of Pregnancy at first visit

o At 20 weeks of pregnancy for gestational age and congenital fetal abnormality
o At 30 – 33 weeks for placental localization
o At term for fetal maturity.

Regular antenatal checkup for:

o Blood Pressure
o Anemia o Weight
o Growth of Fetus

Under the following protocol:

o 4 weekly from confirmation of pregnancy till 28 weeks of pregnancy

o Fortnightly from 28 weeks of pregnancy to 36 weeks
o Then weekly onwards till delivery.

Investigation:

At first visit

o Blood complete picture

o Blood gp & Rh factor
o Urine D/R
o Blood Sugar Random
o Hepatitis B & C
o Blood Hb
o Urine D /R
o Blood Sugar

Medicines:

Medicines to the pregnant ladies are issued on weekly basis which include Multivitamins, Calcium and
Iron.
Immunization:

Full course of Tetanus Injection is provided to the pregnant ladies under the following protocol.

o 1st dose against tetanus any time after 20 weeks of pregnancy

o 2nd dose after 4 weeks of 1st dose
o 3rd dose – 6 months after the 1st dose
o 4th dose after 1 year of 3rd dose
o 5th dose after 1 years of the 4th dose

Postnatal Follow Up

After delivery of the baby, mother regularly visit our centers with the baby where she is looked after for
any anemia, infection , excessive bleeding or any other related problems for first 40 days of her delivery.
She is advised for contraceptive measures for proper birth spacing for the better health of woman & her
newborn. Baby is then registered for vaccination under EPI program of WHO.

Free treatment to the women for their gynecological and obstetrical diseases, which include diagnosis,
medicines, blood tests and ultrasound.

All the above mentioned activities are carried out by the Senior Gynecologist on fortnightly visit to all
centers in a mobile van equipped with Ultrasound, Generators, Laboratory Technicians to collect their
blood at the spot.
Mother And Child Healthcare

Problems of Pregnancy
ANTENATAL COMPLICATIONS
VOMITING OF PREGNANCY

Nausea and / or vomiting in the morning or at other times of the day is the normal symptom of
pregnancy.

Duration:

From about 6th to 12th week of pregnancy. It nearby always stops before the 14th week.

Causes:

It is due to higher level of chorionic gonadotrophin or an increased sensitivity to it.

HYPEREMESIS GRAVIDARUM

It refers to the persistent vomiting of pregnancy, which disturbs the patient’s health.

Clinical Features:

Biochemical Abnormalities:

Occur secondary to vomiting, starvation, dehydration, namely ketosis, electrolyte imbalance and
vitamin deficiency.

Manifestation Include:

o Severe weight loss

o Tachycardia
o Hypertension
o Oligouria
 o Neurological disorder from vitamin – B deficiency and jaundice from hepatic necrosis.

Management:

The mainstay of treatment in symptomatic therapy with close attention to the fluid balance.

1) Exclude any other possible causes like

o Pyelonephritis o Intestinal Obstruction

o Infective Hepatitis o Cerebral Tumor

2) Reassurance

3) Non – Teratogenic Anti-emetics such as:

o Meclozine
o Cyclizine
o Premethazine (up to 3 times a day) along with Vitamin – B (pyridoxine)

If Vomiting is Severe:

o Admission to the hospital often leads to dramatic & immediate improvement.

o Intravenous fluids
o Anti-emetics
o Vitamin supplement (intravenous multivitamins preparations)
o Oral feeding is begun as soon as possible starting with fluids and progressing to semisolids and
eventually to full diet.
o Psychotherapy
o Treatment is regulated by daily studies of the blood chemistry and cessation of vomiting
normal urinary output and weight gain are indications of recovery.

HEART BURN

This is very common. Symptoms are of burning in the chest or discomfort often lying down.

Aetiology

o Weight effect of the pregnant uterus preventing stomach emptying.

o General relaxation of the esophageal sphincter due to progesterone.

Management
 o Liquid antacid preparation
o Stopping smoking
o Reducing alcohol intake.
o Frequent light meals.
o Lying with head propped up at night.

CONSPITATION

Most probably occurs due to:-

o Effects of progesterone in slowing gut motility

o Weight of gravid uterus on the rectum may contribute
o Administration of Iron intake

Management:

A high fiber diet and a mild (non-stimulant) laxative such as lactulose.

VARICOSE VEINS AND PILES

Aetiology

o Relaxant effect of progesterone on vascular smooth muscles.

o Dependent venous stasis caused by the weight of the pregnant uterus on the inferior vena
cava.

Management

– Neither condition should be treated surgically in pregnancy.

– Piles may be improved with local anesthetic anti irritant creams and a high fiber diet.

– Varicose veins on the legs may be symptomatically improved with support stocking, avoidance of
standing for prolonged periods and simple analgesia.

BACKACHE

It is due to the:

o Laxity of spinal ligaments

o Weight of the pregnancy causing an exaggerated lumber lordosis.
Pregnancy can exacerbate the symptoms of a prolapsed interverteberal disc occasionally leading to
complete immobility.

Management

o Maintain of correct posture

o Avoiding lifting heavy objects (including children)
o Avoiding high heals
o Regular physiotherapy
o Simple analgesia (paracetamol or paracetamol-codein combination)

EDEMA

There is a generalized soft tissues swelling and increased permeability which allows intra-vascular fluids
to leak into the extra-vascular compartment.

The fingers, toes and ankles are usually worst affected and the symptoms are aggravated by hot
weather.

Management

a) Edema is best dealt with by advising frequent periods of rest with leg elevation, occasionally support
stockings are indicated.

b) Edema may be a feature of pre-eclampsia , check the women’s blood pressure and urine for protein.

c) Severe edema may suggest under lying cardiac impairment or nephortic syndrome.

CRAMPS IN LEGS

Transient nocturnal painful spasms of the small muscles of the fact or of the pregnancy due to calcium
deficiency or temporary circulatory insufficiency.

Improves spontaneously during later pregnancy but can troublesome if it returns during labor.

MEDICAL DISEASES & PREGNANCY

Hypertension:

In pregnant women, a systolic blood pressure above 140 mm hg or a diastolic blood pressure above 90
mm hg is considered hypertension.

(Hypertension is diagnosed in pregnancy if there is an increase of 30 mm in systolic or 15 mm in diastolic

pressure over the baseline based on two readings taken 6 hours apart)

Gestational Hypertension:
Hypertension occurring after 20 weeks but not accompanied by proteinuria is termed as gestational
hypertension. It was previously called Pregnancy Induced Hypertension. (PIH)

Investigation:

o UCE – Urea , creatinine and electrolytes.

o LFTs – Liver function test
o 24 hours urinary protein / urea creatinine clearance
o Renal Scan
o Auto–antibody Screen
o Complement Studies
o ECG & Echo

Management:

If the blood pressure is consistently noted to be in excess of 150/100 mm hg. Anti-hypertensive

Medication (preferably methyldopa) is indicated to reduce the risk of intracerebral haemonhage or
heart failure. Anti Hypertension medication should maintain the blood pressure below 160 mm hg
systolic and 100 – 110 mm hg diastolic.

Attempt vaginal delivery by induction of labor if the maternal blood pressure is reasonably controlled.

o For delivery before 34 weeks gestation the mother should be given steroids to increase fetal
lung maturation
o If there is evidence of rapidly deteriorating maternal or fetal well being then cesarean section is
appropriate.
o Magnesium sulphate for seizures in patients with signs of fulminating pre- eclampsia.
o Observation is required in the first 48 hours postnatally because of persisting risk of eclampsia.
o Breast feeding is encouraged and although some anti-hypertensive medication may enter the
breast milk, it is not significant.

DIABETESE MELLITUS

World Health Organization has defined diabetes mellitus as either a:

Raised fasting blood glucose level of >7.8 mmol / l (140 mg%)

Or

Level of >11.1 mmol / liter (1998 mg%) following a 75 gram glucose load.
Significant hormonal changes affect carbohydrates metabolism during pregnancy. In particular there is
an increase in human placental lactogen and cortisol, both of which are insulin antagonists and
therefore relative insulin resistance develops in the mother.

These changes are most marked during the third trimester. To balance these changes during normal
pregnancy the maternal pancrease secrets increased amount of insulin to maintain carbohydrates
metabolism. Typically in pregnancy this will result in a fall in the fasting level of glucose.

Glucose crosses placenta by means of a facilitated diffusion process and the fetal blood glucose level
closely follows the maternal level.

Terminology

1. Pre – Diabetes:

When parous women, discovered to have diabetes give a history of previous very large babies (>4.5 kg)
or intrauterine death.

2. Potential Diabetes:

Women who have features in their personal or family history which put them at an increased risk of
developing diabetes in pregnancy.

These features include:

o Diabetes in a first degree relative o Maternal obesity ( e.g > 120% of the ideal body weight) o
Previously large baby (variously considered to be > 4 kg or >4.5 kg.) o Previous unexplained stillbirths o
Previous abnormal glucose tolerance but not diabetes outside pregnancy. o Persistent glycosuria o
Polyhadramnios

Gestational Diabetes Mellitus (GDM):

o GDM is defined as the state of carbohydrate intolerance that has its onset or first recognition
during pregnancy.
o GDM includes type I & type II patients.
o GDM may include a small group of women with previously recognized over diabetes mellitus
type I or type II. However, usually the glucose tolerance is mild before pregnancy.
o Diabetes that appears in pregnancy and disappears after delivery, 50% of women with
gestational diabetes will be established diabetics 10 years later.

Impaired Glucose Tolerance:

 If the 2 hours value in 7.8 – 11.1 mmol /L glucose tolerance is said to be impaired. Impaired glucose
tolerance without any symptoms is sometimes referred to as Chemical Diabetes.

Diagnosis:

o True GDM usually develops in the second trimester or early in third trimester when
organogenesis is already complete.
 If GDM is diagnosed in the first trimester then it is imperative to confirm with the help of HbA1C
whether it may be overt type I or type II diabetes, which may affect the incidence of congenital
malformation.

Screening Method:

Selective Screening of women > /=30 years of age 50 gram oral glucose load between 24-28 weeks
gestation. Urinary glucose has been shown to be unreliable method of detecting potential diabetes and
most screening tests now rely on blood glucose estimation.

Fasting Blood Sugar (FBS):

o Fasting blood glucose of >=7.9 mmol/L or a single blood sugar measurement over 11 mmol/L is
diagnostic without the need to delay treatment while a GTT is performed.
o Patient with plasma glucose level >/=140 mg/dl should be evaluated a diagnostic 3-hours Oral
Glucose Tolerance Test (OGTT) Random Blood Sugar (RBS):

Random Blood Sugar at booking, the sensitivity of this test is only about 60%.

When the values at booking are:

o >5.8 mmol / L (2 hours after meals) or

o >6.2 mmol / L (within 2 hours of a meal)
o then perform OGTT (Oral Glucose Tolerance Test)

NOTE: This test is repeated at 28 weeks gestational when glucose tolerance is under greater stress
because of increased concentration of HPL (Human Placental Lactogen). On further testing 80% of cases
are found to be normal.

Testing the Urine for Glucose:

This is not a discriminating test for diabetes in pregnancy. Owing to a decreased renal threshold,
glycosuria is common in normal pregnancy so that glucose spills with the urine even though plasma
levels are normal. Women with the persistent finding of glucose in the Urine should have a random
blood sugar measurement.

Antenatal Management

o The principle of treatment is to maintain the blood sugar level with a mean 24 hours profile of <
5mmol/L. This will usually require three or four times daily uses of insulin.
o Provided the pregnancy has gone will management would attempt to achieve a vaginal delivery
between 38 – 40 weeks gestation.
o Delivery is recommended at no later than 40 weeks gestation in patients requiring insulin
therapy and at no later than 42 weeks for diet controlled patients.
o No elective delivery should be performed prior to 39 weeks without establishing lung maturity
because of the possibility that even mild GDM can delay lung maturity.
o GDM is not an absolute indication for cesarean section.
o Previous obstetric history and clinical pelvimetry are useful tools in obstetric management.

Timing of Delivery in Women with GDM

The decision about timings of delivery should take into consideration the risk for respiratory distress
syndrome (RDS) favorability of cervix for labor, the size of fetus and on going exposure to the risk of
stillbirth.

Patient with poorly controlled diabetes & macrosomic features are at greater risk for stillbirth and
should be delivered somewhat earlier (37 – 38 weeks) if lung maturity can be assured.

Patients with well-controlled diabetes & normal features are at lower risk for stillbirths and may be
allowed to wait later into their pregnancies for cervical maturity.

RH HEMOLYTIC DISEASE

This problem arises when the Rh-negative mother is carrying a Rh positive baby because of the Rh
positive blood gp of father.

o The first baby is rarely affected

o The first baby may be affected if the mother had an abortion or blood transfusion with Rh-
positive blood group.

Potential Sensitizing Events for Rhesus Diseases:

o Miscarriage
o Termination of Pregnancy
o Antepartum Hemorrhage
o Invasive prenatal testing (chorionic villous sampling, amniocentesis and cardiocentsis)
o Delivery
Clinical Signs:

o Polyhyrramnios
o Enlarged fetal heart
o Ascities & pericardial effusion
o Reduced fetal movements
o Abnormal CTG with reduced variability, eventually a “sinusoidal trace” Clinical Rh hemolytic
diseases may manifest as hydrops fetalis or hemolytic anaemia

Management of Rhesus

This depends on clinical scenario, BOTH THE WOMEN & HER BABY’S FATHER is Rh- NEGATIVE: There is
no risk that the baby will be Rh – Positive. There is therefore no chance of rhesus (Rh) diseases.

THE WOMEN IS RHESUS NEGATIVE AND THE PARTNER IS RHESUS POSITIVE: She has no Rh antibodies &
it is either her first pregnancy or she had not had a pregnancy previously affected by Rh disease.

Monitor atypical antibodies at booking and at 24 – 36 weeks. An increase in antibody titer to > 10 iu /ml
requires review in fetal medicine center, so that early signs of fetal edema can be detected by
Ultrasound and if appropriate, invasive assessment performed.

Once a women is sensitized to the Rh-antigen, no amount of anti-D will even turn back the clock. In this
situation, therefore there is no role whatsoever of anti-D.

Prevention of Rh- Disease:

o Prevention of Rh – disease is by testing women at their first prenatal visit with a blood type and
antibody screen.
o In those women who are Rh-negative with a negative antibody screen, 300 ug (one vial) of anti
– D globulin (Ig G) is given at 28 weeks of gestation, if the antibody screen has remained
negative.
o At the time of delivery, if the newborn Rh – POSITIVE, then anti – D globulin is readministered.
o Administration of anti – D globulin will cause maternal serum antibody titer to be positive to no
greater than a titer of 1:4 for seven weeks after administration.
o One vial of anti-D globulin will protect against 30 cc of fetal whole blood or 15 cc of fetal
packed red blood cells. Prevention of Recurrence of Rh Incompatibility

Every Rh-NEGATIVE mother who has given birth to a Rh-POSITIVE baby should be given one ml of anti-D
immunoglobulin intramuscularly within 72 hours of delivery.

It is also indicated when:

1. Rh – Positive blood is accidentally transfused to a Rh- Negative mother

2. Rh – Negative mother who had an abortion.

Anti – D immunoglobulin “mop-up” any circulating rhesus positive cells before an immune response in
excited in the mother & then prevents formation to antibodies.

ABORTIONS
Abortion denotes the expulsion of product of conception before the 24th weeks of pregnancy. The
most common time for clinically evident abortion is the termination of pregnancy by any means before
the fetus is sufficiently developed to survive.

Types of Abortion:

Spantaneous Abortion

(Chart from the book)

Threatened Abortion:

It means that there is only a threat of abortion, the process has started but it may be arrested.
Threatened miscarriage is one of the most common indications (together with suspected ectopic
pregnancy) for emergency referral to young women to a causality department. The diagnosis is usually
based on clinical examination.

Clinical Features:

o Sign & Symptoms of Pregnancy

o Characteristically (2-3 months) amenorrhea
o Minimal vaginal bleedings occurs (bright red)
o Internal cervical os is closed
o There is very little and no pain
o U/S findings should confirm pregnancy.

Diagnosis:

Based on clinical examination:

1. Pelvic Examination
2. Speculum Examination

3. Ultrasound Examination which determines

o The presence of intrauterine gestational sac

o Size of fetus & given fetal cardiac activity
o Give some clue to dilation of cervix o Reveals any unsuspected abnormality.

4. Hormone Estimation: Diagnostic & prognostic value in 6 – 8 weeks of pregnancy. Soon after missing
the periods serum beta HCG level doubles/48 hours.

MANAGEMENT

o Complete bed rest for a few days till all the blood loss stops.
o U/S scan performed which confirms that pregnancy is progressing.

Treatment:

There is no specific treatment for threatened abortion, only complete bed rest, good hygiene and high
protein diet would be helpful.

Inevitable Abortion:

o This means that process has become irreversible

o Expulsion of conceptus is bound to happen & this cannot be prevented or stopped.
o It is usually preceded by threatened abortion
o An inevitable miscarriage can be complete or incomplete depending on the whether or not all
fetal & placental tissues have been expelled from the uterus.

Clinical Features:

Sign & Symptoms of pregnancy + characteristically 2 – 3 months amenorrhea & the following:

o Profuse, intermittentant, heavy vaginal bleeding.

o Dilated internal cervical Os
o Size of uterus corresponds to duration of gestation & uterus is tender.
o Cramping, rhythmical, painful uterine contraction like lower abdominal cramps.
o U/S findings
o Intrauterine gestational sac (>20 mm diameter) with no embryo or with 6mm embryo with no
heart beat.
Management:

Patient requires admission to hospital, analgesia for pain & evacuation of uterus

(i) < 12 week gestational :

Immediate evacuation of the uterus under general anesthesia

(ii) > 12 week gestational:

Infusion of oxytocin followed by evacuation of retained product of conception.

Incomplete Abortion

o Means abortion has taken place but some product of conception are retained in the uterus o
o Preceded by inevitable abortion
o If RPOCS are not removed, it results in vaginal bleeding, sepsis & adherence to the uterine wall
may get organized to become placental polyp.

Clinical Features:

Symptoms & signs of pregnancy + amenorrhea ( 2 – 3 months) & the following:

(i) Mild to severe vaginal bleeding occurring along with passage of products of conception often
described by the women as “pieces of skin & liver”. Some products are retained.

(ii) Dilatation of internal cervical Os.

(iii) Size of the Uterus, uterus is reduced to the duration of gestation, bulky & softer.

(iv) Cramping, rhythmical, painful uterine contractions.

(v) U/S findings : RPOCS can be seen on ultrasound scanning. Obviously fetal cardiac action is absent.

Management:

o Maintain I/V line

o Injection Methergin 02 ampoules (500 ugm) is given immediately intravenously
o 30 units syntocinon in the 1000 cc drip at 30 d / min is to be started
o Prophylactic antibiotic.
o Urgent evacuation of uterus under anesthesia

Complete Abortion
When all the uterine contents have been expelled spontaneously there is cessation of pain, scanty
blood loss and a firmly contracted uterus with closed cervix.

Clinical Features:

1. Symptoms of pregnancy are no longer present and pregnancy test becomes negative

2. Minimal vaginal bleeding occurs along with passage of tissues.

3. Closed internal cervical os after expulsion

4. Cramping, rhythmical, painful uterine contractions but pain is relieved.

5. U/S scan shows empty uterine cavity.

Management

If there is no more active bleeding, or if an ultrasound scan shows an empty uterine cavity, no further
treatment is required but advise a few days rest.

Anti – D gamma globulin 500 ugm is given 1/M to Rh – Negative women if expulsion occurred within the
last 72 hours.

Missed Abortion:

A missed abortion is a gestational sac containing a dead embryo / fetus before 20 weeks gestational
without clinical symptoms of expulsion.

This diagnosis is usually made by failure to identify fetal heart activity on ultrasound. The patient after
complains of chronic but high vaginal bleeding.

When gestational sac is > 25 mm in diagnosis and no embryonic / fetal part can be seen the term “
BLIGHTED OVUM” or “ANEMBRYONIC PREGNANCY” is used.

Hemorrhage occurs into the choriodecidual space & extends around the gestational sac. The amnion
remains intact & becomes surrounded by hillocks of blood clot with a flashy appearance, hence the term
“CARNEOUS MOLE” is used.

Clinical Features:

Amenorrhea ( 4 – 5 months), regression of symptoms and signs of pregnancy plus the following:

o Vaginal bleeding:- Repeated or dark brown vaginal discharge

o Uterine size remains stationary
 o Cervix is often TIGHTLY CLOSED
o Serum placental hormone & protein measurements are low & if repeated are shown to be
falling
o Ultrasound Scan:

Shows no growth of the fetal (CRL) crown rump measurement & absence of fetal heart activity. In
anembryonic pregnancy, no fetus is seen.

Management:

Urgent EVACUTION OF THE UTERUS is usually achieved in late cases with a combination of the intra
vaginal prostaglandin and an intravenous syntocinon infusion.

All missed abortions would probably be expelled spontaneously in the long term.

Ectopic or Extra Uterine Pregnancy:

An ectopic or extra uterine pregnancy occurs when the fertilized ovum embeds in some site other than
the uterine deciduas

Or

An ectopic pregnancy is when the conceptions implant either:

o Outside the uterus (fallopian tube, ovary & abdominal cavity) or

o In an abnormal position within the uterus (cornua or cervix)
o Combined tubal & uterine (hetrotopic) pregnancies are uncommon

Sites of Implementation:

Ectopic sites of implementation are:-

(i) Fallopian tube (ampulla commonest site)

(ii) Ovary
(iii) Cervix

(iv) Rudimentary horn of uterus

(v) Abdominal cavity

Clinical Course & Management:

Symptoms commonly arise after one menstrual period is missed, although they may occasionally begin
before this. However, it is rare for ectopic pregnancy to advance beyond 8 weeks without the
occurrence of pain & bleeding, a point, which is sometimes helpful in differentiation between the
abortion of an intrauterine pregnancy & an ectopic pregnancy.

Symptoms & Signs Associated with Ectopic Pregnancy:

o Pain in 95% of cases o Gestrointestinal symptoms (80%)

o Amenorrhea with abnormal uterine bleeding (60 – 80%)
o Dizziness or syncope (58%)

Dominate Features is Low Abdominal Pain:

o Pain originates on the side of the ectopic implantation and can be acute or severe
o Dull ache = Unruptured tubal pregnancy
o Sharp Colicky Pain = Hemorrhage in Choriodecidual space
o Severe Pain = Irritation of the under surface of diagram by free blood = shoulder tip pain

Vaginal Bleeding:

o Follows first attack of pain

o Variable continuous to intermittent spotting
o Due to trophoblastic disturbance in tubes =withdrawal of hormones = disintegration of
deciduas in uterine cavity. Profuse, intraperitonal hemorrhage & sever pain will result in sudden
shock and collapse of women. This may be fatal unless immediate transfusion & lapartomy are
undertaken.
Investigation:

1. Serum Beta HCG

2. Transvaginal Ultrasound

But both the findings must be interpreted together.

Beta HCG levels: serial estimation shows lower levels to the period of gestation.

Ultrasound Findings (TVS): the presence or obscene of an intrauterine gestational sac is the principle
point of distinction between intrauterine & tubal pregnancy.

ULTRASONOGRAPHIC FINDINGS of an extra-uterine sac with an embryo or embryonic remnants in the

most reliable diagnosis at ectopic pregnancy.

Gynecological Examination:

Speculum or Bimanual Examination must be performed in an environment where facilities for

resuscitation are available as this examination may provoke the rupture of tube.

Management:

The classical approach to the treatment of ectopic pregnancy has always been Surgical (SALPINGECTOM
or SALPINGOTOMY) either by laparotomy or laparoscopy.

Fate of Tubal Pregnancy:

A tubal pregnancy may terminate in the following ways:

1. Tubal Male

2. Tubal Abortion

3. Tubal Pregnancy

4. Secondary abdominal pregnancy

5. Interstitial (cornual) pregnancy

6. Ovarian Pregnancy

7. Rupture of pregnant rudimentary horn.

8. Cervical Pregnancy.