ABORTION AND DIAGNOSIS

OF PREGNANCY IN FIRST
TRIMESTER
DEFINITION: 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 . This 500 g of fetal development is
attained approximately at 22 weeks (154 days) of gestation.

• About 75% miscarriages occur before the 16th week and of these
about 80% occur before the 12th week of pregnancy.
The etiology of miscarriage is often complex and obscure . The following factors (embryonic or
parental) are important:
 Genetic
 Endocrine and metabolic
 Anatomic
 Infection
 Immunological
 Environmental
 Others
 Unexplained
• COMMON CAUSES OF MISCARRIAGE:

• First trimester: (1) Genetic factors (50%). (2) Endocrine disorders

(LPD, thyroid abnormalities, diabetes). (3) Immunological disorders
(autoimmune and alloimmune). (4) Infection. (5) Unexplained.

• Second trimester: (1) Anatomic abnormalities—(a) Cervical

incompetence (congenital or acquired). (b) Mullerian fusion defects
(bicornuate uterus, septate uterus). (c) Uterine synechiae. (d) Uterine
fibroid. (2) Maternal medical illness. (3) Unexplained.
• THREATENED MISCARRIAGE
• DEFINITION: It is a clinical entity where the process of
miscarriage has started but has not progressed to a state from
which recovery is impossible.
• INEVITABLE MISCARRIAGE
• DEFINITION: It is the clinical type of abortion where the changes
have progressed to a state from where continuation of pregnancy
is impossible dilated internal os of the cervix through which the
products of conception are felt.
 MANAGEMENT
• Before 12 weeks: (1) Dilatation and evacuation followed by curettage of the
uterine cavity by blunt curette using analgesia or under general anesthesia.
(2) Alternatively, suction evacuation followed by curettage is done.

• After 12 weeks: (1) The uterine contraction is accelerated by oxytocin drip

(10 units in 500 mL of normal saline) 40–60 drops per minute. If the fetus is
expelled and the placenta is retained, it is removed by ovum forceps, if lying
separated. If the placenta is not separated, digital separation followed by its
evacuation is to be done under general anesthesia.
• COMPLETE MISCARRIAGE
• DEFINITION: When the products of conception are expelled en masse, it is
called complete miscarriage.

• INCOMPLETE MISCARRIAGE
• DEFINITION: When the entire products of conception are not expelled,
instead a part of it is left inside the uterine cavity, it is called incomplete
miscarriage.
• MISSED MISCARRIAGE
• DEFINITION: When the fetus is dead and retained inside the uterus
for a variable period, it is called missed miscarriage or early fetal
demise.
• SEPTIC ABORTION
• DEFINITION: Any abortion associated with clinical evidences of
infection of the uterus and its contents is called septic abortion.
• Although clinical criteria vary, 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
• RECURRENT MISCARRIAGE
• DEFINITION: Recurrent miscarriage is defined as a sequence of three or more
consecutive spontaneous abortion before 20 weeks.

• Anatomic abnormalities
• Cervical incompetence.
• RECOMMENDATIONS
 In the revised rules, a registered medical practitioner is qualified to perform an
MTP provided: (a) One has assisted in at least 25 MTP in an authorized center and
having a certificate. (b) One has got 6 months house surgeon training in obstetrics and
gynecology. (c) One has got diploma or degree in obstetrics and gynecology.
 Termination can only be performed in hospitals, established or maintained by the
government or places approved by the government.
 Pregnancy can only be terminated on the written consent of the woman. Husband‘s
consent is not required.
 Pregnancy in a minor girl (below the age of 18 years) or lunatic cannot be
terminated without written consent of the parents or legal guardian.
 Termination is permitted up to 20 weeks of pregnancy. When the pregnancy
exceeds 12 weeks, opinion of two medical practitioners is required.
 The abortion has to be performed confidentially and to be reported to the Director
of Health Services of the State in the prescribed form
DIAGNOSIS OF PREGNANCY IN FIRST
TRIMESTER
• DURATION OF PREGNANCY: The duration of pregnancy has
traditionally been calculated by the clinicians in terms of 10 lunar
months or 9 calendar months and 7 days or 280 days or 40 weeks,
calculated from the first day of the last menstrual period. This is
called menstrual or gestational age.
• But, fertilization usually occurs 14 days prior to the expected missed
period and in a previously normal cycle of 28 days duration, it is about
14 days after the first day of the period. Thus, the true gestation period
is to be calculated by subtracting 14 days from 280 days, i.e. 266
days. This is called fertilization or ovulatory age
• SUBJECTIVE SYMPTOMS
• Amenorrhea
• Morning sickness
• Frequency of micturition
• Breast discomfort
• OBJECTIVE SIGNS:
• Breast changes
• Per abdomen :Uterus remains a pelvic organ until 12th week, it may be just felt per abdomen as a suprapubic
bulge.
• Pelvic changes
Jacquemier’s or Chadwick’s sign: It is the dusky hue of the vestibule and anterior vaginal wall visible at
about 8th week
Vaginal sign: (a) bluish discoloration of the anterior vaginal wall
(b) The walls become softened
(c) Copious mucoid discharge appears at 6th week
(d) increased pulsation, felt through the lateral fornices at 8th week called Osiander’s
sign.
Cervical signs: (a) Cervix becomes soft as early as 6th week (Goodell’s sign)
(b) bluish discoloration of the cervix is visible. It is due to increased vascularity.
• Uterine signs: (a) Size, shape and consistency — Th e uterus is
enlarged to the size of hen’s egg at 6th week, size of a cricket ball at
8th week and size of a fetal head by 12th week. The pyriform shape of
the non-pregnant uterus becomes globular by 12 weeks.

• There may be asymmetrical enlargement of the uterus if there is

lateral implantation. This is called Piskacek’s sign. As pregnancy
advances, symmetry is restored. The pregnant uterus feels soft and
elastic.
• (b) Hegar’s sign: demonstrated between 6 and 10 weeks,
 upper part of the body of the uterus is enlarged by the growing fetus
lower part of the body is empty and extremely soft
 the cervix is comparatively firm.
bimanual examination (two fingers in the anterior fornix and the
abdominal fingers behind the uterus), the abdominal and vaginal
fingers seem to appose below the body of the uterus
• (c) Palmer’s sign: Regular and rhythmic uterine contraction can be
elicited during bimanual examination as early as 4–8 weeks.
• IMMUNOLOGICAL TESTS FOR DIAGNOSIS OF PREGNANCY
• Principle: Pregnancy tests depend on detection of the antigen (hCG)
present in the maternal urine or serum with antibody either polyclonal
or monoclonal available commercially.

• Selection of time: Diagnosis of pregnancy by detecting hCG in

maternal serum or urine can be made by 8 to 11 days after conception.
The test is not reliable after 12 weeks.
• ULTRASONOGRAPHY: Intradecidual gestational sac (GS) is identified as early as 29 to 35 days
of gestation.
• Fetal viability and gestational age is determined by detecting the following structures by
transvaginal ultrasonography.
 Gestational sac and yolk sac by 5 weeks
 Fetal pole and cardiac activity by 6 weeks
 Embryonic movements by 7 weeks
 Fetal gestational age is best determined by measuring the CRL between 7 and 12 weeks (variation
± 5 days).
 Doppler effect of ultrasound can pick up the fetal heart rate reliably by 10th week
 DECIDUAL REACTION
• The decidua is the endometrium of the pregnant uterus. It is so named because much of it is
shed following delivery.
• Decidual reaction: The increased structural and secretory activity of the endometrium that is
brought about in response to progesterone following implantation is known as decidual
reaction.
 Changes are most marked at the implantation site and first commence around maternal blood
vessels.
 The fibrous connective tissues of the stroma become changed into epithelioid cells called decidual
cells.
 The glands show marked dilatation and increased tortuosity
 epithelium showing evidences of active cell proliferation with increased secretory activity.
• The well developed decidua differentiates into three layers :

• (1) Superficial compact layer consists of compact mass of decidual cells, gland
ducts and dilated capillaries.
• (2) Intermediate spongy layer (cavernous layer) contains dilated uterine glands,
decidual cells and blood vessels. It is through this layer that the cleavage of
placental separation occurs.
• (3) Thin basal layer containing the basal portion of the glands and is opposed to
the uterine muscle. Regeneration of the mucous coat occurs from this layer
following parturition
• After the interstitial implantation of the blastocyst into the compact layer of the
decidua, the different portions of the decidua are renamed as
Decidua basalis or serotina — the portion of the decidua in contact with the base
of the blastocyst
Decidua capsularis or reflexa — the thin superficial compact layer covering the
blastocyst
Decidua vera or parietalis — the rest of the decidua lining the uterine cavity
outside the site of implantation.
• Functions :
(1) It provides a good nidus for the implantation of the blastocyst.
(2) It supplies nutrition to the early stage of the growing ovum by its rich sources
of glycogen and fat.
(3) Deeper penetration of the trophoblast is controlled by local peptides,
cytokines and integrins.
(4) Decidua basalis takes part in the formation of basal plate of the placenta .
 TERATOGENICITY
• Teratogen causes permanent alteration in the structure and/or function of an
organ, acting during the embryonic or fetal life. teratogens may be chemical
agents (drugs) or physical agents (radiation, heat).
• Mechanism of Teratogenicity: The actual mechanism is unknown. Teratogens
may affect through the following ways
• (1) Folic acid deficiency
• (2) Epoxides or arena oxides
• (3) Environment and Genes
• (4) Maternal disease and drugs
• (5) Homeobox genes
TIMING OF TERATOGEN EXPOSURE AND THE HAZARDS
THANK YOU
DR.SWETHA PADALA
MS. OBS & GYN RESIDENT