ABORTION

DR.P.RAJESWERI DHINESH
DEFINITION

 Termination of pregnancy with a fetus born weighing less than or equal to

500gm
 USUALLY 20-22 WEEKS FETUS REACHES 500GMS
 Incidence 15 percent of all conceptions
 80 percent in first trimester
 50 percent of these because of chromosomal anomalies
Types

 SPONTANEOUS
 INDUCED

SPONTANEOUS
 THREATENED ABORTION
 INCOMPLETE ABORTION
 INEVITABLE ABORTION
 MISSED ABORTION
 SEPTIC ABORTION
INDUCED
 MEDICAL TERMINATION OF PREGNANCY
 CRIMINAL ABORTION
 SEPTIC ABORTION
ETIOLOGY

FETAL FACTORS
GENETIC FACTORS
 54 PERCENT CHROMOSOMAL ANOMALIES
 EXAMPLE AUTOSOMAL TRISOMY, AUTOSOMAL
MONOSOMY,TRIPLOIDY,TETRAPLOIDY
MATERNAL FACTORS

ENDOCRINE AND METABOLIC FACTORS

 LUTEAL PHASE DEFECT
 PCOS
 THYROID ABNORMALITIES
 UNCONTROLLED INSULIN DEPENDENT DIABETES
AGE
 TEENAGE AND AFTER 40 YEARS
INFECTIONS
 MATERNAL CHLAMYDIA, GONORRHEA, GBS, TORCH, HIV, SYPHILIS,
MYCOPLASMA ,UREAPLASMA
 MEDICAL DISORDERS AND IMMUNOLOGICAL
 HYPERTENSION,CARDIOVASCULAR,RENAL DISORDERS AND
THROMBOPHILIAS,CONNECTIVE TISSUE DISEASES LIKE SLE
ENVIRONMENTAL FACTORS

 CIGARETTE SMOKING
 ALCOHOL CONSUMPTION
 EXCESS COFFEE
 IRRADIATION
 DRUGS-ANTINEOPLASTIC DRUGS,QUININE,ERGOTS
ANATOMICAL ABNORMALITIES

 CERVICAL INCOMPETENCE
 CONGENITAL MALFORMATIONS OF UTERUS
 ASHERMAN SYNDROME
 SUBMUCOUS FIBROID
TRAUMA
 SURGICAL
 PHYSICAL
PATERNAL FACTORS
TRANSLOCATION IN THE SPERM
UNEXPLAINED 40-60%
THREATENED ABORTION

 PROCESS STARTED YET FURTHER PROGRESSION CAN BE AVERTED AND

PREGNANCY CONTINUED
CLINICAL FEATURES
 AMENORRHEA
 BLEEDING
 PAIN
EXAMINATION: OS CLOSED WITH MILD BLEEDING
INVESTIGATIONS:
 LAB: UPT, HEMOGLOBIN, BLOOD GROUP, SERUM B HCG
 USG PELVIS
MANAGEMENT

 CONSERVATIVE
 PROGNOSIS 80-90 PERCENT SURVIVE
 WATCH FOR BLEEDING PV
 PAIN RELIEF
PROGESTOGENS:
 NATURAL MICRONISED PROGESTERONE ORAL 200MG BD OR 100MG BD
VAGINALLY
 TABLET DYDROGESTRONE 5-10MG TDS
 INJECTION 17 ALPHA HYDROXY PROGESTERONE CAPREOATE 250-500MG IM
WEEKLY
 ANTI D PROPHYLAXIS IF RH NEGATIVE FOR ALL AFTER 12 WEEKS OR WITH
SIGNIFICANT BLEEDING <12 WEEKS
 HEMATINICS FOLIC ACID AND CALCIUM
DISCHARGE AND FOLLOW UP ADVICE
 AVOID HEAVY WORK,AVOID COITUS FOLLOW UP SCAN FOR FETAL GROWTH
DD

 ECTOPIC PREGNANCY –PAIN,UPT POSITIVE,VAGINAL BLEEDING,NORMAL SIZE

UTERUS,TENDER MASS IN ADNEXA-USG
 OTHER TYPES OF ABORTION-USG
 OVARIAN TORSION -UPT NEGATIVE, USG
 FUNCTIONAL MENSTRUAL DISTURBANCE- UPT NEGATIVE, USG
INEVITABLE ABORTION

 ABORTION PROGRESSED TO THE EXTENT THAT EXPULSION IS ENVITABLE WITH

NO CHANCE OF CONTINUATION OF PREGNANCY
 AMENNORHEA AND COLICKY PAIN
 PATIENT MAY BE PALE,NORMO OR HYPOTENSION, TACHYCARDIA
 PER SPECULUM : CERVIX OS OPEN PRODUCTS SEEN
 PELVIC EXAMINATION: SIZE OF UTERUS MAY BE EQUAL TO OR CORRESPONDING
TO PERIOD OF GESTATION
 COMPLICATIONS :HEMORRHAGE AND SHOCK
 INVESTIGATIONS:UPT, HG ,BLOOD GROUP AND USG
USG
 CARDIAC ACTIVITY ABSENT
 POC SEPARATED FROM DECIDUAL ATTACHMENT
 POC IN LOWER UTERINE AND CERVICAL REGION
MANAGEMENT
 ADMIT
 CORRECT HYPOVOLEMIA USING FLUIDS/COLLOIDS
 IF <12 WEEKS
 TETATNUS TOXOID FOLLOWED BY SUCTION EVACUATION/MANUAL VACUUM
ASPIRATION/DILATATION AND EVACUATION/MISOPROSTOL 200/400MCG
 IV ANTIBIOTIC COVER IF BLEEDING FOR LONGER DURATION
IF >12 WEEKS
 OXYTOCIN DRIP 10 UNITS IN 500ML SALINE
 MISOPROSTOL 400MCG ORALLY OR VAGINALLY
 METHYLERGOMETRINE ORAL IV /IM TO CONTROL BLEEDING
 IF PLACENTA IS RETAINED REMOVE USING OVUM FORCEPS UNDER GENERAL
ANESTHESIA
 AFTER FETUS EXPELLED CHECK USG TO BE DONE
 TISSUE FOR HPE
FOLLOWUP:
 ANTIBIOTICS,HEMATINICS,ANTI INFLAMMATORY AGENTS,ANTI D PROPHYLAXIS IF
RH NEGATIVE 100MCG IM<12 WEEKS OR 300MCG IF >12 WEEKS
 CONTRACEPTIVE ADVICE
 REPORT IF EXCESS BLEEDING OR PAIN
INCOMPLETE ABORTION

 PRODUCTS OF CONCEPTION ARE PARTIALLY EXPELLED

 INEVITABLE BECOMES INCOMPLETE IF NOT TREATED ON TIME
CLINICAL FEATURES
 ANEMIA AND SHOCK AS PER BLOOD LOSS
 HISTORY OF PASSAGE OF CLOTS AND PRODUCTS
 PAIN AND BLEEDING
 SIZE OF UTERUS LESS THAN GESTATIONAL AGE
 OPEN CERVIX AND POCS FELT
 COMPLICATIONS AND INVESTIGATIONS AND MANAGEMENT AND FOLLOW UP
SAME AS INEVITABLE
USG FINDINGS
 POC PRESENT IN UTERINE CAVITY
 CARDIAC ACTIVITY ABSENT
MANAGEMENT
 ADMIT
 CORRECT HYPOVOLEMIA USING FLUIDS
 AFTER TT INJECTION AND ANTIBIOTIC COVER SUCTION
EVACUATION/MVA/DILATATION AND EVACUATION/MISOPROSTOL 200/400MCG
 AFTER FETUS EXPELLED CHECK USG TO BE DONE
 TISSUE FOR HPE
MISSED ABORTION(SILENT MISCARRIAGE)

 DEATH OF FETUS BEFORE 20 WEEKS WITH RETENTION OF ALL PRODUCTS OF

CONCEPTION
 CARNEOUS MOLE/BLOOD MOLE
 PATHOLOGICAL ENTITY CHORIODECIDUAL SPACE RECURRENT BLEEDS WHICH
DONOT RUPTURE CAPSULARIS BUT DISRUPT THE VILLI ATTACHMENTS
CLINICAL FEATURES
 UTERINE SIZE SMALLER THAN EXPECTED
 CARDIAC ACTIVITY ABSENT
 BROWN DISCHARGE WITH OS CLOSED
COMPLICATIONS
INFECTION AND DIC (IF RETAINED NORE THAN A MONTH)
INVESTIGATIONS
 UPT MAY BE NEGATIVE OR WEAKLY POSITIVE
 HEMOGLOBIN
 PLATELET COUNT
 BLOOD GROUP AND TYPING
 BT AND CT
 COAG PROFILE
USG
 CARDIAC ACTIVITY ABSENT
MANAGEMENT

IF LESS THAN 12 WEEKS

 EXPECTANT-OBSERVATION FOR SPONTANEOUS EXPULSION
 MEDICAL
 MISO 800MCG VAGINALLY REPEAT AFTER 24 HOURS IF NEEDED

 SURGICAL
 SUCTION EVACUATION,DILATION AND EVACUATION UNDER ANTIBIOTIC COVER
IF MORE THAN 12 WEEKS
 MISO(PGE1) 200MCG 4 HOURLY MAXIMUM 5 DOSES
 CARBOBROST(PGF2ALPHA) 250MCG IM 3 HOURLY
 OXYTOCIN DRIP 2O U IN 500ML NORMAL SALINE STARTING AT 30 DROPS GOING
UP TO 60-80 DROPS PER MINUTE
FOLLOW UP:
 ANTIBIOTICS
 ANTI D PROPHYLAXIS IF RH NEGATIVE
 CONTRACEPTION
BLIGHTED OVUM

 USG REVEALS G SAC WITH DIAMETER 2.5CM OR MORE WITH NO EVIDENCE OF

FETAL POLE
 HPE:FETAL TISSUE IS ABSENT
MANAGEMENT:
 EVACUATION OF UTERUS USING VAGINAL OR ORAL MISOPROSTOL 400MCG
REPEATED AFTER 6 HOURS IF PATIENT IS STABLE AND WILLING TO FOLLOW UP
TYPES OF CLINICAL SIZE OF UTERUS INTERNAL ULTRASOUND SCAN TREATMENT
ABORTION PICTURE OS

THREATENED SLIGHT CORRESPONDING CLOSED LIVE FETUS CONSERVATIVE

BLEEDING SUBCHORIONIC
HEMORRHAGE
INEVITABLE BLEEDING,PAIN EQUAL OR LESS OPEN DEAD FETUS EVACUATION
,SHOCK

INCOMPLETE BLEEDING,PAIN SMALLER OPEN WITH HETEROGENOUS TISSUES EVACUATION

,SHOCK PRODUCTS WITH OR WITHOUT A
FELT GESTATIONAL SAC
DISTORTING THE
ENDOMETRIAL MIDLINE
ECHO-(RPOC) RETAINED
PRODUCTS OF
CONCEPTION
MISSED ABSENT OR SMALLER CLOSED DEAD FETUS FETAL POLE
MINIMAL CRL >6MM WITH NO
BLEEDING HEART BEAT OR
PERSISTENCE OF CRL
<6MM ON RESCAN AFTER
7-10 DAYS
SEPTIC ABORTION

 ANY TYPE OF ABORTION WITH SYMPTOMS AND SIGNS OF INFECTION OF UTERUS

CLINICAL CRITERIA
 FEVER WITH TEMP >=38 DEGREES(100.4) FOR MORE THAN 24 HOURS
 FOUL SMELLING PUS DISCHARGE
 LOWER ABDOMINAL PAIN AND PELVIC PAIN AND TENDERNESS

 85 PERCENT ENDOGENOUS COMMENSALS OF VAGINA

 MORE COMMON IN ILLEGAL ABORTIONS CAN OCCUR AFTER SPONATEOUS AND
LEGALLY INDUCED ABORTION TOO
MICROBIOLOGY

 GRAM NEGATIVE BACILLI

E COLI KLEBSIELLA PSEUDOMONAS
 GRAM POSITIVE STAPH AND STREPTOCOCCUS
 ANEROBES: BACTEROIDS CLOSTRIDIUM PERFRINGENS AND C.TETANI AND
PEPTOSTERPTOCOCCI
PATHOLOGY:
 ENDOMETRITIS 80 PERCENT
 ENDOMYOMETRITIS 15 PERCENT
 GENERALISED PERITONITIS SEPTICEMIA AND ENDOTOXIC SHOCK
 SYSTEMIC DISORDERS LIKE ACUTE RENAL FAILURE,SEPTICEMIA,COAGULATION
FAILURE
CLASSIFICATION

 GRADE 1: INFECTION LIMITED TO UTERUS

 GRADE 2: BEYOND UTERUS TO PARAMETRIUM,TUBES,OVARIES OR PELVIC
PERITONEUM
 GRADE 3: BEYOND PELVIS IN TO GENERAL PERITONEUM OR DISTANT ORGANS
RESULTING IN GENERALISED PERITONITIS, JAUNDICE, SEPTICEMIA, UREMIA,
ENDOTOXIC SHOCK.
CLINICAL FEATURES

 FEVER CHILLS AND RIGOR

 TACHYCARDIA
 ABDOMINAL AND PELVIC PAIN
 FOUL SMELLING VAGINAL DISCHARGE
 CERVIX OS MAY BE OPEN WITH TENDER FORNICES
 SOFT BOGGY MASS POD-PELVIC ABSCESS
 EVIDENCE OF UTERINE PERFORATION, BLADDER OR BOWEL INJURY
INVESTIGATIONS

 BLOOD GROUP AND TYPE

 HG, TOTAL AND DIFF COUNT
 URINE ROUTINE AND CULTURE,KFT,ELECTROLYTES
 BLOOD CULTURE IF SEPTICEMIA SUSPECTED
 COAG PROFILE SELECTED CASES
 HIGH VAGINAL/CERVICAL SWABS FOR GRAM STAIN AND CULTURE
 PELVIC ULTRASOUND
 XRAY ABDOMEN IF PERITONITIS OR BOWEL INJURY SUSPECTED
 XRAY CHEST IF ATELECTASIS IS SUSPECTED
COMPLICATIONS

EARLY COMPLICATIONS:
 EXCESSBLEEDING
 PERFORATION OF UTERUS
 GENERLISED PERITONITIS
 ENDOTOXIC SHOCK
 ARDS
 DIC
 ACUTE RENAL FAILURE
 PELVIC THROMBOPHLEBITIS
 MATERNAL MORTALITY
LATE COMPLICATIONS
 CHRONIC PELVIC PAIN
 DYSPAREUNIA
 INFERTILITY DUE TO TUBAL BLOCKAGE
 ECTOPIC PREGNANCY
PREVENTION

 WIDER FAMILY PLANNING SERVICES

 AVAILABILITY OF FREE AND SAFE ABORTION IN ALL HOSPITALS
 ILLEGAL ABORTIONS TO BE CURBED BY LAW
 MAINTENANCE OF ASEPSIS DURING EXAMINATION
 PROMPT DIAGNOSIS AND TIMELY MANAGEMENT
MANAGEMENT

 IV HYDRATION
 I/O CHARTING
 VITALS MONITORING
 OXYGEN BY MASK
IV ANTIBIOTICS:
REGIMEN A
 AQUEOUS PENICILLIN 5 MILLION UNITS IV 6 HRLY AFTER TEST DOSE OR
AMPICILLIN 500-1GM IV 6 HOURLY
 INJECTION GENTAMICIN IV 60-80MG IV 8 HOURLY
 INJECTION METRONIDAZOLE 500MG IV 8 HOURLY
REGIMEN B
 INJECTION CIPROFLOXACIN 500 MH IV 12 HOURLY
 INJECTION METRONIDAZOLE 500MG IV 8 HOURLY
REGIMEN C
 FOR SEVERE INFECTIONS
 INJECTION CEFOTAXIME 1GM IV 12 HOURLY OR INJ CEFTRIAXONE 1GM IV 12
HOURLY
 INJECTION METRONIDAZOLE 500 MG IV 8 HOURLY
 INJECTION GENTAMICIN 60-80 MG IV OR IM 12 HOURLY
SURGICAL
EVACUATION OF UTERUS
POSTERIOR COLPOTOMY PELVIC ABCSESS DRAINAGE
LAPROTOMY IF SUSPECTED UTERINE PERFORATION OR BOWEL OF BLADDER
INJURY/ FOREIGN BODY IN THE ABDOMEN
SEVERE CASES HYSTERECTOMY
RECURRENT ABORTION

 2 OR MORE CONSECUTIVE SPONTANEOUS ABORTION LESS THAN 20 WEEKS

 CAUSES
 GENETIC RECURRENT ANEUPLOIDY MGT GENETIC COUNSELLING
 ENDOCRINE THYROID DIABETES LPD PCOS TREAT THE CAUSE EXAMPLE
MICRONISED PROGESTERONE LPD(PROGESTERONE <5NMOL/L ON DAY 21)
 ANATOMICAL UTERINE ANOMALIES ASHERMAN CERVICAL INCOMPETENCE
FIBROID RESECTION OF SEPTUM AND ADHESIONS CERVICAL CERCLAGE
 IMMUNOLOGICAL ANTIPHOSPHOLIPID ANTIBODY SYNDROME (APLA) LOW DOSE
ASPIRIN AND HEPARIN
MTP
 MTP ACT 1971 REVISED 1975 AMENDMENT 2021
 RULES
 MARRIED OR UNMARRIED WOMEN COVERED
 24 WEEKS FOR RAPE SURVIVORS BEYOND 24 WEEKS FOR SUBSTANTIAL FETAL
ANOMALIES
 ONE RMP TILL 20 WEEKS AND TWO RMP 24 WEEKS MEDICAL BOARD APPROVAL
AFTER 24 WEEKS
 CONDITIONS
 THERAPEUTUC AND MEDICAL INDICATION- CARDUAC DISEASE IN MOTHER
 EUGENIC- ANOMALOUS BABY
 HUMANITARIAN -RAPE
 SOCIOECONOMIC- UNPLANNED, FAILURE OF CONTRACEPTION ,MENTAL
DISORDER
 PERSON DGO MS MD OBS 6 MONTHS HOUSE SURGEON IN OBS ASSISTED 25MTP
 PLACE: GOVT HOSP NURSING HOMES AND GOVERNMENT APPROVED CENTERS
 MEDICAL:MIFEPRISTONE FOLLOWED BY MISOPROSTOL
 REFER MMA HANDBOOK
 THANKYOU