Abortion

Definition : Expulsion or extraction from its mother of an embryo or fetus weighing 500gm or
less when it is not capable of independent (WHO).
Incidence : Probably over all incidence 10-20%.
Etiology :

Geneticfactors
Infection
Endocrineandmetabolicfactors
Immunological
Anatomicalfactors
Others

Type of abortion

Spontaneous
o Threatened
o Inevitable
o Incomplete
o Complete
o Missed
o Septic
Induced
o Legal
o Illegal(criminal)

Threatened Abortion
Definition : It is a clinical entity where the process of abortion has started but has not progressed
to a state from which recovery is impossible.
Clinical features :

1. Bleeding per vagina : The bleeding is usually slight and bright red in colour. On rare
occasion, the bleeding may be brisk and sharp, specially in the second trimester, suggestive of
low implantation of placenta. The bleeding usually stops spontaneously.
2. Pain : Usually painless, may be mild backache dull pain in lower abdomen. Pain appears
usually following haemorrhage.

P/V Examination : Usually not done if necessary should be done as gently as possible.
P/S Examination : Reveals bleeding if any escapes through the external os.
Investigation :

BloodforHb%,ABOandRhgrouping,antiDgammaglobulinifRhnegative.
UrineforPgtest.
Ultrasonography(TVS/Abdominal):

Treatment :

1. Rest : When active bleeding present.

2. Drugs : Sedation and relief of pain.
3. General measure : Pulse, Blood Pressure,
4. Temperature, P/V bleeding.

Inevitable Abortion
Definition : In this type of abortion where the changes have progressed to a state from where
continuation of pregnancy is impossible.
Clinical Features :

1. Amenorrhoea
2. P/V bleeding
3. Lower abdominal pain : Aggravation of pain colicky in nature.
4. P/V examination /Bleeding Present (+)or (++) :
P/S: Dilated internal os of the cervix through which the products of conception are felt.

Management :

1. Correction of aneaemia
2. Correction of dehydration

3. To accelerate process of expulsion

4. To maintain strict asepsis (to reduce post abortion omplication).

Treatment :

1. Before 12 weeks : Dilatation, evacuation, curettage Suction evacuation and curettage Under
G/A.
2. After 12 weeks : Oxytocin drip Prosterglandin tablet.

Complete abortion
Definition : When product of conception are expelled completely.
Clinical Features :

1. Amenorrhoea
2. History of expulsion of fleshey mass per vagina.
3. Subsidence abdominal pain.
4. P/V bleeding : Trace or absent
5. P/V examination : Bleeding (+) or absent.

Bimanual examination :

1. Uterus is smaller than the period of amenorrhoea and firm.

2. Cervical os closed.
3. Bleeding : Trace or absent.

Management :

1. Correction of anaemia if needed.

2. Anti-D gamma globulin-50 microgram or 100 microgram if patient Rh negative, within 72

hours of abortion.

Incomplete abortion
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 abortion. Commonest type of abortion amongst
hospital incidence.

Clinical features :

1. Amenorrhoea History of
2. History of Expulsion of product of conception per vagina.
3. Continues lower abdominal colicky pain.
4. Per vaginal bleeding.(irregular).
5. Internal examination :
a. Uterus smaller than the period of amenorrhoea.
b. Patulous cervical os often admitting tip of the finger.
c. Varying amount of bleeding.(P/V)

Management :

1. Correction of anemia if necessary.

2. Antibiotics.
3. Dilatation and evacuation under G/A.
4. Histopathological examination of product of conception after

removed.

Missed abortion
Definition : Sometimes fetus died in uterus and retained inside for a variable period is called
missed abortion.
Clinical features :

1. Amenorrhoea
2. P/V bleeding / Brownish discharge.
3. Subsidence of pregnancy symptoms.
4. Fetal heart sound not audible with doppler.
5. Cervix feels firm.
6. Pregnancy test negative.
7. USG reveals absent fetal heart movement and fetal motion.

Complication : Blood coagulation disorders.

Management :

Less than 12 weeks-dilatation, evacuation & curettage.

More than 12 weeks-induction by
1. Oxytocin
2. Prostaglandins

Recurrent (Habitual) Abortion

Definition :
Three consecutive pregnancies ending in spontaneous abortion therefore constitute the criterion
for the diagnosis of recurrent abortion. In practice, however, investigation, if not treatment,
may be justified by a womans anxiety over having lost 2 pregnancies.

Investigation
1. Occurrence of previous abortions
2. Periods of amenorrhoea
3. subsequent bleeding painful and by home
4. Curettings contain chorionic villi on histological examination

Special tests

Between pregnancies
(1) Blood count and uninalysis.
(2) Serological tests for syphilis in wife and husband.
(3) Determination of the blood groups of wife and husband, with tests for antibodies in the wife.
(4) Glucose tolerance test.
(5) Estimation of theblood urea level, and renal function tests where indicated.
(6) Tests of thyroid function.
(7) Hysterography to determine the shape of the fundus and the competence of the internal os is
essential in all cases. Cervical sphincteric action is beststudied during the luteal phase.
(8) A formiminoglutamic acid (FIGLU) excretion test and blood folate assays.
(9) Study of the chromosome patterns of wife and husband.

During pregnancy
(1) All the above tests except those involving the use of radioactive isotopes and hysterography.
Re-assessment of the folate and vitamin B12 status in early pregnancy is particularly important
since a defect is commonly found even though it is not demonstrable before conception.
(2) Careful vaginal examination to determine the position of the uterus and the competence of
the cervix.

(3) Assays of the urinary excretion of HCG, pregnanediol and oestriol, and of plasma levels of
HCS (HPL) and progesterone, the choice depending on the duration of the pregnancy, can give a
guide to placental function.
(4) A cervical mucus fern test and vaginal cytology to determine the presence or absence of
progesterone dominance. In pregnancy a cornification index of less than 10 is normal.

Treatment

Treatment of the cause

1. Uterine retroversion can be corrected
2. Uterine fibroids can be removed
3. Torn cervix repaired
4. Utriculoplasty
5. Shirodkar operation : It is generally best to perform this operation between the twelfth and
sixteenth weeks of pregnancy removing the ligature 2 weeks before term or at the onset of
abortion or labour.

Empirical remedies

1. General measures before pregnancy

a. Wait 3 months
b. Improve her physical and mental health
c. Dietetic errors
d. Defective folate
e. Folic acid 5 mg t. d. s.
2. General treatment during pregnancy
a. Rest

b. Psychological support
c. Sedatives
d. Diet
3. Special treatment during pregnancy
a. Progestogens
i)

Improving placentation

ii)

Rendering uterine contractions non-expulsive

iii) Raising the tone of the cervical sphincter

Results

Whatever treatment they receive, or if they have none at all, 70 per cent women who have lost 3
consecutive pregnancies by way of abortion will have a live child next time.

Criminal Abortion
Definition :
Every women, being with child, who, with intent to procure her own miscarriage, shall
unlawfully administer to herself any position or other noxious things.

Methods Used

1. Strong purgatives and single administrations of oxytocins.

2. Intra-uterine instrumentation : Domestic instruments such as hair pins, knitting needles and
the like are frequently used.
3. Dilatation of the cervix
4. An intra-uterine injection
5. Potassium permanganate

Dangers

a. Haemorrhage
b. Shock
c. Anuria
d. Peritonitis
e. Septicaemia
f. Air embolism
g. Chemical embolism
h. Intravascular haemolysis

Diagnosis

Sings of recent injury to the

a. Cervix
b. Uterus
c. Vagina are found

Management

If the initial shock due to intravasation of solutions injected into the uterus does not respond to
morphine, infusions, of blood and hydrocortisone given intravenously, exchange transfusion
should be considered.
A. Removal of body of shock antibiotic evacuation of uterus.
B. Prevention.

Abortion Complicated By Infection

Bacteriology : All manner of organisms, especially saprophytes, are normally presents in the
uterus and vagina during and after abortion; they play a physiological scavenger role. Even
Clostridium welchii is commonly found. The growth of particular bacteria from the vagina and
cervix is not necessarily of any significance and has to be interpreted in relation to clinical
features.
1. Bacillus coil
2. Non-haemolytic streptococcus
3. Anaerobic streptococcus
4. Staphylococcus aureus
5. Haemolytic streptococcus
6. Cl. welchii
7. Gonococcus
8. Pneumococcus
9. Tetanus bacillus

Mode of Entry

Although blood stream spread from another site in the body is a theoretical possibility the
organisms nearly always reach the vulva, vagina and uterus by way of one of the following
methods.

1. Droplet infection from the upper respiratory tract of attendants.

2. The hands and instruments of attendants. Lack of care in this respect explains why the most
serious infections commonly follow criminal follow criminal abortion. Some say that a septic
abortion is always a criminal abortion but this is an overstatement. Infection commonly
complicates spontaneous abortion.
3. The patients own hands which may transfer organisms from the nose, month and anus.
4. Atmospheric dust.

5. Bed linen, dressings and utensils such as bed pans.

6. Direct or indirect contact with another individual patient, friend or relative, suffering from any
sort of infection in any site.
Pathology

In 40 percent cases of septic abortion, the infection is limited to the products of conception
themselves, and there is no invasion of maternal tissues. In the others the placental site and
endometrium (decidua) become involved in endometritis which is either localized or spreading.
Localized endometritis 40%

This wss called putrid endometritis in the past, and the organisms involved are usually
endogenous and of low virulence- anaerobic streptococci, coliform bacilli and and staphylococci.
The infection is kept to the superficial layers of the endometrium by a sharp protective response
on the part of the underlying tissues which lay down a barrier of leucocytes.
Spreading endometritis 60%

This was formerly called septic endometritis. This infecting agent is more virulent, often the
exogenous haemolytic streptococcus, and local reaction and resistance are slight. The whole
depth of the endometrium, and sometimes the myometrium, are involved. Occasionally the
uterus becomes gangrenous. The organisms spread by lymph and blood channels to produce
general peritonitis or septicaemia. Infections of intermediate severty cause salpingo-oophoritis,
pelvic peritonitis, pelvic cellulitis and suppurative thrombophlebitis with pyaemia, all of which
are described.
Clinical Features
Pyrexia

This is the most obvious and usually the first sign. It does not necessarily mean that the infection
has spread beyond the products of conceptions and often disappears as soon as abortion is
complete. It may be caused only by degenerating blood clot. The severity of the infection is not
always proportional to the height of the temperature and a low temperature can have serious
portent. Rigors usually denote blood stream spread.
Tachycardia

A rise in pulse rate is a important sign than pyrexia. If the rate is more than 110 per minute it
usually means that the infection is spreading beyond the uterus.
The time at which pyrexia and tachycardia occur in relation to spontaneous or surgically
completed abortion is helpful is diagnisis. Spreading endometritis and septicaemia manifest
themselves within 48 hours, often within 24 hours; pelvic peritonitis on the second or third day;

localized endometritis on the third or fourth day; cellulitis and septic thrombophlebitis on the
tenth day.
Offensive discharge

An offensive, sometimes frankly purulent, uterine discharge is a feauture of localized infections,

hence the old term putrid endometritis. It can be vary foul, and forthy, when Cl. welchii
organisms are present. In the more serious infections, for example septicaemia, the uterus is
often empty and the lochial discharge scanty.
Tenderness of the uterus

This is not significant unless the abortion is complete.

Leucocytosis

There is usually a moderate degree of leucocytosis associated with all abortions. The number of
polymorphonuclear leucocytes has to be grossly increased, or associated with toxic granulation
of the white cells cytoplasm, for the finding to indicate serious infection.
Ileus

Although pelvic peritonitis can cause lower abdominal pain, general peritonitis is often
unaccompanied by pain, tenderness and rigidity. This condition in the puerperium is manifested
mainly by distension and vomiting.
General systemic upset

This varies with the severity of the infection and includes anorexia, vomiting, joint pains,
headache, flushed appearance, sweating, dehydration and ultimately mental disorientation and
coma. Rapid destruction of blood cells to cause profound anaemia is a feature of septicaemia,
especially if the haemolytic streptococcus or Cl. welchii is involved.
Infection with Cl. welchii results in a systemic upset characterized by the rapid onset of severe
prostration, accompained by hypotension and tachycardia. The temperature may be high or
subnormal. The Cl. welchii organisms not only release a myotoxin which breaks down protein to
produce gas, but also a haemotoxin which haemo-lyses blood and can cause coagulation failure
and haemorrhages. Haemolysis results in severe anaemia, port wine coloured urine and jaundice.
The last sign is sometimes a presenting one and can also be the result of liver, spleen and kidneys
are affected by the gas-forming organisms and renal failure is common.

The results and its contents also become necrotic and the presence of gas in the foetus and
the uterus (physometra) can often be detected by crepitus on palpation, and be
demonstrated by radiography.
Complication

1. Bacteramic (endotoxic) shock

2. Oliguria
Treatment

1. Investigation

Vaginalorcervicalswabandpreparecultures
Estimationofitshaemoglobinandcellularcontents
Bloodforculture
Midstreamspecimenofurine

2. Isolation of the patient : Ideally be isolated

3. Antibiotics
4. Blood transfusion
5. Evacuation of the uterus
6. Other surgical procedures
7. Treatment of shock
8. Treatment of oliguria