abortion

Bleeding in Early Pregnancy, Abortion 18

Differential Diagnosis
A complication of early pregnancy should always considered in the differential diagnosis in a woman of reproductive age presenting with irregular vaginal bleeding 1- Miscarriage 2-ectopic pregnancy 3-gsetational trophobastic disease 4-dysfunctional uterine bleeding 5-benign &malignant tumours of reproductive tract

Miscarriage , spontaneous abortion and pregnancy loss

Definition
The natural death of an embryo or fetus it is able to survive independently some use cutoff 20 weeks some use 24 ; after which fetal death is known as still birth Or when fetus born weighing less than 500g.

types

1-thretened :bleeding prior to24w with the cervix not dilated &the fetus alive 2-inevitable :bleeding prior to24w with pain &dilatation of cervix 3-Incomplete:part of the conceptus has been expelled but there is continuous bleeding due to tissues retained 4-complete :the whole conceptus has been expelled 5-recurrent:3 or more consecuative miscarriage 6-missed: pregnancy failure is identified before expultion of fetal/placental tissues

types

7.septic abortion: term used when infection of the uterus & sometimes surrounding structures occur.

Case presentation

A young lady presented with 24 days delayed menses ,she has slight vaginal bleeding ,no abdominal pain What are the investigations needed to reach the diagnosis? What are the differential diagnosis?

Management of bleeding lady

1.History: 2.Examination: general ,abdominal &pelvic [bimanual&speculum] 3.Investigation: hCG& US

Management of bleeding pregnant

The result is either viable fetus needs follow up of the pregnancy, or dead fetus or part of conceptus, needs evacuation.

Aetiology

1.Chromosomal abnormalities: cause at least 50% of early abortions e.g. trisomy, monosomy X (XO) and triploidy tetraploidy&translocation 2. endocrine disorders: diabetes ,hypothyroidism, leuteal phase deficiency,PCOS 3.Abnormalities of the uterus: septa,adhesions (asherman syndrome) , fibroids 4.Maternal infections: e.g.TORCH, listeria monocytogenes, mycoplasma hominis, ureaplasma urealyticum,chiamydia,salmonella . Acute fever for whatever the cause can induce abortion.

5.Trauma: external to the abdomen or during abdominal or pelvic operations. 6.Immunological causes: . Antiphospholipid antibodies,SLE Thrombophilia Histocompatibility between the mother and father and in turn the foetus. 7.Drugs and environmental causes: e.g. quinine, ergots, severe purgatives, tobacco, alcohol, arsenic, lead, formaldehyde, benzene and radiation

. 8.Ageing sperm or ovum. 9.Nervous, psychological conditions and over fatigue. 10.Maternal anoxia and malnutrition 11.cervical incompetence. .

hCG
Secreted by syncytiotrophoblast as early as 8 days after LH peak .[hCG]at time of 1st missed period is 100-600 ;a doubling rate of less than or equal to 2 days is consitant with normal pregnancy .there is rapid increase until reaches peak in 10-12 weeks then platue of the level curve.

Threatened Abortion

Clinical picture 1.Symptoms and signs of pregnancy coincide with its duration. 2.Vaginal bleeding slight or mild, bright red in colour originating from the choriodecidual interface. 3.Pain is absent or slight. 5.Pregnancy test is positive. 6.gentle vaginal examination&passage of speculum will exclude incidental cause?


Treatmentthreatened abortion
1.Rest in bed until one week after stoppage of bleeding. 2.Sedatives: if the patient is anxious 3.reasurance avoiding stress & intercourse . Treatment of controversy: 1.Progestogens: e.g. hydroxyprogesterone caproate (Primulot depot) 250 mg IM twice weekly is given by some if there is evidence of progesterone deficiency. 2.Gonadotrophins may be of benefit in cases of luteal phase deficiency and those get pregnant with ovulatory drugs.

Case history

A 2 months pregnant lady presented with 1- disappearance of pregnancy symptoms with slight dark vaginal discharge 2- colicky abdominal pain with profuse vaginal bleeding ,the internal os was open 3- the patient aborted gestational products before 3 days with continuous profuse bleeding How will you solve these problems? If the patient developed fever, rigor & offensive vaginal discharge

Inevitable Abortion

Clinical picture: 1.Symptoms and signs of pregnancy coincide with its duration. 2.Vaginal bleeding is excessive and may accompanied with clots. 3.Pain is colicky felt in the suprapubic region radiating to the back. 4.The internal os of the cervix is dilated and products of conception may be felt through it. 5.Rupture of membranes between 12-24w is a sign of the inevitability of abortion.

Treatment

If pregnancy is less than 12 weeks: Termination is done by vaginal evacuation and curettage or suction evacuation under general anaesthesia. If pregnancy is more than 12 weeks: Oxytocin is given by intravenous drip to expel the uterine contents.;If the placenta is retained it is removed under general anaesthesia. Ifthe cervix is dilated due to cervical incompetence &membrane intact after16 weeks,insertion of cervical suture may salvage the pregnancy.

Incomplete Abortion

Retention of a part of the products of conception inside the uterus. It may be the whole or part of the placenta which is retained.

Clinical picture

1.The patient usually noticed the passage of a part of the conception products. 2.Bleeding is continuous. 2.On examination, the uterus is less than the period of amenorrhoea but still large in size. The cervix is opened and retained contents may be felt through it. 4.US: shows the retained contents.

Treatment of incomplete abortion

by evacuation


Pathology of spontaneous abortion
Hemorrhage into the decidua basalis , with adjacent tissue necrosis ,then the ovum detaches and this stimulates uterine contractions that result in expulsion

Complete Abortion: conceptus is expelled Clinical picture

1.The bleeding is slight and gradually diminishes. 2.The pain ceases. 3.The cervix is closed. 4.The uterus is slightly larger than normal. 5.US: shows empty cavity.

Missed Abortion

Failure to expel the products of conception after fetal death.Carneous mole is a special variety of missed abortion in which the dead ovum in early pregnancy is surrounded by clotted blood.

Clinical picture

Symptoms: 1.Symptoms of threatened abortion may or may not be developed. 2.Regression of pregnancy symptoms as nausea, vomiting and breast symptoms. 3.The abdomen does not increase and may even decrease in size. 4.No foetal movements if previously present. 5.Milk secretion may start particularly in second trimester abortion. 6.A dark brown vaginal discharge may occur (prune juice ).

Complications

Disseminated intravascular coagulation (DIC) may occur if the dead conceptus is retained for more than 4 weeks. Superadded infection.

Treatment

The dead conceptus is expelled spontaneously in the majority of cases. Evacuation of the uterus is indicated in the following conditions: spontaneous expulsion does not occur within two weeks there is bleeding infection or DIC developed


Septic abortion
Initially infection confined to the uterus,but & even septicemia. In sever cases,endotoxic shock can develop ,sometimes with DIC .Such patient at risk of acute renal failure

Septic abortion

Abortion can be complicated by severe infections . Endomyometritis is the most common manifestation of postabortal infection but can spread into broad ligament& pelvic wall,leading to pelvic cellulitis parametritis , pertonitis , septicemia and endocarditis

Septic Abortion

Microbiology: E.Coli, bacteroids, anaerobic streptococci , clostridia, streptococci and staphylococci are among the most causative organisms


Infection is less common after spontaneous abortion .Typical causative organisms include Escherichia coli, Enterobacter aerogenes, Proteus vulgaris, hemolytic streptococci, staphylococci, and some anaerobic organisms (eg, Clostridium perfringens). One or more organisms may be

Clinical picture

General examination: Pyrexia, tachycardi,rigor suggest bacteraemia Malaise, sweating, headache, and joint pain. Jaundice and /or haematuria is an ominous sign, indicating haemolysis due to chemicals used in criminal abortion or haemolytic infection as clostridium welchii

.As the condition becomes more serious, signs of septic shock may appear, including:hypotension , hypothermia , , oliguria . Respiratory distress (dyspnea ) Septic shock may lead to kidney failure, and disseminated intravascular coagulation (DIC). Intestinal organs may also become infected, potentially causing scar tissue with chronic pain, adhesions and infertility.If the septic abortion is not treated quickly and effectively, the woman may die


Abdominal examination: Suprapubic pain and tenderness. Abdominal rigidity and distension indicates peritonitis.


Peliv examination: 1.Offensive vaginal discharge. Minimal inoffensive vaginal discharge is often associated with severe cases. 2.Uterus is tender. 3.Products of conception may be felt. 4.Local trauma may be detected. 5.Fullness and tenderness of Douglas pouch indicates pelvic abscess which will be associated with diarrhoea.

Management

1.Isolate the patient . Bed rest in semi-sitting position. 2.An intravenous line is established for therapy. In case of shock a central venous pressure (CVP) line to aid in the control of fluid and blood transfusion is added ;in sever cases blood culture done 3.Observation for vital signs: pulse, temperature and blood pressure as well as fluid intake and urinary output. 4.A cervico-vaginal swab is taken for culture (aerobic and anaerobic) and sensitivity,

5-Intensive antibiotic

eg, clindamycin plus gentamicin with or without ampicillin plus uterine evacuation as soon as possible. A typical antibiotic regimen includes clindamycin 900 mg IV q 8 h plus gentamicin 5 mg/kg IV once/day, with or without ampicillin 2 g IV q 4 h. Alternatively, a combination of ampicillin, gentamicin, and metronidazole 500 mg IV q 8 h can be used.

Management

6.Fluid therapy 7.Blood transfusion: is given if CVP is low (normal: 8-12 cm water). It is of importance also to correct anaemia coagulation defects and infection. 8.antitetanic serum (in Cl. tetani.) 9.Oxytocin infusion: to control bleeding and enhances expulsion of the retained products.

Surgical evacuation of the uterus can be done after 6 hours of commencing IV therapy but may be earlier in case of severe bleeding or deteriorating condition in spite of the previous therapy.

Therapeutic Abortion

Abortion induced for a medical indication.

Recurrent (Habitual) Abortion

Three (two by some authors) or more consecutive abortions.



In women with multiple gestations and a short cervix, cerclage placement is not recommended, as this has actually been associated with an increased risk for preterm delivery. [43] .

BASELINE INVESTIGATIONS

Endocrine–LH,FSH,TSH,PRL,Blood sugar , TORCH Anti chlamydial UTERINE– US, HSGIMMUNOLOGICAL – LUPUS,APL,C3,4Thrombophilia screenGenetic study :- karyotype of parents & products


Cervical incompetence may cause miscarriage or preterm birth during the second and third trimesters. Another sign of cervical incompetence is funneling at the internal orifice of the uterus, which is a dilation of the cervical canal at this location.

In cases of cervical incompetence, dilation and effacement of the cervix may occur without pain or uterine contractions. In a normal pregnancy, dilation and effacement occurs in response to uterine contractions. Cervical incompetence occurs because of weakness of the cervix, which is made to open by the growing pressure in the uterus as pregnancy progresses. If the responses are not halted, rupture of the membranes and birth of a premature baby can result.

diagnosis

1)Based on hitosry of painless cervical dilation usually after the first trimester without contractions or labor and in the absence of other clear pathology Abortion process occurs in short time. . the expelled foetus shows no abnormalities, the duration of pregnancy is decreasing each time due to weakness of the isthmus by successive pregnancies


2)assessment of cervical length in second trimester to identify cervical shortening using ultrasound.

Normally, the cervix should be at least 30 mm in length. Cervical incompetence is variably defined. However, a common definition is a cervical length of less than 25 mm at or before 24 weeks of gestational age. The risk of preterm birth is inversely proportional to cervical length: Less than 25 mm; 18% risk of preterm birth Less than 20 mm; 25% risk of preterm birth

3)hysterosalpingography and radiographic imaging of balloon traction on the cervix 4)Hegar or Pratt dilators, the use of a balloon elastance test, and use of graduated cervical dilators


Ask about: Consanguinity between the couple. History of in utero exposure to diethylstilbestrol (DES) that causes uterine anomalies.. Exposure to radiation, infections or environmental pollutants.

cervical incompetence can be diagnosed by:U/Sduring pregnancy Between pregnancies: The cervix can admit easily No. 8 Hegar’s dilator without resistance or pain. A 2 ml (6 mm diameter) Foley’s balloon catheter can be withdrawn through the cervical canal with minimal resistance. Hysterosalpingogram: demonstrates cervical funnelling. Extensive old cervical lacerations may be detected.

Surgical treatment

Cervical cerclage It means encircling the cervix at or as near as possible to the internal os by a non-absorbable suture. The best time for the operation is about 12-14 weeks. The suture is removed at 38 weeks or if labour started at any time. . Preoperative evaluation prior to cerclage placement should include ultrasound assessment to ensure fetal viability, confirm gestational age, and rule out any clinically significant fetal anatomical abnormalities

indications

Elective cerclage at 14-16 weeks: in high risk cases, as identified from the history of previous mid-trimester pregnancy losses Emergency or rescue cerclage: can be used up to 25-26 weeks, in response to an open cervix with bulging membranes; clearly, there are risks of premature rupture of membranes in this situation, and the operation is often unsuccessful in prolonging the pregnancy for a considerable period of time, but it may allow for time to administer steroids and transfer to a neonatal ICU centerCervical cerclage in response to shortened cervical length (as detected by ultrasound): there seems to be increasing evidence that this may be a reasonably successful option


Vaginal cerclage: Shirodkar operation: Two incisions at the reflection of the vaginal wall on the cervix are done anteriorly and posteriorly and bladder is dissected upwards. A nylon or silk suture or a dacron (mersilene) tape is applied around the internal os under the cervical mucosa.

Mc Donald operation: It is the commonest operation. The cervix is surrounded from outside by a nylon or silk purse- string suture. The suture takes bites of cervical tissue at 3,6,9 and 12 o'clock then tied anteriorly or posteriorly. This operation is easier and gives nearly the same results as Shirodkar.

Abdominal cerclage: In case of previous high amputation of the cervix extensive cervical laceration or repeated failure of vaginal cerclage. .