TYPE THREATENED INEVITABLE COMPLETE INCOMPLETE MISSED SEPTIC HABITUAL/RECURRENT

DEFINITION It is a clinical entity where the process of It is a clinical type of abortion where When the products of conception When the entire products of conception are When fetus is dead and retained inside the Any abortion associated with clinical evidences of infection of uterus and its contents. Consecutive 3 or more loss of pregnancy
abortion has started but has not the changes have progressed to a are expelled completely, it is not expelled, instead a part of it is left inside uterus for a visible period, it is called missed without any living issue in between.
progressed to a state from which state from where continuation of called complete abortion. the uterine cavity, it is called incomplete abortion or silent miscarriage or early foetal
recovery is impossible. pregnancy is impossible. abortion. demise.
CLINICAL Symptoms: Symptoms: Symptoms: Symptoms: Symptoms: From history: From history:
FEATURES 1) Bleeding per vagina usually slight and 1) Increased vaginal bleeding, 1) H/O expulsion of fleshy mass • History of variable period of amenorrhoea. 1) Persistence of brownish vaginal discharge, 1. The patient usually gives history of induction of abortion unhygenically by untrained person. 1)Repeated mid-trimester abortion
may be brownish or bright red in colour, 2) Aggravation of pain in the lower through vagina • History of expulsion of a fleshy mass per 2) Subsidence of pregnancy symptoms. 2. There may be fever associated with chills and rigor. without apparent cause.
2) Usually painless but there may be mild abdomen which may be colicky in 2) Subsidence of abdominal pain. vagina followed by: Signs: 3. She may complain of lower abdominal pain and foul smelling vaginal discharge 2)Painless expulsion of the products of
backache or dull pain in lower abdomen. nature, 3) Vaginal bleeding becomes 1) Continuation of pain in lower abdomen, 1) Retrogression of breast changes. From examination: conception is very much suggestive
Pain appears usually following Signs: trace or absent. colicky in nature, although in diminished 2) Cessation of uterine growth. 1 . The patient may look toxic and pale.
haemorrhage, 1)On general examination: Signs: magnitude. 3) Non-audibility of the fetal heart sound even 2. There may be rise of temperature, tachycardia, hurried respiration and hypotension specially if it is associated with excessive On Examination:
Signs: • Pallor On per abdominal examination: 2) Persistence of vaginal bleeding of varying with Doppler cardioscope if it had been audible haemorrhage or septic shock. 1) Interconceptional period: Binmanual
1) On general examination: • Tachycardia. a) Uterus is smaller than the magnitude. before. 3. The abdomen may show tenderness, distension, rigidity or muscle guard. Bowel sound may or may not be present. examination reveals presence of
a) Anaemia, • Hypotension. period of amenorrhoea & a little Signs: 4) Cervix feels firm, os is closed. 4. Vaginal examination may show foul smelling discharge, injury to the cervix or the vagina and foreign body inside the genital unilateral or bilateral tear &/or gaping of
b) Signs of early pregnancy, • Cold clammy extremities firmer. 1) On general examination: tract. the cervix up to the internal OS.
2) On per abdominal examination: b) Cervical os is closed. a) Anaemia, 5. The product may or may not be hanging through the open cervix. 2) During pregnancy: Periodic inspection
Height of the uterus corresponds to the 2)On per abdominal examination: c) Bleeding is trace. b) Signs of shock. 6. Uterine size may correspond to the gestational age or smaller or could not be determined. of the cervix through speculum from 10th
period of amenorrhoea or gestation, Uterus is soft and corresponds to the 2) On per abdominal examination: 7. The fornices may be tender and full. week onwards at intervals. Detection of
3)On per vaginal examination: period of amenorrhoea Uterus is smaller than the period of Clinical features: dialatation of the internal OS with
Should be done as gently as possible . amenorrhoea, 􀂄 The woman looks sick and anxious herniation of the membranes is
and is avoided when USG is available. 3)On per vaginal examination: 3) On per vaginal examination: 􀂄 Temperature: >38°C diagnostic.
a)Cervix feels soft with the os closed, • Cervix feels soft, os is open and bld a) A product of conception is felt on the 􀂄 Chills and rigors (suggest-bacteremia)
b)Blood may be seen at the external os, clots may seen. cervical canal or vagina, 􀂄 Persistent tachycardia ≥ 90 bpm (spreading infection)
c)Uterus is soft. • Products are felt through the open b) Internal os is open. 􀂄 Hypothermia (endotoxic shock) < 36°C
intemal os. c) Uterus feels soft. 􀂄 Abdominal or chest pain
􀂄 Tachypnea (RR) > 20/min
􀂄 Impaired mental state
􀂄 Diarrhea and/or vomiting
􀂄 Renal angle tenderness
􀂄 Pelvic examination: Offensive, purulent vaginal discharge, uterine tenderness, boggy feel in the POD (pelvic abscess)
CLINICAL GRADING:
Grade I: The infection is localized in the uterus.
Grade II: The infection spreads beyond the uterus to the parametrium, tubes and ovaries or pelvic peritoneum.
Grade III: Generalized peritonitis and/or endotoxic shock or jaundice or acute renal failure.

INVESTIGATIONS 1) Blood for Hb%. 1) Blood for Hb%. USG of lower abdomen: No 1) CBC, 1) USG of lower abdomen: empty sac early in (1) Cervical or high vaginal swab is taken prior to internal examination for gram stain, C/S (may show the presence of causative (1) Blood-glucose (fasting and
2) Blood grouping and cross matching. 2) Blood grouping and cross matching. product of conception 2) Blood grouping and cross matching, the pregnancy or no fetal motion or no fetal organism). postprandial), VDRL, thyroid function
3) Rh typing 3) USG of uterus and adnexae. 3) USG of lower abdomen. heart sound later in the pregnancy. (2) Blood for hemoglobin estimation, total and differential count of white cells, ABO and Rh grouping (There will be leucocytosis. test, ABO and Rh grouping (husband
4) Serum b-HCG 2) Coagulation profile (BT, CT, APTT, Haemoglobin level may be low). and wife), toxoplasma antibodies IgG
4) USG of lower abdomen (uterus and Fibrinogen, D-dimer) - For DIC. (3) Urine analysis including culture. and IgM.
adnexae) 3) CBC - for sepsis. (2) Autoimmune screening—lupus
5) VDRL 4) Blood grouping, Rh typing & cross matching. Special investigations— anticoagulant and anticardiolipin
5) Immunological test for pregnancy becomes (1) Ultrasonography of pelvis and abdomen to detect intrauterine retained products of conception, physometra, foreign body— antibodies
negative. intrauterine or intra-abdominal, free fluid in the peritoneal cavity or in the pouch of Douglas (pelvic abscess). (3) Serum LH on D2/D3 of the cycle.
(2) Blood— (4) Ultrasonography—to detect
(a) Culture—if associated with spell of chills and rigors congenital malformation of uterus,
(b) Serum electrolytes, C-reactive protein (CRP), serum lactate—as an adjunct to polycystic ovaries and uterine fibroid.
the management protocol of endotoxic shock. Serum lactate greater than or equal to 4 mmol/L indicates tissue hypoperfusion. (5) Hysterosalpingography in the
May show low bicarbonate level. secretory phase to detect—cervical
(c) Coagulation profile (may show low fibrinogen content). incompetence, uterine synechiae
(3) Plain X-ray— and uterine malformation.
(a) Abdomen—in suspected cases of bowel injury (may show foreign body inside the abdomen and detect perforation of hollow (6) This is supported by hysteroscopy
viscous and intestinal obstruction). and/or laparoscopy.
TREATMENT 1) Absolute bed rest for 2-5 days after all A. General treatment: l) The effect of blood loss, if any, A. GENERAL: 1) Uterus is less than 12 weeks: Vaginal (b) IfChest—for
A. infection cases with pulmonary
is localised complications (atelectasis).
to the uterus: (7)General
1. Karyotyping (husband
measure andpregnancy:
before wife).
bleeding has ceased. l) Treatment of shock if present. should be assessed & treated. 1) Hospitalization. evacuation by suction evacuation or slowly a) Antibiotics are to be given parentally such as, (8) Endocervical
a) Wait 3 monthsswab to detect
from the time of last
2) Relief of pain by Tab. Diazepam 5 mg 2) Bed rest until abortion is complete 2) If there is doubt about 2) IV fluids & blood transfusion if patient in dilatation of the cervix by laminara tent followed Inj. ceftriaxone 1 gm daily chlamydia,
abortion mycoplasma
before and
attempt to bacterial
conceive
twice daily. 3) IV fluid, sedatives. complete expulsion of the shock. by D & E of the uterus under G/A. Inj. Metronidaiole 500mg 8 hourly vaginosis
again,
4) Inj. Morphine 15 mg or Inj.Pethidine products, uterine curettage should 3) Excessive bleeding should be controlled 2) Uterus more than 12 weeks: b) Blood transfusion If needed. b) Improve physical and mental health,
3) Emperical therapy: Progesterone, 100 mg be done. by administering methergine 0.2mg. a) First dilation of cervix then evacuation. c) Analgesics if required. c) Folic acid 5 mg 8 hourly before
orally or IV 3) Transvaginal sonography is B. ACTIVE: b) Induction is done by following drugs: d) Prophylactic antigas gangrene serum of 8,000 units and 3,000 units of antitetanus serum I/M are given if there is a history of conception and continued thereafter
Advice On Discharge: B. Active management: useful to prevent unnecessary 1) Early abortion: D & C under analgesia or Oxytocin drip ( 2nd trimester), Prostaglandins interference.
a Avoid heavy work, strenuous exercise 1) If the pregnancy < 12 weeks: surgical procedure. G/A. (early pregnancy). e) Evacuation and curettage should be performed within 12-24 hours of initiation of antibiotics, if it is incomplete abortion. If there 2. General treatment during
for 2 weeks. • D&C with blunt curette. 4) In Rh-negative women: Anti-D 2) Late abortion: The uterus is evacuated is bleeding evacuation and curettage should be done immediately though there is a chance of spread of infection. Before pregnancy:
b) Avoidance of coitus for 2 weeks. • Ultimately, suction evacuation gamma globulin 50 microgram or under G/A & the products are removed by evacuation and curettage pitocin drip has to be started. Suction curettage is the method of choice. a) Bed rest,
c) Follow up after 1 month for re- followed by curettage is done. 100 microgram in cases early ovum forceps or blunt curette. B. If the infection spreads to pelvic peritoneum leading to pelvic peritonitis and pelvic abscess: In addition to the above- b) The woman should avoid coitus,
examination. 2) If the pregnancy > 12 weeks: abortion or late abortion mentioned management following measures are to be taken: traveling on mechanical vehicles,
• IV oxytocin and wait for spontaneous respectively within 72 hours. a) The patient is to be kept nothing by mouth. physical exertion and weight lifting,
expulsion. b) Parental nutrition is to be maintained by intravenous fluid. c) Balanced diet throughout the
• If the placenta is not separated, c) If there is pelvic abscess, colpotomy should be done to drain the pus. pregnancy
digital separation followed by its C. If there is generalised peritonitis with paralytic ileus: The management will be as follows:
evacuation is to be done under G/A. a) Nasogastric suction 3. Specific treatment:
b) Parenteral nutrition by intravenous fluid. a) Cervical incompetence: Shirodker's
C. Other measure: c) Parental antibiotics such as: operation.
1) Inj TT or TIG Inj. Ceftriaxone 1 gm daily b) Retroversion: Correction with pessary
2) Prophylactic antibiotic. Inj. Metronidazole 500mg 8 hourly c) Fibroid: Myomectomy
3) Anti-D Ig to Rh(-) ve mothers Inj. Gentamycin 80mg 8 hourly d) Cervical tear: Repair
d) Blood transfusion, if necessary. e) Infection: Treatment by appropriate
e) Assessment of the general condition of the patient is to be done to see whether infection is responding to conservative antibiotic
management or not by- f) Hormone supplement: Inj.
i) Well being of the patient, ii) Decrease in the pulse rate, iii) Subsidence of the temperature, iv) Softening and reduced Progesterone depot 500 mg 1M weekly
tenderness of the abdomen v) Reappearance of the bowel sounds. for 6 weeks or orally 5 mg tablets 8
f) If patient is not responding to conservative treatment, laparotomy is indicated. Reasons for non-responding to the conservative hourly for 6 weeks.
treatment are:
i) Collection of pus in the peritoneal cavity ii) Perforation of the uterus iv) Suspected injury to the gut. v) Suspected foreign body
inside the abdomen.

COMPLICATIONS/ 1) In about two thirds, the pregnancy A) Immediate: The retained products may cause: 1) Infection: Sepsis. 1) Immediate:
FATE continues beyond 28 weeks. If the 1. Haemorrhage. 1) Profuse bleeding, 2) Blood coagulation disorder: DIC. A) Hemorrhage
pregnancy continues, there is increased 2. DIC. 2) Sepsis, 3) Psychological upset. B) Injury may occur to the uterus and also to the adjacent structures particularly the bowels.
frequency of preterm labour, placenta 3. Thrombophlebitis. 3) Placental polyp. 4) During labour: C) Spread of infection leads to: (a) Generalized peritonitis—the infection reaches through:
previa, intrauterine growth restriction of 4. Renal failure. -Uterine inertia.: a)Retained placenta, (i) the uterine tubes (ii) perforation of the uterus (iii) bursting of the microabscess in the uterine
the fetus & fetal anomalies. B) Late: b)Post partum haemorrhage. wall and (iv) injury to the gut. (b) Endotoxic shock—mostly due to E. coli or Cl. welchii infection.
2) In the rest, it terminates either as 1. PID (c) Acute renal failure (d) Lungs: atelectasis, ARDS (e) Thrombophlebitis
inevitable or missed carriage. 2. Ectopic pregnancy. 2) Remote:
3. Tubo-ovarian mass. A) chronic debility
4. Infertility. B) chronic pelvic pain and backache,
5. Chronic debility. C) dyspareunia,
6. Dyspareunia. D) ectopic pregnancy,
E) secondary infertility due to tubal blockage and
F ) emotional depression