Abortion and abnormalities of early pregnancy:

Abortion and abnormalities of early pregnancy:

v10-15% of all pregnancies termination as   spontaneous abortions, and further 10-60% are terminated by an induced or (either legal or criminal abortion (Liewellyn-jones 1990).

vThe majority of abortions occur between the 8th-12th weeks of pregnancy when the level of progesterone secreted by the corpus luteum fails and placental hormone has no reached a sufficiently high level to sustain the conceptus.

Causes and predisposing factors of abortions:

The causes can be either fetal causes ,

maternal causes or Local conditions:

1 FETAL CAUSES:

vMaldevelopment or disease of fertilized ovum.

vChromosomal anomalies these may account 60% of spontaneous abortions first trimester.

vMalformation of trophoblast or poor

implantation of blastoctst may result in

placental separation with consequent hypoxia

 and impaired embryonic development.

vNormal development of the embryo may affect by hypoxia resulting from separation of and damaged of placenta.

Maternal causes:

2 MATERNAL CAUSES:

a) General conditions:

vDiseases acquired during pregnancy such as renal disease, accompanied by hypertension,

vInfections: febrile conditions such as influenza may cause fetal death.

b)  Effect of drugs:

 large doses of any drug are poisonous and

should be avoided,anaesthetic gases medication

prescribed in for malignancy and diseases of

immune system results in increased incidence of

 abortions first trimester.

vABO incompatibility:

vBetween mother and embryo may result in abortion.

vPsychological such as stress and anxiety can affect the functioning of the hypothalamic region of the brain and the pituitary gland.

vThis affects the uterine activity leading to abortion.

Local condition causes:

3 LOCAL CONDITIONS:

vCondition that interfere with embedding ,development and nutrition of the ovum. E.g. retroverted uterus.

vDevelopmental defect e.g. bicornuate uterus and myomas which distort the uterine cavity and inhibit uterine enlargement may cause midtrimester abortion.

vCervical incompetence due to congenital weakness, trauma resulting from previous dilatation curettage or lacerations sustained during past child bearing.

v20% women has cervical incompetence (Grant 1989)

vUterine malformations.

General Signs and symptoms:

vVaginal bleeding due to partial detachment  of embedded ovum.

vPain felt in the abdomen, intermittent, accompanied by backache, due to uterine contraction.

vDilatation of cervix when  the abortion is inevitable.

Types of abortions:

Abortions may be spontaneous or induced

abortion:

vThreatened abortion

vHabitual  abortion

vMissed  abortion

vTherapeutic abortion

vCriminal  abortion

vSeptic abortion Threatened abortion abortions:

1 Threatened abortion:

ØDisturbance is slight that the is possible for the pregnancy to go  to term.

Ø  Bleeding is minimal(slight).

Ø   No backache.

ØOS is closed

ØMembrane is intact

Very occasionally intermittent pain is felt low abdominal.

*possible outcomes of threatened abortion:

 pregnancy goes to term if signs and symptoms subside.

Threatened abortion can be inevitable or missed abortion

Inevitable abortion: when free bleeding continue and painful uterine contractions are present.

Missed abortion:

This occurs when the fetus dies and it is retained in uterus.

Treatment of threatened abortions:

Treatment of threatened abortion:

ØPatient should rest and have reassurance.

ØKeep pads for observation

ØVulva swabbing twice per day

ØSedatives. (anxiety /worries.

ØAperients if constipation persist

ØVital signs  twice per day (BD)

ØSpeculum examination to exclude cervical lesions.

Advice on discharge:

ØAdvice to take extra rest at home.

ØRestrict extra activities.

ØAvoid heavy lifting strenuous exercise and excitement

ØCoitus is contraindicated for 2-3 weeks.

ØGo to bed immediately if bleeding starts.

a) Inevitable abortion:

ØIncase it is not possible for the pregnancy to continue:

Ø heavy bleeding means that a considerable part of placenta has become detached.

ØIntermittent uterine contractions.

ØIf membrane rupture and the ovum protrude through the dilating os, abortion must take place.

Treatment of Innevitable abortion abortions:

ØGive ergometrine 0.2mg im or Misoprostol 400mg orally ,repeat once after 4hrs.

ØPerform MVA (manual vacuum aspiration) if pregnancy is less than 16 weeks.

•If greater than 16 weeks await spontaneous expulsion of products of conception, infuse oxytocin 40 units in 1liter normal saline or ringers lactate.

•MVA to remove any remaining products.

ØBefore  8th week an abortion is more likely to be complete because the fetal sac is expelled intact.

When an abortion is complete: (signs and symptoms)

§  light bleeding

§Pain ceases.

§Cervix closes

§Involution of uterus takes place.

Management of complete abortions:

Management of complete abortion:

ØEvacuation of uterus not necessary

ØObserve for heavy bleeding

ØGive ergometrine 0.2 mg IM or misoprostol 400ug orally.

ØRefer if bleeding does not stop.

Incomplete  abortions:

b) Incomplete abortion:

ØThe fetus and membrane are expelled.

ØChorionic tissue remains attached

ØBleeding continues.

ØUltrasound shows debris in the uterine cavity.

ØUterus smaller than dates.

Management of incomplete  abortions:

Management of incomplete abortion:

ØIf bleeding is moderate use ring forceps to remove products of conception protruding through cervix.

ØErgometrine 0.2mg IM repeat after 15 minutes or misoprostol 400ug by mouth.

ØIf bleeding is heavy and pregnancy is less than 16weeks perform MVA.

 

ØIf MVA not available perform curettage.

ØIf both not available refer urgently.

ØIf bleeding is heavy and pregnancy is above 16 weeks give ergometrine 0.2mg IM or misoprostol.

ØIf MVA is available.

ØInfuse oxytoxin 40 units in 1 lt normal saline or ringers lactate 40 drops per minute until expulsion of the products of conception occurs.

ØGive misoprostol if necessary

ØPerform MVA to remove remaining products of coneption.

Habitual abortions:

Habitual abortion:

ØWhen the woman has had two consecutive spontaneous abortion.

ØInvestigate to exclude nephritis, hypothyroidism.

ØPelvic examinations is done to diagnose uterine abnormalities displacements or fibroids.

Management of Habitual abortions:

ØCervical erosion, laceration are dealt with if present.

ØCouple is advised to take well balanced diet,esp proteins, minerals and vitamins.

ØOther pregnancy may be started as soon as the woman is in good health.

ØReports to clinic when she thinks she is pregnant.

ØStress and coitus should not take place during early pregnancy.

ØAdvise adequate rest

ØPsychological support.

ØMild sedative.

Cervical suture:

ØAbortion occurring at about midterm may be due  to incompetence of the cervix allowing the membrane to rupture.

ØNon-absovable material is inserted about 8th week

ØRemoved at  the 38th week, or sconer if the woman goes  into premature rupture of membrane.

Missed abortion:

ØRetention of fetus in utero for several weeks.

ØThe breast becomes soft.

ØOther signs of pregnancy  disappear.

ØThe woman has brown  vagina discharge.

ØNo pain.

ØUltrasound is used to confirm the absence of fetal heart beat.

ØBlood coagulation disorder may develop in case of missed abortion which persist  for over 6 – 8 weeks .

  Blood mole:

Øoccurs rarely presented with brownish red mass.

ØBig as medium sized orange.

ØArises incase of missed abortion when the decidua capillaries remain intact and permits the ovum to be surrounded with layers of blood.

ØIt forms before the 12th week.

ØRetained in utero for period of months.

ØThe fluid is extracted from the blood and the fleshly firm hard known as a corneous mole.

ØWhen cut it resemble a small placenta.

Treatment of blood mole:

ØProstaglandin E2 may be administered by extra –ovular route (between the fetal  sac and uterine wall.

ØA high dose of oxyctocin drip may be given 10 units syntocinon in 540 mls of glucose 5%.

ØIncrease the dose accordingly.

Therapeutic abortion:

ØTherapeutic abortion is one done for some special reasons .(too young, contraindicated e.g. CCF 3rd degree, severe hyperemesis gravidurum)

ØTermination of pregnancy carried out under the provision of the abortion Act 1967.

Criminal abortion

ØIs one performed when the conditions set out in the abortion Act 1967 are not fulfilled.

ØThe procedure is illegal and is punishable by imprisonment.

ØCriminal abortion is performed in unsterile conditions by operators with little  or no medical training.

ØThe abortion achieved is incomplete.

ØIntrauterine infection is frequent complication.

ØSeptic shock and death are the consequences.

Septic abortion

ØUterine infection at any stage of an abortion.' usually associated with incomplete abortion.

ØCondition is similar to puerperal sepsis following child birth.

ØInfertility and ill health  may develop.

Signs and symptoms
of septic abortion

ØUterus is tender on palpation.

ØLochia is offensive and profuse.

ØAbdominal pain may or not be present.

ØPulse is rapid and temperature raised.(38-39 degree centrigrade.)

Management of septic abortion

ØMinimize the risk of septic shock.

ØCervical and high vaginal smears

ØSeveral blood culture are taken.

ØBroad spectrum antibiotic such as cephaloridine and metronidazole.

ØCurretage as soon as possible.

ØBroad spectrum antibiotic such as cephaloridine and metronidazole.

ØCurretage as soon as possible.

ØBroad spectrum antibiotic such as cephaloridine and metronidazole.

ØCurretage as soon as possible.

Hydatidform mole:

ØHydatidform mole is a mass of vesicles resulting from cystic proliferation of chorionic epithelium.

ØIt forms inside the uterus at the beginning of pregnancy.

ØIt is a type of gestational trophoblastic disease (GTD) originates in the placenta.

Incidence and risk factors of hydatidform mole:

ØOverproduction of the tissue, that is supposed to develop into the placenta.

ØThe placenta normally feeds the fetus during pregnancy.

ØThe tissue develop into an abnormal growth called mass(no fetus at all.

Possible causes:

ØDefects in the egg, problems within uterus ,nutritional deficiencies, women under 20 yrs or 40 yrs above have a higher risk to develop, diet low in protein, folic acid, and carotene.

ØVaginal bleeding first trimester

ØNausea and vomiting

ØAbnormal growth in size of uterus for stage of smaller than expected growth 33%.

a) Signs and symptoms of hyperthyroidism:

§rapid heart rate,

§Restlessness nervousness.

§Heat intolerance

§Unexplained weight loss

§Loose stool

§Trembling hands.,

Skin warmer and moist than usual.

b) Symptoms similar to eclampsia:

Øthat occur in1st trimester or early 2nd trimester (this differs to real enclampsia at this stage of pregnancy) high BP,Swelling in feet,

    ankles, Leg and Proteinuria.

On pelvic exams:

Ø   shows normal pregnancy, but no heart beat sound, and there is vaginal bleeding.

Diagnosis and investigation:

Ø  serum HOG

Ø   Utra sound of pelvis.

Ø   Chest  x-ray

Abdominal CT or MRI

ØD&C (suction curettage)

ØHysterectomy (done to women who does not need children in future.

ØAfter curettage serum HOG levels will be followed.