More Related Content
Similar to abortions( hemorrhagic in early pregnancy (20)
abortions( hemorrhagic in early pregnancy
- 1. HAEMORRAHGE IN EARLY PREGNANCY DR WAJEEHA ABBAS (OBSESTETRIC AND GYNAECOLOGIST)
- 2. HAEMORRAHGE IN EARLY. PREGNANCY The causes of bleeding in early pregnancy are broadly divided into two groups: Those related to the pregnant state: 1) abortion(95%). 2) ectopic pregnancy. 3). Hydatidiform mole 4)implantation bleeding Those associated with the pregnant state: 1). Cervical lesions 2) vascular erosions 3) polyp 4) ruptured varicose vein 5) malignancy .
- 3. ABORTION DEFINATION: Abortion is expulsion or extraction from its mother of before 22 weeks or an embryo or fetus weighing 500 gm or less ,when it is not capable of independent survival (WHO). ▪ This 500gm of fetal development attained approximately at 22 weeks of gestation. ▪ The expelled embryo or fetus is called abortus. ▪ The term miscarriage , which is mostly used with spontaneous abortion.
- 4. ABORTION Abortion is classified into groups : 1). Spontaneous abortion. 2). Induced abortion 1). Spontaneous abortion Its further divided into : a) Threatened b) inevitable. c ) complete. d ) incomplete. e ) missed. f ) septic. ( Less common) 2). Induced abortion its further divided into: a) Legal b) un- legal
- 5. SPONTANEOUS ABORTION ETIOLOGY OF SPONTANEOUS ABORTION : Genetic factors : ▪ majority of early miscarriage are due to chromosomal abnormality in the conceptus. ▪ In this include autosomal trisomy( is the commonest 50%) , polyploidy (is about 22%), monosomy(is 20%) , structure chromosomal rearrangement(are observed 2-4%) , other chromosomal abnormalities (mosaic , double trisomy ) about 4%. Endocrine and metabolic factors ▪ It is about 10-15% luteal phase defect result in early miscarriage as implantationand placentationare not supported adequately. ▪ Deficient progesterone secretionfrom corpus luteum or poor endometrial response to progesterone is the causes. ▪ Thyroid abnormalities hypothyroidism or hyperthyroidism are associated with increased fetal loss ▪ Diabetes mellitus when poorly controlled causes increased miscarriages.
- 6. SPONTANEOUS ABORTION Anatomical and metabolic factors ▪ Cervico-uterine factor (these are related to second trimester abortion) ➢ Cervical incompetence (congenital or acquired) ➢ Congenital malformation of the uterus: (causes of fetal loss): i. Reduce intra uterine volume ii. Reduce expansile property of the uterus iii. Reduce placental vascularity when implanted on the septum iv. Increase uterine irritability and contractility ➢ Uterine fibroid ➢ Intrauterine adhesion
- 7. SPONTANEOUS ABORTION Infections: ▪ Are the accepted causes of late as well as early abortions. ▪ Transplacental fetal infections occur with micro organisms ▪ Viral rubella , cytomegalo , variola , vaccinia or HIV. ▪ Parasitic: toxoplasma , malaria ▪ Bacterial : ureaplasma , chlamydia , Brucella , ▪ Spirochetes: hardly caused abortion before 20th weeks because of effective thickness of placental barrier. ➢ Immunological disorder (5-10%) ▪ Autoimmune disease ( anti bodies responsible are ANAs, LAC , aCL ▪ Alloimmune disease (antigen HLA)
- 8. SPONTANEOUS ABORTION Other etiologies are: ▪ Maternal medical illness ▪ Blood group incompatibility ▪ Premature rupture of the membrane ▪ Paternal factors ▪ Inherited thrombophilia ▪ Environmental factor (cigarette smoking , alcohol , drugs chemicals , And 40- 60 % unexplained abortion CAUSES OF ABORTION ▪ FIRST TRIMESTER: ▪ 1). genetic factor(50%), 2). endocrine disorder (LPD, thyroid abnormalities , diabetes). 3). Immunological disorder (autoimmune and Alloimmune). 4). Infection 5). Unexplained.
- 9. SPONTANEOUS ABORTION ▪ SECOND TRIMESTER: ▪ 1). Anatomic abnormalities a). Cervical incompetence (congenital or acquired). b). Mullerian fusion defects (bicornuate uterus , septate uterus ). c ). Uterine synechiae d). Uterine fibroid. 2). Maternal medical illness 3). Unexplained. MECHANISM OF ABORTION: ▪ IN the early weeks, death of the ovum occurs first , followed by its expulsion ▪ in the later weeks , maternal environmental factor are involved to leading the expulsion of the fetus ▪
- 10. SPONTANEOUS ABORTION . ▪ Before 8 weeks: the ovum , surrounded by the villi with decidual coverings, is expelled out intact. Some time the external os fails to dilate so that the entire mass is accommodated in the dilated cervical canal and is called cervical abortion. ➢ 8-14 weeks: expulsion of the fetus commonly occurs leaving behind the placenta and membranes . A part of it may be partially separated with brisk haemorrhage or remains totally attached to the uterine wall ➢ Beyond 14 weeks: the process of expulsion is similar to that of a” mini labour”. the fetus is expelled first followed by expulsion of a the placenta after a varying interval
- 11. THREATENED ABORTION DEFINITION: it is a clinical entitywere the process of abortion has started but has not progressed to a state from which recovery is impossible. CLINICAL FEATURE: 1)BLEEDING PER VAGINAM: the bleeding is usually slight and bright red in colour. ▪ on rare cases the bleedingmay be brisk and sharp , specially in the late second trimester, suggestive of low implantationof placenta. ▪ The bleeding usually stop spontaneously. 2) PAIN: bleeding is usually painless but there may be mild backache or dull pain in lower abdomen ➢ PELVIC EXAMINATION : should be done as genteelly as possible ▪ Speculum examination reveals : bleeding if any thing escape through the external os. ▪ Any local lesion in the cervixmay co exist.
- 12. Threatened abortion DIGITAL EXAMINATION: reveal the closed external os. ▪ the uterine size corresponds to the period of amenorrhea. ▪ The uterus and cervix feelshort. ▪ Pelvicexamination is avoided when ultrasonography is available. ➢ INVESTIGATION: routine checkup blood test HB , hematocrit , ABO , Rh grouping. and urine test. ▪ ultrasonography (TVS): check wellformed gestation ring for indicating healthy fetus. ▪ Observationof fetal cardiac motion withthis 98 % chance for continuation of pregnancy. ▪ A blighted ovum is evidenced by loss of definition of gestation sac , smaller mean gestational sac diameter , absent fetal echoes and absent fetal cardiac movement. ▪ Serum progesterone value 25 ng / ml more generally indicates a variablepregnancy in about 95%. ▪ Serum hCG levelis helpful to assess the fetal well being normally hCG should b double by every 48 hours.
- 13. Threatened abortion TREATMENT: ▪ patient should be in bed for few days until bleeding stop. ▪ Drugs: phenobarbitone 30mg or diazepam 5 mg twice a daily for sedation and relief pain. ADVICE ON DISCHARGE: the patient should limit her activities for at least two weeks and avoid heavy work.
- 14. INEVITABLE ABORTION DEFINATION: it is a clinical type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible. ➢ Clinical feature: increase vaginal bleeding ▪ Aggravation of pain in lower abdomen which may be colicky in nature. ▪ The general condition of the patient is proportionate to visible blood loss. ▪ On Internal examination dilated cervical os ▪ On second trimester it may start with rupture of membranes or lower abdominal pain ( mini labour) ➢ Management: ▪ To take appropriate measures to look after the general condition. ▪ To accelerate the process of expulsion ▪ To maintain strict asepsis as outlined in conduction of labour.
- 15. INEVITABLE ABORTION Give methergin 0.2mg in excessive bleeding . The shock is corrected by intravenousfluid therapy and blood transfusion. Active therapy: before 12 weeksdilation and evacuation followed by curettage of uterine cavity by blunt curette under general anesthesia. Alternatively suction evacuation followed by curettage . After 12 weeks: ▪ 1). the uterine contraction is accelerated by oxytocindrip (10 units) in 500 ml of normal saline40 to 60 drops per minute. ▪ If the fetus is expelledand placenta is retained it is remove by ovum forceps if lying separately. ▪ If the placenta is not separated ,digital separation by its evacuationis to be done under general anesthesia . ▪ 2). If bleeding is profuse with the cervixclosed (suggestiveof low implantation of placenta)- evacuationof the uterus may have to be done by abdominal hysterotomy.
- 16. COMPLETE ABORTION DEFINATION: when the products of conception are expelled completely. Clinical feature: there is a history of a fleshy mass per virginal. ▪ Subsidence of abdominal pain ▪ Vaginal bleeding becomes trace or absent ▪ Internal examinationuterus is smaller than the period of amenorrhea and a little firmer, Cervical os is closed , bleeding is trace. ▪ Examination of expelled fleshy mass is found intact. ➢ Management: the effect of blood loss , if any should be assessed and treated . ▪ if there is doubt about completeexpulsion of products , uterine curettage should be done. ▪ Transvaginal sonography is useful to prevent unnecessary surgical procedure. ▪ Anti-D gamma globulin 50 microgram or 100 mg IV in case of Rh negative women late and early abortion in both case within 72 hour.
- 17. INCOMPLETE ABORTION DEFINATION : when the entire product of conception are not expelled completely instead a part of it is left inside the uterine cavity. This is a commonest type of abortion in which women hospitalized . Clinical feature: continuation of pain lower abdomen , colicky in nature. ▪ persistence of vaginal bleeding . ▪ On examination uterus smaller than the period of amenorrhea , patulous cervical os often admitting tip of finger , varying amount of bleeding and on examination the expelled mass is found incomplete. ➢ Management: the same process are to be followed like that of inevitable abortion. ➢ Early abortion: dilation and evacuation under general anesthesia is to be done. ➢ Late abortion: the uterus is evacuated under general anesthesia and product are removed by ovum forceps or by blunt curette.
- 18. MISSED ABORTION (silent miscarriage) DEFINATION: when the fetus is dead and retained inside the uterus for variable period. Pathology: ▪ carneous mole (blood mole or fleshy mole) it is the pathological variant of missed abortion affecting the fetus before12 weeks. ▪ Small repeated haemorrhages in the choriodecidual space disrupt the villi from its attachment. ▪ The bleeding is slight so it does not cause rupture of the decidua capsularis . ▪ The clotted blood with the contained ovum is known as blood mole. ▪ By this time; the ovum becomes dead and either completely absorbed or remains as a rudimentary structure. ▪ Gradually the fluid portion of the blood surrounding the ovum gets absorbed and the wall becomes fleshy hence the term fleshy or carneous mole.
- 19. MISSED ABORTION (silent miscarriage) Clinical feature: ▪ Persistence Brownish vaginal discharge. ▪ Subsidence of pregnancy symptoms. ▪ Retrogression of breast changes. ▪ Cessation of uterine growth which in fact becomes smaller in size. ▪ Non audibility of the fetal heart sound even with doppler cardioscope. ▪ Cervix feels firm ▪ Immunological test for pregnancy becomes negative. ▪ Real time ultrasonography reveals an empty sac early in pregnancy or absence of fetal motion or fetal heart movement.
- 20. MISSED ABORTION (silent miscarriage) ➢ Management: ▪ Uterus is less than 12 weeks : vaginal evacuation can be carried out without delay. ▪ This can be effectively done by suction evacuation or slow dilation of cervix by laminaria tent followed by dilation and evacuation (D&E) of uterus under general anesthesia. ▪ The risk of damage to the uterine walls and brisk hemorrhage during the operation should be kept in mind. ▪ Uterus more than 12 weeks: induction is done by following methods ▪ ___ oxytocin - to start with 10-20 units of oxytocin in 500 ml of normal saline at 30 drops per minute. ▪ ____ prostaglandins –are more effective than oxytocin in such cases a. prostaglandin E1 analogue (misoprostol) 200 micro gram tablet is inserted into posterior vaginal fornix every 4 hours for maximum of 5 such.
- 21. SEPTIC ABORTION DEFINATION : any abortion associated withclinical evidences of infection of the uterus and its contents is called septic abortion. ▪ Rise of temp at least 100.4 ▪ Offensive or purulent vaginal discharge ▪ Other lower abdomen pain and tenderness ➢ Mode of infection : ▪ the micro organism involved in sepsis are usually those normally present in vagina ▪ Micro organism are anaerobic or aerobic ➢ Pathology: ▪ in majority 80 % the organisms are of endogenous origin and the infection is localized to the conceptus without any myometrial involvement. ▪ About 15 % the infection either produces localized endometritis surrounded by leukocytic barrier, and spread to parametrium , tubes , ovaries, or pelvic peritoneum. ▪ In about 5% there is generalized peritonitisand endotoxicshock.
- 22. SEPTIC ABORTION ➢ Clinical feature: ▪ Pyrexia (chills and rigors suggested blood stream infection it is feature of endotoxic shock) ▪ Pain abdomen ▪ A rising pulse rate( 100 -120/ mint it indicate infection spread to beyond the uterus) ▪ Variable systemic and abdominal finding ▪ On internal examination (reveals offensive purulent vaginal discharge or tender uterus) ➢ Clinical grading: ➢ Grade1: the infection is localized in the uterus ▪ Grade 11 :the infection spread beyond the uterus to the parametrium , tubes , ovaries and pelvic peritoneum. ▪ Grade 111: generalized peritonitis and endotoxic shock or jaundice or acute renal failure.
- 23. SEPTIC ABORTION Investigation: ▪ Cervical or high vaginal swab is taken for culture ,sensitivity and smear. ▪ Blood of hemoglobin , count of white blood cell , ABO and Rh grouping. ▪ Urine analysis . ▪ Special investigation ultrasonography , blood for culture serum electrolytes , coagulation profile. ➢ Complications : ▪ Most of fetal complication are associated with illegally induced abortion of grade 3. ▪ Hemorrhage ▪ Injury ▪ Spread of infection (generalized peritonitis , endotoxicshock , acute renal failure, thrombophlebitis.
- 24. SEPTIC ABORTION Management: General management : ▪ Hospitalization. ▪ To take high vaginal or cervical swab for culture or gram staining. ▪ Vaginal examination ▪ Over all assessment of the case is to be done and the patient is levelled in accordance with clinical grading . ▪ Investigation protocols ➢ Principal of management are : to control sepsis , to remove the sources of infection . ➢ To give supportive therapy to bring back the normal homeostatic and cellular metabolism. , ➢ To assess the response of treatment.
- 25. SEPTIC ABORTION Treatment: GRADE I : ▪ Antibiotics , prophylactic anti gas –gangrene serum 8000 unit and 3000 units of anti tetanus serum intramuscular. ▪ And analgesics and sedatives ▪ And blood transfusion to improve anemia and body resistance. ▪ Evocation of the uterus if abortion is incomplete. ➢ GRADE II: ▪ Drugs antibiotics : for gram positive penicillin G5 million units IV every 6 hours. ▪ Ampicillin 0.5 -1 gm IV every 6 hours . ▪ For gram negative gentamicin 1.5 mg / kg IV every 8 hours and ceftriaxone IG IV every 12 hours ▪ For anaerobes metronidazole 500mg IV every 8 hours or clindamycin 600mg IV every 6 hours
- 26. SEPTIC ABORTION Surgery. 1). Evacuationof the uterus 2). Posteriorcolpotomy ( when the infection localized in the pouch of Douglas pelvic abscess formed ) GRADE. III : ▪ Antibiotics discuss above ▪ Active Surgery indication ▪ 1). Injury to the uterus 2). Suspected injury to the bowel 3). Presence of the foreign body in the abdomen as evidence by the sonography. ▪ Unresponsive peritonitis suggestive of collectionof pus. ▪ Septic shock or oliguria ▪ Uterus too big to be safely evacuated pervaginum. ▪ Lapartomy: it should be done by experienced surgeon with a skilled anesthetist. ▪ Removal of the uterus should be done irrespective of parity. ▪ Adnexa is to be removedor preserved according to pathology found.