1. HAEMORRHAGE IN EARLY PREGNANCY

2. CAUSES OF BLEEDING Those related to the pregnant state Abortion
Ectopic pregnancy
Hydatidiform mole
Implantation bleeding
Those associated with the pregnant state
Cervical lesions

3. ABORTION

4. Normal Implantation

5. DEFINITION
Termination of pregnancy before 20 weeks gestation calculated from date of onset of last menses
Early Abortion: before 12 weeks
Late Abortion: from weeks
Delivery of a fetus of weight less than 500 grams

6. INCIDENCE: About 10-20% of hospital pregnancy 10% Illegal
75% occur before 16wks

7. CLASSIFICATION OF ABORTION
SPONTANEOUS
INDUSED
ISOLATED
RECURRENT
Threatened
Inevitable
Complete
Incomplete
Missed
Septic
Legal
Illegal/ Criminal

8. ETIOLOGY: 1.OVULAR OR FETAL FACTORS(GENETIC FACTORS)
a) OVO-FETAL FACTORS
Chromosomal abnormality
Gross congenital malformation
Blighted ovum
Hydropic degeneration of villi
Death or Disease of fetus

9. OVULAR OR FETAL FACTORS(GENETIC FACTORS)…..Contd
b) INTERFERENCE WITH CIRCULATION
Knots
Twists
Entanglements
c) LOW ATTACHMENT OF PLACENTA
d) TWINS OR HYDRAMNIOS.

10. ETIOLOGY…..Contd 2. MATERNAL FACTORS Maternal illness Infection Trauma
Maternal hypoxia
Chronic illness
Endocrine factors
Trauma
Direct
Psychic
Susceptible individual
Amniocentesis
Toxic agents

11. MATERNAL FACTORS……Contd
Cervico-uterine factors
Cervical incompetence
Congenital malformation of uterus
Uterine tumour
Retroverted uterus
Immunological
Autoimmune disease
Alloimmune disease
Antifetal antibodies
Blood group incompatibility
Premature rupture of membranes
Dietetic factors

12. ETIOLOGY…..Contd
3.PATERNAL FACTORS 4. UNKNOWN

13. Mechanism of Abortion Before 8 wks
Ovum surrounded by the villi with decidual covering is expelled out intact
External os fails to dilate
Entire mass is accomadated in the dialated cervical canal
Also called as cervical miscarriage
8-14 wks
Expulsion of fetus leaving placenta & membranes
Beyond 14th wks
Like mini labour

14. SPONTANEOUS ABORTION
DEFINITION It is defined as the involuntary loss of the products of conception prior to 20 weeks of gestation. INCIDENCE 15% of all confirmed pregnancy 80% occur in first trimester

15. THREATENED ABORTION

16. DEFINITION
It is a clinical entity where the process of miscarriage has started and not progressed to a state from which recovery is impossible

17. CLINICAL FEATURES BLEEDING PER VAGINAM Slight bleeding
Brownish or bright red in colour
Rarely brisk and sharp bleeding specially in the second trimester
PAIN
Mild backache or dull pain in the lower abdomen

18. PELVIC EXAMINATION
Speculum examination – Bleeding escapes through the closed external os
Digital examination – Closed external os
Uterine size corresponds to the period of amenorrhoea
Uterus and cervix feels soft

19. INVESTIGATIONS
BLOOD
URINE
USG

20. TREATMENT BED REST DRUG
Sedation and relief of pain – Phenobarbitone 30mg or diazepam 5mg
Enema should not be given

21. GENERAL MEASURES Advice to preserve vulval pads
Report pain/bleeding if aggravated
Routine note of TPR,Bp and vaginal bleeding

22. ADVICE ON DISCHARGE Limit her activities for two week
Avoid heavy work, strenuous exercise and excitement
Coitus is contraindicated

23. INEVITABLE ABORTION

24. DEFINITION
It is the clinical type of abortion where the changes have progressed to the state where continuation of pregnancy is impossible

25. CLINICAL FEATURES Increased vaginal bleeding
Aggravation of pain in the lower abdomen
Pain may be colicky in nature
Dilated internal os of cervix through which the products of conception are felt
May starts with rupture of membranes or intermittent lower abdominal pain

26. MANAGEMENT AIM To accelerate the process of expulsion
To maintain strict asepsis
GENERAL MEASURES
Methergin 0.2mg
IV fluid
Blood transfusion
ACTIVE TREATMENT
Before 12weeks
D/E followed by blunt curette
S/E followed by curettage
After 12weeks
Uterine contraction accelerated by oxytocin
Placenta if seperated and retained removed with ovum forceps
If placenta is not seperated,digital seperation followed by evacuation

27. COMPLETE ABORTION

28. DEFINITION
When the products of conception are expelled en masse,it is called complete miscarriage

29. CLINICAL FEATURES Subsidence of abdominal pain
Vaginal bleeding becomes trace or absent
INTERNAL EXAMINATION
Uterus is smaller than the period of amenorrhoea and little firmer
Cervical os is closed
Bleeding is trace
Expelled mass is found complete

30. MANAGEMENT S/E or curettage if uterine cavity is not empty
Rh negative women – Anti D gamma globulin

31. INCOMPLETE ABORTION

32. DEFINITION
When the entire products of conception are not expelled, instead a part of it is left inside the uterine cavity, it is called as incomplete miscarriage

33. CLINICAL FEATURES Continuation of pain lower abdomen
Persistence of vaginal bleeding
INTERNAL EXAMINATION
Uterus smaller than the period of amenorrhoea
Patulous cervical os often admitting the tip of the finger
Varying amount of bleeding
Expelled mass is found incomplete

34. COMPLICATIONS
Profuse bleeding
Sepsis
Placental polyp

35. MANAGEMENT IN RECENT CASES
Evacuation of the retained products of conception(ERCP)
She should be resuscitated before any active treatment
EARLY ABORTION
D/E under analgesia or GA
LATE ABORTION
Uterus is evacuated
Products are removed by ovum forceps or blunt curette

36. MEDICAL MANAGEMENT
Tablet Misoprostol 200µg vaginally every 4 hours

37. MISSED MISCARRIAGE

38. DEFINITION
When the fetus is dead and retained inside the uterus for a variable period it is called missed miscarriage or early fetal demise

39. PATHOLOGY….BEYOND 12 WEEK
Baby is dead
Become macerated
Liquor amnii gets absorbed
Placenta becomes pale,thin and adherent

40. PATHOLOGY….BEFORE 12 WEEK
CARNEOUS MOLE
Small hemorrhages in the choriodecidual space
Disrupt the villi from its attachment
Bleeding is slight, it does not rupture the decidua capsularis
Clotted blood remain within the ovum
BLOOD MOLE
Ovum is dead
Fluid portion of the blood gets absorbed and walls become fleshy
FLESHY OR CARNACEOUS MOLE

41. CLINICAL FEATURES Persistence of brownish vaginal discharge
Subsidence of pregnancy symptoms
Retrogression of breast changes
Cessation of uterine growth
Non audible FHS
Cervix feels firm
Immunological test of pregnancy becomes negative
USG – empty sac,absence of fetal motion or fetal cardiac movement

42. COMPLICATION Psychological upset Infection Blood coagulation disorders
During labour
Uterine inertia
Retained Placenta
PPH

43. MANAGEMENT
EXPECTANT
MEDICAL
SURGICAL

44. MANAGEMENT….UTERUS LESS THAN 12 WEEKS
EXPECTANT
Expel the conceptus spontaneously
MEDICAL
PG E1(Misoprostol) 800mg vaginally
Repeated after 24 hours
Expulsion occur within 48 hours
SURGICAL
S/E
D/E

45. MANAGEMENT….UTERUS MORE THAN 12 WEEKS
PROSTAGLANDIN E1 (MISOPROSTOL)
200 µg
Vaginally in the posterior fornix
Every 4hours for a maximum of 5
OXYTOCIN
ERPC
D/E

46. SEPTIC MISCARRIAGE

47. DEFINITION
Any abortion which is associated with clinical evidences of infection of the uterus and its contents is called septic abortion

48. CLINICAL FEATURE Pyrexia with chills and rigor Pain abdomen
A rising pulse rate of /min
Variable systemic and abdominal findings
INTERNAL EXAMINATION
Purulent vaginal discharge
Tender uterus
Patulous os or boggy feel of the uterus

49. CLINICAL GRADING GRADE I Infection is localised in the uterus GRADE II
Infection spreads beyond the uterus
GRADE III
Peritonitis,endotoxic, shock,jaundice,acute renal failure

50. INVESTIGATION
Cervical or high vaginal swab taken prior to internal examination
Blood for hemoglobin
Urine analysis
SPECIAL INVESTIGATION
USG
X-ray
Blood – culture, coagulation profile and S.Electrolyte

51. COMPLICATIONS IMMEDIATE Haemorrhage Injury Spread of infection
Generalised peritonitis
Endotoxic shock
Acute renal failure
Thrombophlebitis
REMOTE
Chronic debility
Chronic pelvic pain
Dyspareunia
Ectopic pregnancy
Secondary infertility

52. MANAGEMENT GENERAL MANAGEMENT Hospitalisation
To take high vaginal or cervical swab
Vaginal examination
Overall assessment of the case
Investigation protocol
Formulate line of treatment
AIM
To control sepsis
To remove source of infection
To give supportive therapy
To remain vigilant

53. MANAGEMENT…….Contd GRADE I Antibiotic
Prophylactic anti gas – gangrene serum of units - IM
Antitetanus serum 3000 units – IM
Analgesics and sedatives
Blood transfusion
Evacuation of the uterus

54. MANAGEMENT…….Contd GRADE II Antibiotic
Clinical monitoring – TPR,urine output, progress of pain, tenderness and mass in the lower abdomen
Evacuation of the uterus
Posterior colpotomy

55. MANAGEMENT…….Contd GRADE III Antibiotic Clinical monitoring
Supportive therapy
Management of Endotoxic shock and renal failure

56. RECURRENT MISCARRIAGE

57. DEFINITION
Recurrent miscarriage is defined as three or more consecutive spontaneous miscarriage

58. ETIOLOGY FIRST TRIMESTER ABORTION Genetics Endocrinal
Poorly controlled diabetic
Presence of thyroid autoantibodies
Inadequate leuteal phase
PCOD
Infection
Immunological causes
Autoimmunity
Alloimmunity
Idiopathic

59. SECOND TRIMESTER ABORTION CAUSES
CERVICAL INCOMPETENCE
DIAGNOSIS
History
Internal examination
INVESTIGATION
Passage of No 6-8 Hegar dilator
Pre menstrual hystero- cervicography
USG

60. SECOND TRIMESTER ABORTION CAUSES…Contd
UTERINE SYNECHAE UTERINE FIBROID RETROVERTED UTERUS CHRONIC MATERNAL ILLNESS INFECTION IDIOPATHIC

61. INVESTIGATION Blood glucose TFT ABO and Rh Toxoplasma antibodies
Serum LH
USG
Hysterosalpinography
Hysteroscopy or laproscopy
Karyotyping
Endocervical swab

62. TREATMENT INTERCONCEPTIONAL PERIOD Alleviate anxiety
To correct uterine pathology
Genetic counselling
Treat PCOS
Treat endocrine dysfunction

63. TREATMENT DURING PREGNANCY Reassurance and tender loving care USG Rest
Avoid strenuous activities, intercourse and travelling
Progesterone and HCG
Aspirin,Prednisolone and heparin injection
Circlage operation
Alloimmunity husbands leukocyte injectios