1. PREGNANCY INTERRUPTING N. Bahnij

2. Pregnancy interrupting – spontaneous preterm interrupting of pregnancy:
To 12 weeks of pregnancy – early spontaneous abortion
13-22 weeks – late spontaneous abortion
days– preterm labor

3. Causes of spontaneous abortions
Maternal
Infections – Listeria, Mycoplasma hominis, Ureaplasma urealyticum, Toxoplasmosis,Rubella, Cytomegalovirus.
Endocrine factors - luteal phase inadequacy, HyperthyroidismDiabetes Mellitus
Environmental factors
Uterine abnormalities
2. Paternal - chromosomal abnormality in either parent.
3. Fetal - genetic abnormalities of the conceptus, approximately half of which are autosomal trisomies.

4. Classification of abortions
Spontaneous
Induced
Clinically:
Threatened
Initial
Inevitable
Completed
Incomplete
Missed

5. Threatened abortion Signs – lover abdominal pain.
In bimanual examination – cervix is closed, enlargement of the uterus corresponds with gestational period
Management – conservative.

6. Initial abortion
Signs – lover abdominal pain, bloody vaginal discharge.
In bimanual examination – cervix is closed, enlargement of the uterus corresponds with gestational period
Management – conservative.

7. Inevitable abortion
Signs – cramp abdominal pain thanks to uterine contractions, bloody vaginal discharge till profuse hemorrhage.
In bimanual examination – cervix is dilated, products of conception are presented on cervical channel, enlargement of the uterus doesn’t correspond with gestational period – smaller
Management –surgical – uterine curettage.

8. Incomplete abortion – retention of some conceptus inside the uterus
Signs – lover abdominal pain, bloody vaginal discharge. In bimanual examination – cervix is dilated, enlargement of the uterus doesn’t correspond with gestational period – smaller, some products of conception should be expelled out. Management–uterine curettage

9. Complete abortion – all products of conception are expelled out of uterus
Signs - lover abdominal pain, bloody vaginal discharge.
In bimanual examination – cervix is dilated or closed, enlargement of the uterus doesn’t correspond with gestational period – smaller.
Management–uterine curettage

10. Conservative treatment in the case of threatened and initial abortion
Bed rest
Sedative drugs
Spasmolitics – No-Spani, Papaverini hydrochloride
Analgetics – Analgin, Baralgin
Progesterone – Utrogestan, Duphastone,Endomerin
Chorionic Gonadotropin Hormone
Vitamines – vit. E
Hemostatics – Tranexamic acid

11. Stages of uterine curettage
Anesthesia - paracervical block or general.
Bimanual examination
Disinfection of perineal region
Speculum insertion
Grasping the cervix for anterior lip with a toothed tenaculum.
Uterine probing- to identify the status of the internal os and to confirm uterine size and position.
Dilation of the cervix by Hehar’s dilators
Uterine curettage by sharp curette

12. Conservative treatment in the case of threatened and initial abortion in late terms (after 16 weeks)
Bed rest
Sedative drugs – Valeriannae, Persen, Novopaside.
Tokolotic agents: Magnesii sulfatis 40 ml 25 % in 400 ml isotonic solution, b2- adrenomimetics (2 ml ginipral in 500 ml isotonic solution).
Progesterone – Utrogestan – 100 mg twice a day, Duphastone – 10 mg 2-3 times a day, Endometrin
Spasmolitics – No-Spani, Papaverini hydrochloride

13. Cervical incompetence
Premature effacement (shortening of the vaginal portion of the cervix and thinning of the walls) and dilation of the cervix
The dilation results in the amniotic membranes bulging through the opening and eventually rupturing, often before the baby can survive outside of the uterus. This irritates the uterus and brings on pregnancy interrupting.

14. Diagnosis of Cervical Incompetence
Diagnosis is made by:
medical history,
physical exam,
and ultrasound study.

15. Ultrasound findings
Funneling of the cervix with the changes in forms T, Y, V, U (correlation between the length of the cervix and the changes in the cervical internal os).
Cervix length < 25 mm
Internal cervical os more than 10 mm
Protrusion of the membranes.
Presence of fetal parts in the cervix or vagina.

16. Funneling of the cervix with the changes in forms T, Y, V, U

18. A Shirodkar suture using Merselene tape at the level of the internal os is the treatment available.

19. McDonald suture with #4 mersilk at the level of the internal os

20. Preterm labor - is the term used to define infants who are born between and 36+6 weeks of gestation with the weight 500 – 2500 gram and length cm

21. Classification Threatened preterm labor Initial preterm labor
Inevitable preterm labor

22. Signs and Symptoms of Preterm Labor
Threatened preterm labor is characterized by:
symptoms of pelvic pressure, low back pain;
increase uterine tone;
absence of cervical effacement and dilation in vaginal examination.
Initial preterm labor is characterized by:
irregular crampy – like painful uterine contractions;
presence of cervical effacement and dilation of the cervix till 3-4 cm in vaginal examination;
amniotic fluid gush is present very often.
Inevitable preterm labor is characterized by:
regular uterine contractions;
cervical dilation more than 3-4 cm.

23. Management of preterm labor
1. Expectant Management - nonintervention or expectant management, in which nothing is done and spontaneous labor is simply awaited
2. Active Management - intervention that may include corticosteroids, given with or without tocolytic agents to arrest preterm labor in order that the corticosteroids have sufficient time to induce fetal maturation.

24. Indications for expectant management:
threatened and initial preterm labor;
intact membranes;
gestational age of pregnancy till 36 weeks of gestation;
satisfactory maternal and fetal conditions;
cervical dilation till 2-4 cm;
absence of infection, regular uterine contractions, serious obstetric and extragenital pathology.
28-34 weeks of pregnancy with preterm ruptured membranes, absence of regular uterine contractions and infection.
28-34 weeks of gestation, intact membranes, 100 % cervical effacement and cervical dilation till 3-4 cm.

25. Expectant Management of Preterm labor in the case of Ruptured amniotic membranes:
1. Ultrasound examination is performed to help confirm gestational age, and assess amniotic fluid volume. Continuous fetal heart rate General blood analysis – twice a day determination of leucocytes number, urine, vaginal smear, bacteriological examination once a 5 days.
2. To 34 weeks of pregnancy for hours Inhibiting preterm labor drugs are prescribed:
3. From 24-to 34 weeks: Accelerated Maturation of Pulmonary Function –
4. Group B-streptococcal infection prevention is recommended: Ampicillin 2g i/v initial dose than 1g i/v every 4 hours till delivery,or Cefazolin 2g i/v initial dose than 1g i/v every 8 hours till delivery,or Erythtomycin 500 mg i/v every 4 hours till delivery

26. Indications for active management:
preterm ruptured membranes;
regular uterine contractions;
presence of infection;
fetal jeopardy, hypoxia;
severe maternal diseases;
birth defects of the fetus;
obstetric complications of pregnancy (severe pregnancy induced hypertension, polyhydramnios).
Vaginal delivery is indicated in cephalic presentations, cesarean section is performed in the case of breech presentation and transverse lie.

27. Expectant Management of Preterm labor in the case of Intact amniotic membranes:
For tokolysis: - b-adrenergic inhibitors 2 ml Ginipral is dissolved in 500 ml isotonic solution with the rate 10 drops per minute,
Niphedipine 10 mg every 15 min – 40 mg
Magnesium sulfate – 20 ml 0.25 %in 200 ml isotonic solution

28. Accelerated Maturation of Pulmonary Function
betamethasone (12 mg intramuscularly in two doses 24 hours apart) to prevent respiratory distress in the subsequently delivered preterm infant.
dexamethasone, 6 mg intramuscularly every 12 hours mg all dose between 22 and 34 weeks.
Repeated dose of hormones is not indicated.

29. Intrapartum Management
Labor. Whether labor is induced or spontaneous, abnormalities of fetal heart rate and uterine contractions should be sought, preferably by continuous electronic monitoring.
Delivery.
Perineal protective maneuvers don’t apply.

30. Prevention of pregnancy interrupting in high risk patients !