TYPES OF ABORTION part 2 IN ENGLISH
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Types of Abortions PART 2
Missed abortion-
When the fetus is dead and retained inside the uterus for a variable
period, it is called missed miscarriage. The causes of prolonged retention of
the dead fetus in the uterus are not clear. Beyond 12 weeks, the retained fetus
becomes macerated or mummified. The liquor amnii gets absorbed and the placenta
becomes pale, thin and may be adherent.
Clinical manifestations-
The patient usually presents with features of threatened miscarriage
followed by:
(1) Persistence of brownish vaginal discharge.
(2) Disappearance of pregnancy symptoms
(3)Retrogression of breast changes.
(4) Cessation of uterine growth which in fact becomes smaller in size.
(5) Non-audibility of the fetal heart sound even with Doppler ultrasound
if it had been audible before.
(6) On PV examination cervix feels firm
(7) Immunological test for pregnancy becomes negative.
Management-
If pregnancy is less than 12 weeks: (i)
Medical
Management includes insertion of Prostaglandin E1 (misoprostol) 800 mg
vaginally in the posterior fornix and repeated after 24 hours if needed.
Expulsion usually occurs within 48 hours.
(ii) Suction evacuation or dilatation and evacuation is done either as a
definitive treatment or it can be done when the medical method fails
If pregnancy is more than 12 weeks:
(a) Prostaglandin E1 analog (misoprostol) 200 μg tablet is inserted into
the posterior vaginal fornix every 4 hours for a maximum of 5 times.
(b) Oxytocin—10–20 units of oxytocin in 500 mL of normal saline at 30
drops/min is started. If fails, escalating dose of oxytocin to the maximum of
200 mlU/min may be used with monitoring.
(c) Many patients need surgical evacuation following medical treatment
after ultrasonography.
(d) Dilatation and evacuation is done once the cervix becomes soft with
use of PGE1. Otherwise cervical canal is dilated using the mechanical dilators
or by laminaria tent. eacuation of the uterine cavity is done thereafter
slowly.
Septic
Abotion-
Any abortion associated with clinical evidences of infection of the
uterus and its contents is called septic abortion. It is considered septic
abortion when there are: (1) rise of
temperature of at least 100.4°F (38°C) for 24 hours or more, (2) offensive
orpurulent vaginal discharge and (3) other evidences of pelvic infection such
as lower abdominal pain and tenderness.
Causes and Risk factors-
Main factor causing septic abortion is unsafe abortion technique by
unqualified and unauthorized person. While the majority of cases, the
infection occurs following illegal induced abortion but infection can occur
even after spontaneous abortion. by the
sepsis are usually those normally present in the vagina (endogenous). The
microorganisms are:-
(a)
Anaerobic—Bacteroides group (fragilis),
anaerobic Streptococci, Clostridium welchii and tetanus bacillus.
(b)
Aerobic—Escherichia coli (E.
coli), Klebsiella, Staphylococcus, Pseudomonas and group A
beta-hemolytic Streptococcus (usually exogenous), methicillin-resistant
Staphylococcus aureus
Clinical manifestations-
Depending upon the severity the clinical picture varies widely. These
includes-
•
„„The woman looks sick and
anxious
•
„„Temperature: >38°C
•
„„Chills and rigors
(suggest-bacteremia)
•
„„Persistent tachycardia ≥
90 bpm (spreading infection)
•
„„Hypothermia (if in
shock) < 36°C
•
„„Abdominal or chest pain
•
Tachypnea
(RR) > 20/min
•
„„Impaired mental state
•
„„Diarrhea and/or vomiting
•
„„Renal angle tenderness
Diagnostic Investigations-
(1) Cervical or high vaginal swab is taken prior to internal examination
for—
(a)
culture
in aerobic and anaerobic media to find out the dominant microorganisms,
(b)
sensitivity of the microorganisms to
antibiotics and
(c)
smear for Gram stain.
(2) Blood for hemoglobin
estimation, total and differential count of white cells, ABO and Rh grouping.
(3) Urine analysis including culture.
(4) Ultrasonography of pelvis and abdomen to detect intrauterine retained
products of conception
(5) Blood culture
(6) Serum electrolytes
Cinical Grading-
Septic abortions are of three types as per severity-
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.
Management-
In case of Grade I:
(1)Broad spectrum Antibiotics to
control infection.
(2) Prophylactic anti gas gangrene serum of 8,000 units and 3,000 units
of anti tetanus serum
intramuscularly are given if there is a history of unsafe abortion.
(3) Analgesics and sedatives as per need.
(4)Blood transfusion is given to improve anemia and body
resistance.
(5)Evacuation of the uterus: As abortion is often incomplete, evacuation should be performed at a
convenient time within 24 hours following antibiotic therapy.
In case of Grade II:
(1)Broad spectrum Antibiotics to
control infection. Empirical therapy is started first and is changed when
culture sensitivity report is available including Piperacillin-tazobactam and
carbapenems:.
(2) Prophylactic anti gas gangrene serum of 8,000 units and 3,000 units
of anti tetanus serum intramuscularly are given if there is a history of unsafe
abortion.
(3) Analgesics and sedatives as
per need.
(4)Blood transfusion is given to improve anemia and body resistance.
(5) Evacuation of the uterus—Evacuation should be withheld for at least
48 hours when the infection is controlled and is localized, the only exception
being excessive bleeding.
In case of Grade III:
(1) Clinical monitoring: To note pulse, respiration, temperature,
urinary output and progress of the pain, tenderness and mass in lower abdomen.
(2) Broad spectrum Antibiotics to
control infection. Empirical therapy is started first and is changed when
culture sensitivity report is available including Piperacillin-tazobactam and
carbapenems.
(3) Prophylactic anti gas gangrene serum of 8,000 units and 3,000 units
of anti tetanus serum intramuscularly are given if there is a history of unsafe
abortion.
(4) Supportive therapy is directed to treat generalized peritonitis by
gastric suction and intravenous crystalloids infusion. Management of endotoxic
shock or renal failure.
(5)Patient may need intensive care unit management in case of
respiratory, cardiovascular and kidney problems appear.
(6) Laprotomy with Removal of the uterus should be done irrespective of parity. Adnexa is to be removed or preserved according to the pathology found. Thorough inspection of the gut and omentum for evidence of any injury is mandatory
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