Abortions😍

Abortions

Definition of abortion

• M/c cause of bleeding in early pregnancy

• Pregnancy loss before 20 weeks of pregnancy

• or before fetus weight is 500 gm (WHO).
• Still birth → 28 weeks, 1000g

• Note:
• Fetus weight at 20 weeks: 330 gm.
• Fetus weight @ 22 weeks: 500 gm.

M/C Cause of T1 and T2 Spontaneous, Isolated Abortion

• Aneuploidy > Trisomy > Monosomy X > Trisomy 16.

• Most frequently observed autosomal aneuploidy that leads to spontaneous abortions
• Trisomy 16

• M/c uterine cause of T1 abortion or T1 recurrent abortion: 
• Septate uterus.

• M/c uterine cause of T2 abortion or T2 recurrent abortion: 
• Cervical incompetence.

• (T1: 1st trimester, T2: 2nd trimester).

Recurrent Abortion

• Conventional definition: ≥3 abortions.

• Definition by ASRM:
• If two or more consecutive losses of recognised pregnancies by USG or HPE before 20 weeks, start evaluating.

• Four Established Causes of RPL:
1. APLA syndrome (Single most common cause): 16%.
2. Uterine structural abnormalities:
• Congenital - septate uterus
• Acquired - cervical incompetence, fibroid, polyp.
3. Chromosomal abnormalities (Balanced translocation of chromosome):
• Responsible for RPL in 4% cases.
4. Hypothyroidism.

• Note:
• Infections including syphilis and TORCH do not cause RPL.
• They cause sporadic losses.

• M/C group causing RPL: Endocrine causes > Uterine causes.

• Investigation for RPL:
• Ultrasound uterus (TVS).
• APLA antibodies.
• Parental karyotype.
• TSH.

• Investigation not done in RPL: TORCH, HIV & VDRL test.

• RPL: Recurrent Pregnancy loss.

M/c risk factors for abortion

• ↑maternal age.

• Previous H/o abortion.

Types

• POG: Period of gestation.

Threatened abortion:

• Abortion process begins.

• Process is reversible.

• Os: Closed.

• No H/O expulsion of products of conception (POC).

• Mx:
• Expectant management
• Bed rest and Progesterone

Inevitable abortion:

• Abortion process cannot be reversed.

• Internal os: Open.

• No H/O POC coming out.

• Mx: Emergency suction evacuation if bleeding is heavy.
• Otherwise, consecutive management awaiting spontaneous completed abortion.

Incomplete abortion:

• POC starts coming out.

• Process is incomplete.

• Mx: Emergency suction evacuation.

Complete abortion:

• Entire POC comes out spontaneously.

• Mx: Conservative if intrauterine pregnancy was confirmed.

• Otherwise, serial b-hCG titres until negative

• to ensure ectopic pregnancy not missed.

Missed abortion:

• Ultrasound based diagnosis.

• MSD is ≥25 mm and CRL cannot be measured OR.

• CRL is ≥7 mm and fetal cardiac activity cannot be detected OR.

• Cardiac activity was present earlier, then disappears.

• MSD: Mean sac diameter.

• CRL: Crown rump length.

Approach

No H/O product of conception coming out.

• P/V: Internal OS.
• Closed:
• Height of uterus equal to POG.
• Cardiac activity +:
• Threatened abortion.
• Open:
• Height of uterus equal to POG.
• Cardiac activity -:
• Missed abortion.
• Height of uterus ≤ POG.
• Cardiac activity -:
• Inevitable abortion.

H/O product of conception coming out.

• P/V: Internal OS.
• Open: Incomplete abortion.
• Closed: Complete abortion.

Cervical Insufficiency/Incompetence

• Purse string suture.

• Note:
• Shape of cervix on USG as it dilates: 
• Normal → T shaped → Y shaped → V shaped → U shaped

Definition

• Spontaneous dilatation of cervix (Internal os)

• due to shortening of cervix.

• H/o painless recurrent T2 abortions.

≥2 recurrent painless cervical dilatation T2 abortions:

• Confirms cervical insufficiency.

USG-based Diagnosis

• TVS → IOC

• Done at 12 weeks

• H/O one second trimester abortion +

• TVS in present pregnancy shows length of ≤2.5 cm.

On TVS: Cervical Insufficiency

• Length of cervix: ≤2.5 cm (Normal Pregnant female: 4cm).

• Shape of cervix: ‘U’ shaped.

Management of Cervical Insufficiency

1. Progesterone.

2. Cervical (Cx) cerclage.

Next Steps

Cervical Cerclage

C/I

• Uterine contractions

• Fetus with anencephaly

• Ruptured membranes (Chorioamnionitis).

• Bleeding.

• Current pelvic infection.

• Fetal demise/gross congenital anomalies.

• If fully dilated cervix + Membranes intact
• Rescue cerclage / Emergency cerclage

• Can be done in pregnant females and non pregnant females.

• Ideal time: At 12 - 14 weeks
• Can be done upto 28 weeks
• May be less effective

• Progesterone always given with Cerclage

ACOG 2021 / RCOG 2022:

• If ≥1
• Second-trimester painless midterm loss /
• Preterm birth <34 weeks +
• Risk factors (like conization)
• ⇒ history-indicated cerclage can be offered at 12–14 weeks.

• If not definite
• TVS cervical length monitoring from 16 weeks onwards is preferred.

Pregnant Females:

1. Transvaginally:

• Mnemonic: Mcdonaldsnte () cheerayil () worms ()

• McDonald cerclage (M/c):
• Time to remove stitch: 37 weeks.
• M/c done.
• Suture: Nonabsorbable monofilament.
• Purse string sutures: Applied on portiovaginalis
• Time: 14-16 weeks.
• Earliest: By 12 weeks.
• Maximum: By 24 weeks.
• Relative C/I: Placenta previa.

• Shirodkar cerclage.

• Wurms cerclage 
• 2 sutures applied;
• AKA Hefner cerclage
• Done as emergency cerclage.
• 2 stitches anteroposteriorly.

2. Transabdominally:

• Mnemonic: So eat Burfee

• Benson and Durfee cerclage:
• Can be done laparoscopically.
• Can be done during or before pregnancy.
• Indications:
• Failed transvaginal cerclage.
• Drawback:
• Sutures removed transabdominally.
• Suture should be removed only after female completed her family.
• Delivery should be done:
• By caesarean section.

Non-pregnant Females:

1. Abdominally
• Laparoscopic cerclage
• DONE NOW

2. Vaginally: LASH & LASH procedure.
• Here defective cervix is removed surgically.
• Patient advised to give 3 month gap before conceiving.
• Fetus should be delivered by caesarean section.
• NOT DONE due to ↑ complications.

Antiphospholipid Antibody

Cause of abortion

• It inhibits trophoblast function.

• M/C single cause of recurrent abortions
• APLA syndrome.

Recent Update:

• ≥3 consecutive abortions
• At < 16 weeks

• ≥1 fetal death
• At ≥16 to 34 weeks

• Severe Pre-eclampsia OR Severe Uteroplacental insufficiency
• At <34 weeks

Diagnostic Criteria

• KASSOWITZ (congenital syphillis) vs APLA
• Kassovitz → NO PLACENTAL Insufficiency
• APLA → PLACENTAL Insufficiency ++

Modified Sapporo criteria/SYDNEY criteria

• 1 Clinical + 1 Lab criteria for diagnosis.

• Clinical:
1. ≥1 episode of thrombosis (Arterial/venous/small vessel).
2. ≥3 fetal loss at <10 weeks.
3. ≥1 fetal loss ≥10 weeks.
4. ≥1 preterm delivery before 32 weeks due to severe pre-eclampsia or uteroplacental insufficiency.

• Lab:
• Antibodies
1. Lupus anticoagulant.
2. Anticardiolipin antibody (IgM, IgG).
3. Anti b2 glycoprotein (IgM, IgG).
• Any one of the 3 antibodies positive
• on 2 occasions at least 12 weeks apart.

Management

• Aspirin:
• Should be started as soon as pregnancy is diagnosed.
• Without thrombotic event and without pregnancy loss: Aspirin only.

• Heparin:
• Should be started once intrauterine pregnancy is confirmed.
• H/o thrombotic event or with pregnancy loss: LMWH + Aspirin.

• Intrapartum:
• Stop anticoagulation.

• Postpartum:
• Resume or start anticoagulation in 6 hours (After vaginal delivery) or
• 12 hours (After cesarean section).

PRETERM LABOUR

Management of PTL and PPROM:

• <34 wks: Steroids + GBS prophylaxis + TOCOLYTIC
• Tocolytics
• Nifedipine
• Indomethacin if < 32 weeks
• ≥ 32 weeks → PDA closure
• Atosiban
• Oxytocin Receptor antagonist
• Preferred with heart diseases
• Ritodrine
• β₂ agonist (tocolytic drug)
• → Inhibits uterine contractions
• Avoided in Diabetic Pregnancy
• they cause hyperglycemia, hypokalemia
• Terbutaline
• Only 1 dose
• Preferred for ECV
• C/I for Tocolysis
• Preferred method is Vaginal delivery
• Abruption
• Eclampsia
• Chorioamnionitis

• < 32 wks:
• Add Magnesium sulfate

• > 34 weeks:
• GABS prophylaxis +/- Steroids

Induce in PPROM:

• Chorioamnionitis, abruption, fetal distress

Management of chorioamnionitis

• Clinical diagnosis
• Infection of amniotic membranes + amniotic fluid

• Features
• Maternal fever
• Maternal tachycardia
• Fetal tachycardia
• Uterine tenderness
• Thick / turbid / foul-smelling amniotic fluid
• Leukocytosis

• Risk Factors
• PROM > 12 hours
• Preterm labor
• Multiple vaginal examinations
• Pre-existing genital tract infection

• C/I drugs
• Steroids
• Tocolytics

• Investigations
• Leukocytosis
• Amniotic fluid:
• ↓ Glucose
• ↑ IL-6
• Positive leukocyte esterase
• Gold standard:
• Gram stain / culture

• Management
• Do not delay treatment for investigations
• Immediate management (Next step)
• Start IV broad-spectrum antibiotics
• Ampicillin + Gentamicin
• Add Clindamycin or Metronidazole → anaerobic cover
• Immediate induction of labor