Practical Cases in Obstetrics and Gynecology Kanan Yelikar
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OBSTETRICS

Abortions1

Abha Singh
  1. What is abortion?
WHO definition is induced or spontaneous termination of pregnancy before 20 weeks of gestation.
  1. What is the incidence of abortion?
About 10–20% of all pregnancies. 3/4th occur before 16 weeks and out of these 75% before 8 weeks.
  1. What are the different common types of abortion met in clinical practice?
Common varieties of abortion are:
  • Threatened
  • Inevitable
  • Incomplete
  • Complete
  • Missed
In developing countries incidence of septic abortions are also quite high approximately 10% of abortion requiring admission to the hospital.
  1. What is the most common cause of first trimester abortion?
Genetic factors in the form of chromosomal abnormalities in the conceptus is the most common cause.
  1. What are the common chromosomal abnormalities of the conceptus?
Autosomal trisomies occur in about 50% cases. The most common trisomy is 16.
  1. What is blighted ovum?
Blighted ovum is the failure of development of fetal pole even after the gestational sac diameter of 2.5 to 3 cm or more on trans abdominal sonography.
  1. At what gestational age, fetal pole should appear in the gestational sac normally (it is a sonographic diagnosis)?
4.5 weeks by TVS (18 mm gestational sac)
5.5 weeks by TAS (25 mm gestational sac)2
  1. How will you treat a patient diagnosed to have a blighted ovum?
If the duration of gestation is confirmed termination of pregnancy is advised after counselling, otherwise a repeat USG scan should be done after a week.
  1. How will you diagnose a case of threatened abortion.
Threatened abortion is the one where process has started but has not progressed to inevitable, so clinically patients will present with bleeding per vaginum which is bright red in color, mild to moderate in amount with some degree of lower abdominal pain and backache. Bleeding precedes the pain.
On examination the general condition is good, external OS is closed and uterus corresponds to the period of amenorrhoea. It is important to subject the patient to USG for confirmation of cardiac activity.
  1. What are the features of inevitable abortion? How will you treat it?
Continuous contraction and dilatation of OS is associated with inevitable abortion. Sonographically it shows gestational sac separated from decidua and in the process of expulsion.
According to weeks of gestation measures are used to complete the process of expulsion.
  • If < 12 weeks, D and E or S and E
  • If > 12 weeks, Syntocinon 10 units in 500 ml of NS, 40–60 drps/min.
If profuse bleeding is there but OS closed hysterectomy may have to be done (very rare).
  1. Which is the most important prognostic factor on USG in threatened abortion.
Presence of fetal cardiac activity. It is associated in 98% cases with continuation of pregnancy.
  1. What is incomplete and complete abortion?
When a part of conceptus is left inside the uterus it is known as incomplete variety. It is most commonly met with and is a dangerous entity as patient may present with shock due to continuous bleeding per vaginum.
Clinical features of incomplete abortion
  • Continuous pain
  • Bleeding P/V (at times profuse)
  • Patulous external OS.
Complete abortion—when whole of conceptus is expelled enmasse with subsidence of pain and bleeding.
  1. What are the sonographic criteria for missed abortion?
  • Absence of cardiac activity
  • Sac diameter 25 mm or > without a yolk sac/ embryo (TAS).
  • Sac diameter 18 mm without yolk sac/embryo TVS
  1. What are the features of septic abortion?
  • Increase temperature 100.4° F per 24 hrs or/more
  • Offensive vaginal discharge
  • Lower abdominal pain and tenderness.3
  1. What are the common organisms associated with septic abortion?
A. Mixed infection is common. Organism associated are Bacteroides, Streptococci, Cl. welchii, Cl. Tetani, E. coli, Klebsiella, Staphylococcus and Pseudomonas.
  1. How is severity of septic abortion classified?
It is classified in grades. Mildest being grade I.
Grade I—Infection limited to uterus.
Grade II—Infection involving tubes, ovaries and adjacent organ.
Grade III—Generalized peritonitis, endotoxic shock, acute renal failure.
  1. What are the complications associated with septic abortion?
  • Septicemia
  • Hemorrhage
  • Shock
  • Bowel injuries
  • Uterine perforation.
  1. Indications of active surgery in septic abortion?
  • Hemorrhage
  • Presence of foreign body
  • Intestinal injury
  • Unresponsive peritonitis.
  1. What are the basic investigations in any of the varieties of abortion?
  • Urine analysis
  • Complete blood count
  • Serum quantitative B HCG
  • Rh factor determination
  • Pelvic USG.
  1. How can cervical trauma be minimized?
Preoperatively
  • Consider USG assessment of the gestational age
  • Appropriate cervical preparation
  • PG analogue should preferably be used.
Intraoperatively
  • Grasp the cervix with TWO vulsellum tenacula
  • Use graduated dilators
  • Dilate against appropriate countertraction.
Management of cervical tear
  • If small and not bleeding—no action
  • If large amount of bleeding—hemostatic polyglactin sutures
  • May require packing and admission for over night observation.
  1. What is habitual or recurrent pregnancy loss?
Three or more consecutive abortions before 20 weeks is known as recurrent pregnancy loss.4
  1. What causes are associated with recurrent pregnancy loss? **
Etiology of RPL
  1. Genetic abnormalities (50% to 60%)
    • Autosomal trisomy 16, 21 and 22
    • Triploidy
    • Monosomy 45 x
    • Tetraploidy
    • Structural rearrangements.
  2. Endocrine abnormalities 10 to 50%
    • Luteal phase defect, progesterone deficiency
    • Serum progesterone levels less than 15 ng/ml, indicates progesterone supplementation.
    • Thyroid deficiency
    • Diabetes
    • Increased androgen
    • PCOS.
  3. Chorioamniotic separation 5 to 10%
  4. Incompetent cervix 8 to 15%
  5. Infections 3 to 5%
    Bacterial vaginosis and TORCH group of infections. Abortions occur around 14 weeks.
  6. Abnormal placentation 5 to 15%
  7. Immunological abnormalities 3 to 5%
    Anti phospholipid antibody syndrome
    Anticardiolipin antibody
    Lupus anticoagulant
    Alloimmune etiology is less common.
  8. Uterine anatomic abnormalities 1 to 3%
    • Uterine synechiae
    • Mullerian abnormalities
    • DES exposure in uterus.
  9. Unknown reasons.
  1. How will you proceed to investigate a case of RPL?
  1. Interconceptional period
    (thorough medical, surgical and obstetric history)
    zoom view
    5
  2. Trimester
  1. Blood sugar 1. Fasting 2. Post meal
    • VDRL
    • ABO grouping of husband and wife
    • Thyroid function
    • TORCH
  2. Urine analysis
  3. Dilator test for incompetence
  4. Hysterocervicography
  5. High cervical swab
  6. Karyotyping
  1. What are the surgical options for the treatment of cervical incompetence? Name the commonly used operations.
Commonly used surgical procedures are Shirodkar and McDonald. Other surgical procedures—Lash and lash, Page's procedure, Arias operations, Baden and Baden, Wurm procedure, Ritter and Ritter, Shirodkar's and McDonald's operation.
  • What is the success rate of McDonalds vs Shirodkar operation?
In both varieties 80–90%.
  • Which one is preferred and why?
MacDonalds, because it is technically easy.
  • When will you remove the stitch?
At 37 completed weeks of gestation or if patient goes in labor, whichever is earlier.
  1. What is the optimal timing for cerclage operations?
A. It should be done preferably in 2nd trimester at 14–16 weeks, 2 weeks prior to the wastage of previous pregnancy.
  1. What is the percentage of risk with increasing number of abortion and with increasing abortions.
Nos of abortion
Subsent risk
0
15%
1
19%
2
35%
3
47%
  1. What are the contraindications of encirclage operation?
  • IUD
  • Congenitally abnormal fetus
  • Bleeding P/V
  • Intrauterine infections
  • Uterine contraction
  • Ruptured membranes
  • Cervical dialatatiion > 4 cm effacement > 50%
  • GA > 32 weeks.