Practical Cases in Obstetrics & Gynecology Kanan Yelikar
Chapter Notes

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Abha Singh,
Pradeep Ingale
1. What is abortion?
WHO defines abortion as induced or spontaneous termination of pregnancy before 20 weeks of gestation or with fetus weighing less than 500 g.
2. What is the incidence of abortion?
About 10–20% of all pregnancies end up in abortion, of which 3/4th occur before 16 weeks and out of these 75% before 8 weeks.
3. What are the different common types of abortion met in clinical practice?
Common varieties of abortion are:
  • Threatened
  • Inevitable
  • Incomplete
  • Complete
  • Missed
  • Septic.
In developing countries, incidence of septic abortions are also quite high, approximately 10% of abortions requiring admission to the hospital.
4. What is the most common cause of first trimester abortion?
Genetic factors in the form of chromosomal abnormalities in the conceptus are the most common causes.
5. What are the common chromosomal abnormalities of the conceptus?
Autosomal trisomies occur in about 50% cases. The most common trisomies are 16, 21 and 22.
6. What is blighted ovum?
Blighted ovum is the failure of development of fetal pole even after the gestational sac diameter of 2.5–3 mm or more on transabdominal sonography.
7. 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).
8. 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 counseling, otherwise a repeat USG scan should be done after a week.
9. 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 amenorrhea. It is important to subject the patient to USG for confirmation of cardiac activity.
10. What are the features of inevitable abortion? How will you treat it?
Continuous contraction and dilatation of cervix 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:
    • Tab misoprostol 800 mcg per vaginally single dose
    • Dilation and evacuation (D and E)
  • If >12 weeks:
    • Tab misoprostol 600 mcg per vaginally followed by 400 μg per vaginally 3 hourly maximum 5 doses
    • Oxytocin 10 units in 500 mL of NS, 40–60 drops/min.
If profuse bleeding is there but os closed, hysterectomy may have to be done (very rare).
11. 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.
12. 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, profused)
    • Patulous external os.
  • Complete abortion—when whole of conceptus is expelled en masse with subsidence of pain and bleeding.
13. What are the sonographic criteria for missed abortion?
  • Absence of cardiac activity
  • Sac diameter 25 mm or more without a yolk sac/ embryo (TAS)
  • Sac diameter 18 mm or more without yolk sac/embryo (TVS).
14. What are the features of septic abortion?
  • Increased temperature 100.4°F per 24 hours or more
  • Offensive vaginal discharge
  • Lower abdominal pain and tenderness.
15. What are the common organisms associated with septic abortion?
Mixed infection is common. Organisms associated are (a) Anaerobic: Bacteroides group, anaerobic streptococci, Clostridium welchii, C. tetani, C. perfringens, C. sordellii, (b) Aerobic-Escherichia coli, Klebsiella, Staphylococcus and Pseudomonas.
16. How is severity of septic abortion classified?
It is classified in grades. Mildest and most common being grade I-endomyometritis.
  • Grade I—Infection limited to uterus.
  • Grade II—Infection spreads beyond uterus involving parametria, tubes, ovaries and pelvic peritoneum.
  • Grade III—Generalized peritonitis, endotoxic shock and acute renal failure.
17. What are the complications associated with septic abortion?
  • Septicemia
  • Hemorrhage
  • Shock
  • Bowel injuries
  • Uterine perforation.
18. Indications of active surgery in septic abortion?
  • Hemorrhage
  • Presence of foreign body
  • Intestinal injury
  • Unresponsive peritonitis with collection of pus.
19. What are the basic investigations in any of the varieties of abortion?
  • Complete blood count
  • Serum quantitative β-hCG
  • Rh factor determination
  • Pelvic USG.
20. How can cervical trauma be minimized?
  • Consider USG assessment of the gestational age
  • Appropriate cervical preparation
  • Prostaglandin analogue should preferably be used.
  • 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 overnight observation.
21. What are the causes of first trimester abortions?
  • Genetic abnormalities
  • Luteal phase defect
  • Thyroid deficiency
  • Maternal diabetes
  • Polycystic ovarian syndrome
  • Autoimmunity.
22. What are the causes of second trimester abortions?
  • Genetic abnormalities
  • Antiphospholipid antibodies (APLA) syndrome
  • Incompetent cervix
  • Müllerian anomalies
  • Inherited thrombophilias—protein C and S deficiency, factor V Leiden mutation.
23. What is habitual or recurrent pregnancy loss?
Three or more consecutive abortions before 20 weeks are known as recurrent pregnancy loss (RPL).
24. What causes are associated with recurrent pregnancy loss?
Etiology of RPL— is most often obscure.
  • Genetic:
    • Parental—chromosomal abnormalities (3.5–5%) Most common—balanced translocation
    • Single gene defects
    • Multifactorial
  • Endocrine abnormalities (17–20%):
    • Luteal phase defect/progesterone deficiency
    • Serum progesterone levels less than 15 ng/mL, indicate need for progesterone supplementation
    • Thyroid disorders
    • Diabetes
    • Increased androgen
    • Polycystic ovarian syndrome
    • Prolactin disorders
  • Immunological factors (20–50%):
    • Antiphospholipid antibody (APLA) syndrome
    • Anticardiolipin antibody
    • Lupus anticoagulant
    • Antithyroid antibody
    • 3Antitriphoblast antibody
    • Blocking antibody deficiency
    • Defective cellular immunity.
Alloimmune etiology is less common.
  • Anatomical causes (12–16%):
    • Congenital
      1. Cervical incompetence
      2. Müllerian abnormalities
      3. Diethylstilbestrol exposure in uterus
    • Acquired
      1. Cervical incompetence
      2. Uterine synechiae
      3. Leiomyoma
      4. Adenomyosis.
  • Infections (0.5–5%)
  • Others:
    • Adhesion molecule defects
    • Medical illness—cardiac, renal, hepatic
    • Smoking
    • Illicit drug abuse
    • Environmental toxins
    • Unknown reasons.
25. How will you proceed to investigate a case of RPL?
  1. Valuable tests:
    • Anticardiolipin and lupus anticoagulant testing
    • Thyroid function tests (TFTs)
    • Platelet count
    • Hysteroscopy, hysterosalpingography
    • Parenteral peripheral blood karyotyping
    • Thrombophilia testing—factor V Leiden mutation, serum homocysteine, protein C and protein S
  2. Tests with unproven/unknown utility:
    • Ovarian reserve testing
    • FSH, LH, serum androgen
    • Antithyroid antibody testing
    • Cellular immunity dysregulation testing
    • Cervical cultures
  3. Tests with no utility:
    • Parental HLA
    • Mixed lymphocyte culture
    • Suppressor cell factor determination.
26. What is antiphospholipid antibody syndrome?
Antiphospholipid antibody syndrome (APLA) is defined using Sapporo criteria, presence of one or more clinical and laboratory criteria must be present.
  • One or more episodes of confirmed vascular thrombosis–venous, arterial, small vessel
  • Pregnancy complications:
    • 3 or more spontaneous pregnancy loss at <10 weeks
    • 1 or more fetal deaths >10 weeks
    • 1 or more preterm births at <34 weeks secondary to severe pre-eclampsia or placental insufficiency
  • Positive anticardiolipin antibodies (ACAs) at medium to high levels
  • Positive lupus anticoagulant (LAC).
27. How will you manage a case of RPL with APLA syndrome?
Treatment of antiphospholipid antibody syndrome consists of prophylactic heparinization and low dose aspirin. For unfractionated heparin, the initial dose is 5000 units subcutaneous twice daily, and may be increased to 7500–10,000 units. Another choice is of low molecular weight heparin (LMWH) 40 mg subcutaneous twice daily. Low molecular weight heparin has advantage of reducing chances of heparin-induced thrombocytopenia and spontaneous bleeding episodes. The usual dose of aspirin is 60–80 mg orally daily.
28. What is the percentage of risk of abortion with increasing number of abortions?
No. of abortions
Subsequent risk (%)
29. What is cervical incompetence?
Cervical incompetence or insufficiency is a condition characterized by the inability of the cervix to retain a pregnancy in absence of uterine contractions.
30. 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, etc.
31. What is the success rate of McDonalds vs Shirodkar operation?
Both varieties—80–90%.
32. Which one is preferred and why?
McDonalds, because it is technically easy.
33. When will you remove the stitch?
At 37 completed weeks of gestation or if patient goes in labor, whichever is earlier.
4 34. What is the optimal timing for circlage operations?
It should be done preferably in 2nd trimester at 14–16 weeks, two weeks prior to the wastage of previous pregnancy.
35. What are the contraindications of encirclage operation?
  • IUD
  • Congenitally abnormal fetus
  • Bleeding P/V
  • Intrauterine infections
  • Uterine contraction
  • Ruptured membranes
  • Cervical dilatation >4 cm effacement >50%
  • GA >32 weeks.
36. Discuss Medical Termination of Pregnancy Act (MTP Act, 1972).
In India MTP is legal up to 20 weeks of gestation and is governed by MTP Act, 1972. The law was revised in 1975; latest revision has been done in June 2003.
The following provisions are laid down:
  • The continuation of pregnancy would result in serious risk of life or cause grave injury to physical or mental health of the pregnant woman
  • There is substantial risk of the child being born with serious physical or mental abnormalities so as to be handicapped for life
  • When the pregnancy is caused by rape, both in minor and major girls and in mentally imbalanced women
  • Pregnancy caused as a result of failure of contraception. The law recommends that MTP should be done only by a registered medical practitioner, in government hospitals/hospitals approved by government, only after written consent of woman and only up to 20 weeks.
The abortion is to be kept confidential and reported only to the Directorate Health Services (DHS) of State.
A registered medical practitioner should have:
  • Diploma or degree qualification in obstetrics and gynecology, or
  • 6 months house officer training in obstetrics and gynecology, or
  • Having certificate of assisting 25 MTP at registered center.
Opinion of 2nd Registered Medical Practitioner (RMP) is required for second trimester pregnancy termination (12–20 weeks).
37. What are the different forms used under MTP Act?
  • Form A: Form of application for approval of MTP center
  • Form B: Certificate of approval
  • Form C: Consent form
  • Form I: Opinion form for second trimester MTPs
  • Form II: Monthly report form
  • Form III: Admission register.
38. What are the investigations recommended prior to performing MTP?
  • Hemoglobin
  • Urine—albumin, sugar
  • ABO and Rh type
  • USG—optional.
39. What are the different methods of termination of pregnancy?
First trimester MTP
Second trimester MTP (< 20 weeks)
Manual vacuum aspiration (MVA)
Dilatation and evacuation (13–14 weeks)
Suction and evacuation/curettage
Extra-amniotic instillation of ethacridine lactate
Medical methods (Mifepristone 200 mg + Misoprostol 800 μg up to 9 weeks)
Prostaglandins PGE1 (misoprostol) PGF2-alpha, PGE2 (not approved in India)
40. Discuss Preconception and Prenatal Diagnostic Techniques Act, 1994.
  • The Preconception and Prenatal Diagnostic Techniques (Prohibition of Sex Selection) Act (PCPNDT) was passed in 1994 and amended in 2002
  • It prohibits the use of preconception and prenatal techniques for sex determination and sex selection
  • While prenatal diagnostic tests like ultrasound or amniocentesis can be used for purposes defined under the Act; to reveal the sex of the fetus is illegal
  • Act defines the conduct and codes while performing procedures, which have ability to reveal the sex of fetus
  • Imaging center/genetic center needs approval by district appropriate authority
  • All records are preserved for period of 3 years
  • Information is to be sent to district appropriate authorities prior to 5th of every month
  • Offences under the Act are cognizable, nonbailable and noncompoundable.