Dr.Suresh Babu Chaduvula
Professor
Dept. of OBGyn, College of Medicine,
KKU, Abha, KSA
 1]
Abortion
 2] Ectopic Pregnancy
 3] Hydatidiform mole
 4] Implantation bleeding
 5] Local causes – Erosion, Polyp, Varicose
veins rupture, Cervical malignancy
 Definition:
Termination of pregnancy before
the period of viability or fetus weighing less
than 500 grams.
 Expulsion or Extraction of an embryo or fetus
before viability
 Period
of viability: Developing countries – 28
weeks.
 UK, USA – Less than 22 to 24 weeks
 10
– 20%
 75 % occur before 16th week
 75 % occur at 8th week
 1]
Spontaneous
 2] Threatened
 3] Inevitable
 4] Incomplete
 5] Complete
 6] Missed
 7] Septic
 8] Recurrent
 9] Induced – Legal or Illegal [ Criminal ]
 1]
Genetic factors –
 Chromosomal abnormalities – Autosomal
trisomy – 50 % - Trisomy 16 is common
 Polyploidy – 20 % - Presence of extra haploid
number of chromosomes – 69 or 92
chromosomes – Triploidy is common
 Chromosomal rearrangements – Inversion,
deletion, translocation
 Others - Mosaic
 2]
Endocrine factors:
 Luteal Phase defect
 Deficient Progesterone
 Hyper & Hypothyroidism
 Uncontrolled Diabetes Mellitus
 3]
Uterine Anomalies:
 Cervical incompetence
 Bocornuate uterus
 Septate uterus
 4] Sub-mucus Fibroid:
 5] Intra-uterine synechiae: [ Asherman’s
syndrome ]
 6]
Infections:
 Viral
– Rubella, Cytomegalo, varicella,
variola
 Parasitic:
 Bacterial:
Toxoplasmosis, Malaria
Chlamydia, Ureaplasma, Brucella
 Spirochetes:
Treponema pallidum
 7]Immunological
disorders:
 Antinuclear Antibodies
 Anti phospholipid antibodies like Lupus
anticoagulant and Anti cardiolipin antibodies
 8]
Medical Disorders:
 Cyanotic heart diseases
 Hemoglobonopathies
 9] Paternal Factors:
 Sperm chromosomal anomaly
 10] Inherited Thrombophilia
 11] Environmental - Smoking, Radiation,
Teratogenic drugs, chemicals, Alcohol
 12] Unexplained – 40- 60%
 1]
Genetic
 2] Endocrine disorders
 3] Immunological disorders
 4] Infections
 5] Unexplained
 1]
Cervical Incompetence
 2] Bicornuate uterus
 3] Septate uterus
 4] Uterine synechiae
 5] Submucus fibroid
 6] Maternal Diseases
 7] Unexplained
 Clinical
features:
 Vaginal bleeding
 Mild lower abdominal pain
 Vitals stable
 Vaginal examination – Cervix is closed and
uterus size will correspond to pregnancy
 Diagnosis – CBC, Ultrasound, Serum
Progesterone and Serum HCG levels
 Treatment – Rest, sedation and synthetic
progesterone and HCG injections?
Clinical features:
 Vaginal Bleeding with passage of products of
gestation
 Pain lower abdomen
 Vitals - disturbed according to the blood loss
 Vaginal examination: Cervix is dilated with
hanging of fetal products and uterus size will be
lesser than amenorrhea
 Diagnosis - Ultrasound
 Treatment – Stabilize vitals and Suction
evacuation / curettage
 After 12 weeks – Under GA and IV oxytocin drip
products are removed by ovum forceps /
Curettage

 Clinical
features:
 Vaginal Bleeding with passage of products of
gestation
 Pain may be less or absent
 Vitals - disturbed according to the blood loss
 Vaginal examination: Cervix is closed and
uterus size is lesser than amenorrhea
 Diagnosis - Ultrasound
 Treatment – No active intervention
 Clinical
features:
 Vaginal Bleeding
 Pain lower abdomen
 Vitals - disturbed according to the blood loss
 Vaginal examination: Cervix is dilated with
hanging of fetal products and uterus size will
correspond to amenorrhea
 Diagnosis - Ultrasound
 Treatment – Stabilize vitals and Suction
evacuation / curettage
 After 12 weeks – IV oxytocin drip
 Fetus
is dead and retained for variable
period [ 4 – 6 weeks ]
 Clinical Features:
 Brownish vaginal dischage
 Subsidence of pregnancy symptoms
 Retrogression of breast changes
 Vaginal examination: Uterus will be less than
amenorrhea and cervix is closed
 Diagnosis – Ultrasound
 Complications:
 Disseminated
intravascular Coagulation
 Coagulation Profile is essential
 Treatment:
 Dialatation
and Curettage – less than 12
weeks
 After 12 weeks – IV Oxytocin drip /
Prostaglandin vaginal pessaries or Gel / IM
injections of PG F2 alfa.
 Any
abortion associated with evidence of
infection in the uterus and its contents
 Clinical features:
 Temperature – 100.4 degree F for 24 hrs or
more
 Offensive or purulent vaginal discharge
 Lower abdominal pain and tenderness
 This is mostly due to incomplete and illegal
abortions or also following spontaneus
abortion
 Peritonitis
features may be present
 Vaginal examination – cervix may be closed
or dilated , pus like offensive discharge
 Tender uterus and size of uterus will be
lesser than amenorrhea
 Organisms responsible for sepsis:
 E.coli, Klebsiella, Staph.aureus, Clostridium
welchi and perfringens etc.,
 Complications - Endotoxemic shock, acute
renal failure, DIC, Peritonitis and Gas
gangrene
 Investigations:
 Endo
cervical swab for culture & sensitivity
 High vaginal swab for culture & Sensitivity
 CBC
 DIC profile if required
 Blood culture
 Urine Culture
 Ultrasound
 Treatment:
 IV
Antibiotics – for aerobic, anaerobic
organisms – IV Ampicillin, Gentamycina and
Metronidazole
 Anti Gas Gangrene serum
 Treatment of complications
 Surgery – Evacuation of uterus and
Laparotomy if necessary depending on
peritonitis features
 Development
of gestational sac without any
evidence of fetus or fetal parts
 Diagnosis – Ultrasound
 Treatment – Dilatation and Curettage
 Tissue should be sent for Fetal karyotyping
A
sequence of three or more consecutive
abortions before 20 weeks
 Incidence – 1 %
 Causes:
 First Trimester – Genetic, Endocrine and
Metabolic, Infection, Inherited
thrombophilia, Immunological and
unexplained
 Second Trimester – Bicornuate uterus,
Unicornuate uterus, septate uterus, Cervical
incompetence.
 Cervix
is unable to with hold the fetus faulty
defect in the sphincteric mechanism.
 Retentive power of cervix is impaired
 Causes:
 Congenital
 Iatrogenic – Dilatation and Curettage,
Amputation of the cervix, cone biopsy
 Clinical features: History of recurrent mid
trimester abortions where leaking followed
by painless expulsion of fetus
 Diagnosis:
 Ultrasound
– Cervical length less than 2.5 cm
and cervical dilatation more than 1.5 cm
with funneling of cervix and bulging of
membranes
 Periodic per speculum examination
 Treatment:
 Cervical Circlage with Merseline tape at 16 –
18 weeks – Mc Donald operation
 Shiridkar’s operation
 Medical
Termination of Pregnancy
 Indications:
 Failure of contraception
 Rape
 Medical diseases that may deteriorate
mother’s health
 Congenital anomalies
 First
Trimester
 Surgical :
 Manual Vacuum Aspiration
 Dilatation and Curettage
 Suction and Evacuation
 Medical:
 Prostaglandin preparations
 Mifepristone
 Misoprostol
 Second
Trimester:
 Intraamnitic instillation of PGF2 alfa or
Hypertonic saline
 Extraamniotic ethacrydine lactate or PGf2
alfa
 Oxytocin Infusion
 Hysterotomy