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INTRODUCTION

Abortion is defined as the termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior to viability. An abortion can occur spontaneously, in which case it is usually called a miscarriage, or it can be purposely induced. The term abortion most commonly refers to the induced abortion of a human pregnancy. DEFINITIONS Abortion is the expulsion or extraction from its mother of an embryo or fetus weighing 500gms or less when it is not capable of independent survival. (WHO ) INCIDENCE 15% of conception ends up in miscarriage. Among this 80% are 1st trimester abortion, due to congenital anomalies. ETIOLOGY 1) MATERNAL FACTORS >Maternal infection like TORCH (Toxoplasmosis, Rubella, Cytomegalovirus, Herpes infections) > Environmental Factors (Smoking, Alcohol, Drugs Exposure to radiations and other teratogens) >Endocrine Factors (Thyroid dysfunction etc)

>Immunological Factors (Antiphospholipid Syndrome, Alloimmune disorders etc) >Maternal diseases like: (HTN,GDM, RENAL FAILURE etc.) >Uterine Anomalies (Cervical incontinence, Mullarian anomalies, etc)

2) FETAL FACTORS >Chromosomal abnormalities >Multiple Pregnancy >Genetic Disorders > Hydropic degeneration of villi Among this 50% of spontaneous miscarriage is due to chromosomal anomalies of fetus, it can be either structural or numerical anomalies. MECHANISM OF ABORTION BEFORE 8 WEEKS The ovum surrounded by the villi with decidual coverings expelled out completely. 8-14 WEEKS Expulsion occurs, living behind the placenta and membranes. BEYOND 14th WEEK Expulsion is similar to that of a MINI LABOUR that is fetus expelled first followed by expulsion of placenta. CLASSIFICATION ABORTION

SPONTANEOUS

INDUCED

ISOLATED ILLEGAL

RECURRENT

LEGAL

THREATENED SEPTIC

INEVITABLE

COMPLETE

INCOMPLETE

MISSED

1) THREATENED ABORTION Definition It is a clinical entity where process of abortion is started but not progressed to a state where recovery is not possible. Clinical Features Bleeding Perineum- Usually slight and bright red in color, stops spontaneously. Pain- Mild back-ache, dull pain in lower abdomen. Investigation *Blood: Hb, Grouping etc *Urine: Immunological test of pregnancy. *Ultrasonography: Trans-vaginal Ultrasonography findings:

>A well formed gestational sac >Observation of fetal cardiac motions >Blighted ovum is evidenced Treatment *Rest *Drugs: Sedatives and Analgesics *General measures >Advice to use vaginal pads for inspection. >Report if pain or bleeding is present. >Assess for vital signs.

2) INEVITABLE ABORTION Definition It is a clinical entity where the process of abortion has progressed to a state where continuation of pregnancy is impossible. Clinical Features *Increased vaginal bleeding *Poor general condition *Internal examination reveals dilated internal os Management *General Measures >Excessive bleeding should be controlled.

>Maintain fluid and electrolyte balance. *Active Management >Before 12 weeks >Dilation & Evacuation followed by curettage >Suction & Evacuation followed by curettage >After 12 weeks >Oxytoxin drip >Hystrectomy

3) COMPLETE ABORTION Definition Products of conception are expelled out completely, is called complete abortion. Clinical Features *Subsidence of abdominal pain. *Vaginal bleeding become trace or absent. *Internal examination reveals >Smaller uterine size >Cervical os is closed >Intact expelled products Management *Correct the blood loss.

*Curettage if needed. 4) INCOMPLETE ABORTION Entire products of conception are not expelled out complete is called incomplete abortion. Etiology Common etiological factors Clinical Features *Continuous, colicky type pain in lower abdomen. *Persistent vaginal bleeding. *Internal examination reveals: >Uterus smaller than period of amenorrhea >Patulous abdomen >Varying amount of bleeding >Expelled mass found incomplete Management Early Abortion *Dilation and evacuation under general anesthesia Late Abortion *Suction evacuation and curettage 5) MISSED ABORTION (Silent Miscarriage) When the fetus is dead and retained inside the uterus for a variable of time it is called missed abortion.

Etiology Common etiological factors Clinical Features *Persistent brownish vaginal discharge *Subsidence of pregnancy symptoms *Retrogression of breast changes *Cessation of uterine growth *Absence of fetal heart sounds *Crrvix feels firm *Immunological test of pregnancy remains negative *Ultrasonography shows empty sac

Management *Less than 20 weeks >Vaginal evacuation *More than 20 weeks >Oxytoxin drip >Prostaglandin analog intravaginally and intramuscularly 6) SEPTIC ABORTION Any abortion associated chemical evidences of infection of the uterus and its contents is called septic abortion. Etiology

Common etiological factors Clinical Features *Pyrexia, associated with chills and rigor. *Pain in lower abdomen of varying degree. *Raising pulse rate i.e. 100-120 beats/mts. *Variable systemic and abdominal findings depending on the spread of infection. *Internal examination reveals: >Purulent vaginal discharge. >Tender uterus *Clinical grading Grade 1: The infection is localized to the uterus only. Grade 2: The infection spreads beyond the uterus to the perimetrium, tubes, and ovaries.

Grade 3: The infection leads to generalized peritonitis, endotoxic shock, jaundice or actual failure. Investigations >Routine investigations *Cervical or vaginal swab *Blood investigations renal

*Urine analysis >Special investigations *Blood investigations: Coagulation profile, culture & sensitivity etc *Ultrasonography: Pelvis and abdomen Management Principles of management Control of sepsis Remove source of infection Give supportive therapy Assess response of treatment

General Management: Hospitalization for isolation. Vaginal or cervical swab for culture & sensitivity. Vaginal examination for the removal of retained products, if any. Assessment for clinical grading.

*Grade 1: > Prophylatic antibiotics >Analgesics and sedatives >Blood transfusion if needed >Evacuation of uterus within 24 hrs following antibiotic therapy.

*Grade 2 > Antibiotics > For Gram positive aerobes

*Penicillin G, 5 million units, IV, 6th hourly. *Ampicillian, 0.5 1g, IV, 6th hourly. >For Gram Negative aerobes *Gentamycin 1.5mg, IV, 8th hourly. *Ceftriaxone, 1g, 12th hourly. > For Anaerobes *Mertronidazole, 500mg,IV, 8th hourly. *Clindamycin, 600mg, IV, 6th hourly. >Analgesics, Anti Gasgangrine, Anti Tetanus serum. >Clinical monitoring for Vital Signs >Surgical Management *Evacuation of uterus *Posterior Colpotomy *Grade 3: >Antibiotics > Surgery (Laprotomy, Hysterectomy etc) 7)RECURRENT MISCARRIAGE Definition Recurrent miscarriage is that when, a sequence of three or more consecutive spontaneous abortion occurs before 20 weeks. Etiology 1st Trimester

>Genetic Factor: Chromosomal anomalies >Endocrine and Metabolic Disorders: *Poorly controlled diabetes *Thyroid abnormalities *Leuteal phase defect *Infection *Inherited thrombophelia *Immunological defects - Autoimmune disorders - Alloimmune disorders 2nd Trimester >Anatomic Abnormalities: Defective mullarian fusion Investigations *History collection: - Nature of previous abortion *Blood investigations *Autoimmune screening tests *Cervical swab testing *Ultrasonography *Hysteroscopy *Karyotyping

Treatment >Interconceptual Period *To alleviate anxiety and improve psychology of patient. *Hysterioscopic resection of uterine septa. *Chromosomal anomalies are detected. *GnRH analog therapy for hypersecretion of LH. *Correction of edocrine disorders. *Genital tract infection can be treated by antibiotics. >During Pregnancy *Reassurance and tender loving care. *Adequate rest should be giveh *Ultrasound should be used detect anomalies. *Prenatal diagnosis to detect chromosomal anomalies. *Correction of alloimmune disorders. *Circulage operations. >Principles A non-absorbable encircling suture is placed around cervix at the level of Internal os. It operates by interfering with uterine polarity, preventing the internal os and the adjacent lower segment from being taken-up. >Time of Operation: The operation should be done around 14 weeks of Pregnancy or at least 2 weeks earlier than the lowest period of previous wastge, as early as the 10th week. Prior to the operation, fetal growth and

anatomy is assessed by sonography.

>Two types operations are: *Shirorkar operations *Mc Donald Operations >Post Operative: * The patient should be in bed for atleast 2-3 days . * Isoxsuprine 10 mg tablets is given thrice daily to avoid uterine irritability. >Advice on discharge *Usual antenatal care * Avoid intercourse *Avoid rough journey *Report if there is any vaginal bleeding or abdominal pain *Periodic ultrasonographic monitoring of the fetus and the cervix. >Removal of sutures *The stitch should be removed at 38 week or earlier if labor pain starts or features of abortion appears. If the stitch is not cut in time, uterine rupture or cervical tear may occur. >Contraindications *Intrauterine infection

*Ruptured membranes *History of vaginal bleeding *Severe uterine irritability *Cervical dilation > 4cm >Complications *Slipping or cutting through the suture. *Chorioamnionitis *Rupture of membranes *Abortion/Preterm labour MTP ACT 1971 Since Legalization of abortion by a Registered Medical Practitioner in the interest of mothers health and life is protected under the MTP Act 1971.The following provisions are: >The condition under which a pregnancy can be terminated. >The person or persons who can perform such terminations. >The place where such terminations can be performed. CONDITION UNDER WHICH PREGNANCY CAN BE TERMINATED >Medical: Where condition of pregnancy might endanger the mothers life or cause grave injury to her physical or mental health. >Eugenic: Where substantial risk of the child being born with serious handicaps due to physical or mental abnormalities. >Humanitarian: Where pregnancy is a result of rape.

>Socioeconomic: Where actual or reasonably foreseeable environments could lead to the risk of injury to the health of mother. >failure of contraceptive devices: The pregnancy resulting from a failure of any contraceptive devices. Conclusion Abortion continues to represent one of the most controversial and divisive issues in society. Those who are opposed to abortion often regard the issue as one of morality. Those who are in favor of abortion often defend their stance from a political and legal perspective. However, if we look back in history at American society, we see that quite often what is viewed as "morality" equates to the socially reinforced notions of what is or is not moral handed down and perpetuated through institutions like government, religion and the law. BIBLIOGRAPHY # Diane. M. Fraser, Margaret. A. Cooper. Myles text books for midwives. 14th edition. Churchil living stone; 2003 # Diane. M. Frasher. Margaret A. Cooper. Mylws text book for midwives 15th edition. Elsever publication 2009 # D.C Dutta, Text book of gynecology. 6th edition. New central book agency (p) LTD. Culcutta 2006 # Kamini. A. Raw, Text book of midwifery and obstrtics for nurses. Elsever publication 2011 # Michael. D. Benson. OB/ GYN Mentior edition J P Brothers medical publishers New delhi # Neville.F. Hacker, Joseph C Cambone, Calvin. J. Hobel. Essential of obstetrics and gynecology, Elsever publications