Module on “Early Pregnancy Bleeding – Abortion” By- Dr. Anuradha Roy

“Early Pregnancy Bleeding -Abortion”

Dr. Anuradha Roy

Department of Prasuti Tantra, Faculty of Ayurveda, IMS; BHU, Varanasi

 

Pregnancy is a blissful phase of every women’s life. Women are only gifted with the ability to procreate by the Devine God. Vaginal bleeding during early pregnancy up to 28weeks may be due to various causes, which may count from

-Abortion (95% of all cases)

-Hydatidiform mole

-Disturbed ectopic pregnancy

– Pregnancy with associated causes like cervical polyp, carcinoma cervix etc.

ABORTION:

It is termination of pregnancy (expulsion or extraction of embryo/fetus)before 20weeks or below 500gms weighing fetus (WHO).

In clinical practice (as per medico-legal age of viability at 28weeks) of pregnancy termination is taken to 28weeks for abortion.

Timing: 80% spontaneous abortion occurs during second and third months of pregnancy.

Causes of spontaneous abortion:

1. Early abortion within 12 weeks

2/3^rd causes- Chromosomal embryonic defect

1/3^rd causes- Failure of implantation, Uterine malformation, trauma, psychological, infection

 

 

1. Mid-pregnancy abortion:

Fetal factors- fetal death, malformation, genetic chromosomal abnormalities.

Maternal factors- More common, Anatomical defect (cervical incompetence), infection (syphilis, Toxo, malaria), endocrinal (luteal phase defect, PCOD, uncontrolled diabetes, hypo and hyper thyroidism)

Types:

THREATENED ABORTION:

It is a clinical entity where the process of abortion has started but has not progressed to a state from which recovery is impossible.

Clinical features– 1) bleeding per vaginum

2) Painless bleeding

Pelvic examination– Pelvic examination could be avoided when USG is available

Per speculum-reveals bleeding if any

Per vaginal- on digital examination cervical Os will be closed

-Uterine size corresponds to the period of amenorrhoea

– Uterus and cervix feel soft.

Management:

1. Bed rest.
2. Sedation and pain relief
3. Patient is advised to preserve the vulval pads for inspection for any expelled thing.
4. To report if pain or bleeding aggravates.
5. Routine note of pulse, temperature and vaginal bleeding.

 

 

 

INEVITABLE ABORTION: It is a clinical type of abortion where the changes have progresses to a state from where continuation of pregnancy is impossible.

Clinical features– 1) Increased bleeding per vaginum

2) Aggravation of pain in lower abdomen which may be colicky in nature.

Pelvic examination– reveals dilated internal cervical Os through which the products of conception are felt.

Management:

1. To take appropriate measures to look after the general condition
2. To accelerate the process of expulsion.
3. To maintain strict asepsis as outlined in conduction of labour.
4. Active management as per the gestational age.

COMPLETE ABORTION: In this clinical type of abortion when the product of conception is expelled en masse, it is called complete abortion.

Clinical features – 1) history of expulsion of a fleshy mass per vaginum.

2) Which is followed by subsidence of abdominal pain.

3) Vaginal bleeding becomes trace or absent.

Pelvic examination– 1) cervical Os is closed

2) Bleeding is in trace or absent

3) Examination of the expelled fleshy mass is found intact.

4) Uterus is smaller than the period of amenorrhea and a little farmer.

Management:

1. The effect of blood loss, if any should be assessed and treated. If there is doubt about complete expulsion of the product uterine curettage may be done.
2. Transvaginal sonography is useful to prevent unnecessary surgical procedure.

 

INCOMPLETE ABORTION: When the entire products of conception are not expelled, instead a part of it is left inside the uterine cavity, it is called incomplete.

Clinical features–

1) History of expulsion of a fleshy mass per vaginum followed by

2) continuation of pain lower abdomen, colicky in nature, although in diminished magnitude.

3) Persistence of vaginal bleeding of varying magnitude.

Pelvic examination– 1) uterus is smaller than the period of amenorrhoea.

2) Patulous cervical Os after admitting tip of the finger.

3) Varying amount of bleeding.

4) On examination, the expelled mass is found incomplete.

Management:

1. Same principles as like of inevitable abortion. It is emphasized, that the patient may be in a state of shock due to blood loss. She should be resuscitated before any active treatment is undertaken.
2. Managed according to the gestational age.

 

MISSED  ABORTION: When the fetus is dead and retained inside the uterus for more than four weeks.

Clinical features- 1) Persistence of brownish vaginal discharge

2) Subsidence of pregnancy symptoms.

– Retrogression of breast changes.

– Cessation of uterine growth.

– Non-audibility of the fetal heart sound.

– Cervix feels firm.

– Immunological test becomes negative.

Management:

1. Uterus is less than 12 weeks- vaginal evacuation can be carried out without delay.
2. Uterus more than 12 weeks- same principle of management protocol as advocated in intrauterine fetal death are to be followed.

 

SEPTIC ABORTION: Any abortion associated with clinical evidence of infection of the uterus and its contents.

Clinical features: abortion with septic symptoms and sign

• Rise of temperature at least 100.4 degree F(38 degree centigrade) for 24hrs or more.
• Offensive and purulent vaginal discharge.
• Other evidences of pelvic infection as lower abdominal pain and tenderness.

Management:

• Hospitalization
• To take high vaginal or cervical swab for culture and drug sensitivity.
• Manage accordingly.

 

MCQs

 

1.     Which among the following is not a type of spontaneous abortion A.    Threatened B.    Inevitable C.    Legal D.    Septic

2.     Most common cause of first trimester abortion is: A.    Chromosomal anomalies B.    Maternal medical illness C.    Cervical incompetence D.    Uterine fibroids

3.     Pregnancy which continues following threatened abortion is likely to have increased incidence of: A.    Preterm labor B.    IUGR C.    Fetal malformations D.    All of the above

4.     A woman with 20 weeks pregnancy presents with bleeding per vaginum. On speculum examination, the os is open but no products have come out. The diagnosis is: A.    Missed abortion B.    Incomplete abortion C.    Inevitable abortion D.    Complete abortion

5.     When the product of conception are expelled en masse, it is called A.    Inevitable abortion B.    Complete abortion C.    Incomplete abortion D.    Missed abortion

6.     The retained products in an incomplete miscarriage may cause: A.    Profuse bleeding B.    Sepsis C.    Placental  polyp D.    All of the above

7.     A 28 year old female with H/o 8 weeks amenorrhea complains of brownish vaginal discharge and lower abdominal pain. On USG examination there is gestational sac with absent fetal parts. The diagnosis is:   A.    Ectopic pregnancy B.    Incarcerated abortion C.    Threatened abortion D.    Corpus luteum cyst

8.     In cervical incompetence, encirclage operation done are A.    McDonald operation B.    Shirodkar operation C.    Abdominal sling operation D.    Both a and b

9.     Which among the following is wrong about incompetence of cervix A.    Repeated 1st trimester abortion B.    History of trauma to cervix C.    Multiple gestation D.    Prior preterm birth

10.  Causes of repeated 2nd trimester fetal loss: A.    Chromosomal anomalies B.    Intrauterine infections C.    Anatomical abnormalities D.    Hormonal imbalances

11.  In India, the abortion was legalized by ‘Medical Termination of Pregnancy Act’ which has been enforced in the year: A.    1971 B.    1972 C.    1974 D.    1975

12.  According to MTP Act, 2 doctor’s opinion is required when pregnancy is: A.    10 weeks B.    >12 weeks C.    >20 weeks D.    8 weeks

13.  For medical termination of pregnancy consent should be obtained from? A.    The male partner B.    The female partner C.    Male as well as the female partner D.    Consent is not required

14.  Anti progesterone compound RU-486 is effective for inducing abortion, if the duration of pregnancy is: A.    63 days B.    72 days C.    88 days D.    120 days

15.  All of the following drugs have been used for medical abortion except: A.    Mifepristone B.    Misoprostol C.    Methotrexate D.    Atosiban

16.  Mifepristone is not used in: A.    Threatened abortion B.    >35 year age C.    Heavy smokers D.    All of the above

17.  Which of the following is not an advantage of suction evacuation and curettage: A.    It is done as an outdoor procedure B.    Ideal for termination for therapeutic indications C.    Minimal blood loss D.    Suitable method for bigger size uterus of more than 10 weeks

18.  Which among the following is a wrong statement regarding carboprost tromethamine A.    Given as IV in every 3 hours B.    Success rate is about 90% in 36 hours C.    Nausea and vomiting are the side effects D.    Contraindicated in Bronchial Asthma

19.  Suction evacuation can be done upto …… weeks to terminate pregnancy A.    10 B.    12 C.    15 D.    18

20.  Best method for MTP in 2nd trimester abortion: A.    Oxytocin B.    Prostaglandins C.    Ethacridine D.    Hypertonic saline

 

 

KEY to the MCQs

 

1.	C	DC Dutta, 185
2.	A	Sakshi Arora, 284
3.	D	DC Dutta, 185
4.	C	Sakshi Arora, 295
5.	B	DC Dutta, 190
6.	D	DC Dutta, 190
7.	B	Sakshi Arora, 296
8.	D	William’s 361
9.	A	William’s 361 & DC Dutta, 197
10.	C	DC Dutta, 196
11.	B	DC Dutta, 202
12.	B	Sakshi Arora, 291
13.	B	Sakshi Arora, 291
14.	A	DC Dutta, 203
15.	D	William’s 368
16.	D	DC Dutta, 204
17.	D	DC Dutta, 204
18.	A	DC Dutta, 205
19.	B	DC Dutta, 204
20.	B	Sakshi Arora, 294

 

*DC Dutta’s Textbook of Obstetrics by Hiralal Konar, 8^th edition, published by Jaypee The Health Sciences Publisher New Delhi, 2015.

**Self Assessment and Review Obstetrics by Sakshi Arora Hans, 12^th edition, published by Jaypee The Health Sciences Publisher New Delhi, 2019

***Williams Obstetrics, edited by F Gary Cummingham, 24^th edition published by MC Graw Hill Medical New York.

 

Supplementary Resources

 

1. DC Dutta’s Textbook of Obstetrics by Hiralal Konar, 8^th edition, published by Jaypee The Health Sciences Publisher New Delhi, 2015.

 

2. Self Assessment and Review Obstetrics by Sakshi Arora Hans, 12^th edition, published by Jaypee The Health Sciences Publisher New Delhi, 2019

 

3. Williams Obstetrics, edited by F Gary Cummingham, 24^th edition published by MC Graw Hill Medical New York.

 

4. Dewhurst’s Textbook of Obstetrics & Gynaecology, Eighth Edition, Editor(s):
5. Keith Edmonds FRCOG, RRACOG, First published:5 January 2012

Print ISBN:9780470654576 |Online ISBN:9781119979449 |DOI:10.1002/9781119979449

 

5. Oxford Handbook of Obstretrics and Gynaecology  by Sally Collins, Sabaratnam Arulkumaran at all.  3^rd (http://gynecology.sbmu.ac.ir/uploads/4_5841359559276364169.pdf)

 

6. Clinical Obstetrics and Gynaecology, Third Edition, Edited by Brian A Magowan Philip, Owen, Andrew Thomson. (https://in.pinterest.com/pin/649996158693954389/).

 

7. Pezeshki, Kevin & Feldman, Joseph & Stein, Daniel & Lobel, Susan & Grazi, Richard. (2000). Bleeding and spontaneous abortion after therapy for infertility. Fertility and sterility. 74. 504-8. 10.1016/S0015-0282(00)00707-X. (https://www.researchgate.net/publication/12347840_Bleeding_and_spontaneous_abortion_after_therapy_for_infertility) DOI: 1016/S0015-0282(00)00707-X

 

8. Khan, M E & Barge, Sandhya & Philip, George. (1996). Abortion in India: An overview. Social Change. 26. (https://www.researchgate.net/publication/266471725_Abortion_in_India_An_overview)

 

9. Hern, Warren. (1995). ABORTION: Medical and Social Aspects. (https://www.researchgate.net/publication/272494843_ABORTION_Medical_and_Social_Aspects)

 

10. Mavric, Bisera. (2012). Legal, Social and Psycho-Medical Effects of Abortion. Epiphany. 5. 10.21533/epiphany.v5i1.48. DOI: 21533/epiphany.v5i1.48 (https://www.researchgate.net/publication/301944707_Legal_Social_and_Psycho-Medical_Effects_of_Abortion)

Post miscarriage counseling:

patient’s FAQs What did I do to cause it?

Nothing. It was not stress at work, carrying heavy shopping, having sex, or any other reason women commonly worry about. Sadly, miscarriages happen in up to about 40% of pregnancies. If I had had a scan earlier could you have stopped it happening? No, we might have found out it was happening sooner, but we could not have stopped it. There is no effective treatment available to stop a 1st-trimester miscarriage. How bad will the pain be if I opt for expectant management? It will be like severe period pain, which comes to a peak when tissue is being passed, then settles down shortly afterward. Ibuprofen, paracetamol, or codeine should help and may be taken. If pain is very bad contact hospital for advice. What is heavy bleeding? Soaking more than 3 heavy sanitary pads in under 1h or passing a clot larger than the palm of your hand. If you bleed heavily you should seek medical attention urgently. How long will I bleed for? It should gradually get less and less but may be up to 3wks after the miscarriage before the bleeding stops completely. Do I need bed rest afterward? No, not necessarily, but obviously it can be physically and emotionally draining so a few days off work may help. You can return to normal activities as soon as you feel ready. How long will the pregnancy test remain positive? hCG is excreted by the kidneys and it can take up to 3wks after a miscarriage for it all to be removed from the bloodstream and a pregnancy test to record as –ve. How long before we can try again? There is no good evidence that the outcome of a subsequent pregnancy is affected by how soon you conceive after a miscarriage. As long as you have had either a period or a –ve pregnancy test since you miscarried, you can try again as soon as you feel physically and emotionally ready. Does this make me more likely to have another miscarriage? There are a very small number of women who will have recurrent miscarriages, but for the vast majority, next time they get pregnant they will face the same odds; 40% risk of miscarriage and 60% chance of a baby. Association of Early Pregnancy Units. M www.earlypregnancy.org.uk Miscarriage Association. M www.miscarriage association.or