Dr Win PeClinical Professor / Consultant

Department of Obstetrics & Gynaecology

University of Medicine, Mandalay

• Accounts for ¾ of gynaecological admissions

• Important cause of maternal morbidity and mortality

Causes of early pregnancy bleeding

• Spontaneous miscarriage

• Ectopic pregnancy

• Gestational trophoblastic disease

• Implantation bleeding

Gynaecological complications

• Cervical cancer• Infections• Cervical polyp

The normal pregnancy

Symptomatology • Classical trial• Amenorrhoea• Pelvic or low abdominal pain• Vaginal bleeding

First test is to demonstrate the presence of HCG - HCG

• Glycoprotein

• 2 subunits

• Half life 6 to 24 hours

• Peak level at 9 to 13 weeks

Urine test

• Sensitivity is around 25 IU/Ltr

• Positive results around 14 days after ovulation

Plasma HCG

• 0.1 to 0.3 iu/L is able to detect a pregnancy 6 to 7 days after ovulation

Definition

• The expulsion of the concepts before 24 weeks of pregnancy

Aetiological factors of early pregnancy disorders

Miscarriage

Chromosomal abnormalities (Material age >35 yrs)

Trisomies (Down’s syndrome)

Triploidies and tetraploides

Monosomy X (Turner’s syndrome)

Transiocation (hereditary)

Endocrine disorders Diabetes, hypothyroidsm, luteal phase deficiency, polycytic ovarian syndrome

Abnormalities of the uterus

Uterine septa (bicornute utetus)

Endometrial adhesions (post-curettage or Asherman’s syndrome)

Miscarriage

Infections Salmonella typhi, malaria, cytomegalvirus, Brucella, toxoplasmnosis, Mycoplasma hominis, Chlamydia trachomatis, and Ureaplasma urealyticum

Chemical agents Tobacco, anaesthetic gases, arsenic, benene, solvents, ethlene oxide, formaldehyde, pesticides, lead, mercury, and cadmium

Pshychological disorders

Immunological disorders

Antiphospholipid syndrome

Thrombophilia (hereditary)

Different types of abortion

1.Threaten abortion is characterised by• Bleeding aft amenorrhoea• No uterine contraction and pain• The cervix is closed• Uterus size is similar to date

2.Inevitable abortion• There will be – more bleeding• Uterine contraction and pain• The cervix is dilated

3. Complete abortion• The whole conceptus is expelled• Uterus contracts to normal size• Bleeding stops• The cervix is closed

4. Incomplete abortion• There will be products of conception• Bleeding continue and severe

accompanied by shock• There will be pain• Infection may supervene

5. Missed abortion• Dead fetus retained in the uterus• Size of uterus is smaller than dates• Signs + symptoms of pregnancy reduced• Brownish discharges per vaginum• The os is closed• In ultrasound there is no fetal heart

movement

6. Septic abortion• Caused by incomplete abortion

complicated by infection• There will be pyrexia• Abdominal pain + pelvic tenderness• Foul smelling purulent discharge per vagina

7. Habitual abortion• Three or more consecutive abortion

(spontaneous)

Management of different types of abortion

• Threatened abortion• Reassurance• Bed rest• Sedation• Uterine relaxants• Hormone (progestogen)• USS to check viability• All pads + everything passed may be saved

for examination• Modern approach – no treatment has

proved the value

Management of different types of abortion

• Inevitable abortion• Incomplete abortion• Missed abortion• Complete abortion

– No treatment required– Habitual abortion

• Treat the cause if cause is found• Treat general disease if present

Management of septic abortion

• General• Nursing care• Nutrition• Fluid and electrolytes balance• Correct anaemia• To note urine out put

Specific• Cervical swab• High vaginal swab for C & S• Blood culture• IV Antibiotics• C Pen & ampicillin – gm(+)• Gentamycin – gm (-)• Metronidazole – anaerobes• Antitetanus toxoid• Remove the septic focus

• Management of septic abortion• Evacuation and curettage for RPOC• POD puncture and drainage• Laparotomy and drainage• TAH if perforation detected

Septicaemic shockSepticaemic shock• Keep is ICU

• O2

• Correct acidosis• Blood transfusion if require• Antibiotics intravenously• Blood and heparin for DIC

Renal failureRenal failure (Urine output < 30 ml/hr) increased urea and electrolytes

• Restrict fluid• High carbohydrate, low protein• Restriction of sodium and potassium• Dialysis if blood urea more than 25 mmol/l• Manitol• frusemide