Induced abortion or termination of pregnancy

Induction of abortion -
Deliberate termination of pregnancy before the viability of the fetus is called induction of abortion. The induced abortion may be legal or illegal (criminal). There are many countries in the globe where the abortion is not yet legalized.

Indications -
- Maternal disease such as heart disease, severe hypertension etc.
- Pregnancy caused by rape.
- Contraceptive failure pregnancy.
- Poor multiple with unplanned pregnancy.
- Eugenic indication such as down syndrome.
- Pregnancy caused as a result of failure of a contraceptive.

Methods of termination of pregnancy -

First trimester (upto 12 weeks) :-
Surgical -

• Manual vacuum aspiration
• Suction evacuation and/or curettage
• Dilatation and evacuation

Medical -

• Mifepristone
• Mifepristone and Misoprostal
• Methotrexate and Misoprostol

Second trimester (13-20 weeks) :-

• Dilatation and Evacuation
• Intrauterine instillation of  hyperosmotic solutions
• Prostaglandins
• Oxytocin infusion
• Hysterotomy - less commonly done.

Continuous miscarriage (Recurrent miscarriage)

Recurrent miscarriage is defined as a sequence of three or more consecutive spontaneous abortion before 20 weeks. A woman procuring three consecutive induced abortion is not a habitual abortion.

Causes - 
The causes of recurrent abortion are complex and most often obscure. More than one factor may operate in a case. Factors may be recurrent or non-recurrent. There are known specific factors which are responsible for early or late abortion and they are following:
- Genetic factors
- Endocrine and metabolic disorders
- Infection
- Inherited thrombophilia
- Immunological causes such as autoimmune and alloimmune disorder
- Cervical incompetence

Septic abortion

Any abortion associated with clinical evidence of infection of the uterus and its contents, is called septic abortion. The micro-organisms involved in the sepsis are usually those normally present in the vagina, such as anaerobic streptococci, tetanus bacillus, E.coli etc.

Clinical features -

• Pyrexia
• Pain
• A rising pulse rate - 100-120/ min or more
• Internal examination reveals offensive purulent vaginal discharge.

Clinical grading -
Grade 1 :- The infection is localized in the uterus.
Grade 2 :- The infection spreads beyond the uterus to the parametrium, tubes and ovaries or
                 pelvic peritoneum.
Grade 3 :- Generalized peritonitis and/or endotoxic shock or jaundice or acute renal failure.

Investigation -

• Ultrasonography (USG)
• Urine analysis including culture
• Cervical or high vaginal swab is taken for culture in aerobic and anaerobic media.

Complications -

Immediate :-

- Haemorrhage related to abortion process and also due to the the injury.

- Generalized peritonitis.

- Endotoxic shock.

- Acute renal failure.

- Thrombophlebitis.

Remote :-

- Dyspareunia.

- Ectopic pregnancy.

- Secondary infertility due to tubal blockage.

- Emotional depression.

Prevention - 

• To boost up family planning.
• To prevent unwanted pregnancy.
• To take antiseptic and aseptic precautions either during internal examination or during operation in spontaneous abortion.

Management -

General management :-

- Hospitalization is essential for all cases of septic abortion.

- To take high vaginal or cervical swab for culture and drug sensitivity.

- Vaginal examination is done to note the state of abortion process and extension of the infection.

- Investigation protocols are outlined.

- Principle of management is to control sepsis and remove the source of infection.

What is blood mole abortion

Blood mole -

In missed abortion, the clotted blood with the contained ovum is known as a blood mole. By this time, the ovum becomes dead and is either completely absorbed or remains as a rudimentary structure. Gradually, the fluid portion of the blood surrounding the ovum gets absorbed and the wall becomes fleshy, hence the term fleshy or carneous mole.

What do you know about silent miscarriage (missed abortion)

When the fetus is dead and retained inside the uterus for a variable period, it is called missed abortion or silent miscarriage. The cause of prolonged retention of the dead fetus in the uterus is not clear. Beyond 12 weeks, the retained fetus becomes macerated. The liquor amnii gets absorbed and the placenta becomes pale thin and may be adherent. Before 12 weeks, the pathological process differs when the ovum is more or less completely surrounded by the chorionic villi.

Clinical features -
- Continuation of pain in lower abdomen.
- Persistence of vaginal bleeding.
- Brownish vaginal discharge.
- Non audibility of fetal heart sound.
- Absence of fetal motion.
- Immunological test for pregnancy becomes negative.

Management -

Uterus is less than 12 weeks :- 

Vaginal evacuation can be carried out without delay. This can be effectively done by suction evacuation or slow dilatation of the cervix by laminaria tent followed by dilatation and evacuation
(D & E) of the uterus under general anaesthesia.

Uterus more than 12 weeks :- 
i) Oxytocin - To start with 10-20 units of oxitocin in 500 ml of normal saline.
ii) Prostaglandins - It is more effective than oxytocin in such cases. Prostaglandin Ei analogue (misoprostol) tablet is inserted into the posterior vaginal fornix every 4 hours for a maximum 5 times.

What is incomplete abortion

When the entire product of conception are not expelled, instead a part of it is left inside the uterine cavity, it is called incomplete abortion.

Clinical features -
- Continuation of pain lower abdomen.
- Persistence of vaginal bleeding.
- On examination, the expelled mass is found incomplete.
The products left behind may lead to profuse bleeding, sepsis, placental polyp.

Management -

• Early abortion :- Dilatation and evacuation under general anaesthesia.
• Late abortion :- The uterus is evacuated under general anaesthesia and the products are removed by ovum forceps or by blunt curette.

Complete abortion

When the products of conception are expelled completely with masse, it is called abortion.

Clinical features -
- Subsidence of abdominal pain.
- Vaginal bleeding becomes trace or absent.
- Cervical os (opening) is closed.

Management -
a) The effect of blood loss should be assessed and treated. If there is double about complete expulsion of the products, uterine curettage should be done.
b) Transvaginal sonography is useful to prevent unnecessary surgical procedure.

Inevitable abortion

It is the clinical type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible.

Clinical features -
- Increased vaginal bleeding.
- Pain in the lower abdomen.
- Internal examination reveals dilated internal opening of cervix.

Management -

General measures :-
- Excessive bleeding should be controlled by administering methergin 0.2 mg.
- The shock is corrected by I.V. fluid therapy and blood transfusion.

Active management :-
1. Before 12 weeks - Dilation and evacuation followed by curettage of the uterine cavity by blunt curette under general anaesthesia. Alternatively, suction evacuation followed by curettage is done.

2. After 12 weeks - The uterine contraction is acceleration by oxytocin drip. If bleeding is profuse with the cervix closed evacuation of the uterus may have to be done by abdominal hysterotomy.

What is threatened abortion

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

Clinical features -
1. Bleeding :- The bleeding is usually slight and bright red in colour.
2. Pain :- Pain appears usually following haemorrhage.

Investigation - 
Ultrasonography is helpful in observation of fetal status.

Treatment - 
Rest :- 
The patient should be in bed for few days until bleeding stops.

Drugs :- 
Sedation and relief of pain may be ensured by phenobarbitone 30 mg or diazepam 5 mg
tablet twice daily.

General measures :- 
- The patient is advised to preserve the vulval pads and anything expelled out per vaginum,
  foor inspection.
- To report if bleeding or pain.
- Routine note of pulse, temperature and vaginal bleeding.

Advice on discharge -

• The patient should limit her activities for at least two weeks.
• Avoid heavy work.
• Coitus is contraindicated during this period.

Types of abortion

Abortion is the expulsion or extraction from its mother of an embryo weighting 500 gm or less when it is not capable of independent survival. It is mainly divided into two types -
1. Spontaneous abortion
2. Induced abortion

Spontaneous abortion - It is divided in following types:

• Threatened abortion
• Inevitable abortion
• Complete abortion 
• Incomplete abortion 
• Missed abortion
• Septic abortion

Induced abortion - It has two types:

• Legal abortion - Medical termination of pregancy (MTP)
• Illegal (criminal) abortion

Factors responsible for abortion

1. Endocrine and metabolic factors -
Luteal phage defect (LPD) results in early miscarriage as implantation and plancental are not supported adequately. Deficient progesterone secretion from corpus luteum or poor endometrial response to progesterone is the cause. Diabetes mellitus when poorly controlled, causes increased miscarriage.

2. Anatomical abnormalities - 
These are related mostly to the second trimester abortions.
- Cervical incompetance.

- Congenital malformation of the uterus is cause of fetal loss.

- Reduced intrauterine volume.

- Increased uterine irritability and contraction.

- Intrauterine adhesions interfere with implantation, placental and fetal growth.

3. Infections -

Infections are accepted causes of late as well as early abortions. Infections could be :

i) Viral :- Rubella, HIV.

ii) Parasitic :- Toxoplasma, malaria.

iii) Bacterial :- Chlamydia, brucella.

4. Immunological disorders

5. Environmental factors

6. Genetic factors

7. Others -

- Maternal medical illness.

- Cyanotic heart disease (CHD).

- Blood group incompatibility.

- Premature rupture of membranes.

- Inherited thrombophilia.

Immunological disorders are responsible for abortion

Both autoimmune and alloimmune factors can cause miscarriage.

• Autoimmune disease :- It can cause miscarriage usually in the second trimester. These patient form antibodies against their own tissue and the placenta. These antibodies ultimately cause rejection of early pregnancy. placental thrombosis, infarction and fetal hypoxia is the ultimate pathology of cause abortion.

• Alloimmune disease :- Paternal antigens which are foreign to the mother invoke a protective blocking antibody response. These blocking antibodies prevent maternal immune cells from recognising the fetus as a foreign entity. Therefore, the fetal allograft containing foreign paternal antigens are not rejected by the mother. Paternal human leukocyte antigen (HLA) sharing with the mother lead to diminished fetal-maternal immunologic interaction and ultimately fetal rejection (abortion).

How environmental factor is responsible for abortion

Smoking -
Cigarette smoking increases the risk due to formation of carboxy haemoglobin and decreased oxygen transfer to the fetus. Alcohol consumption should be avoided or minimized during pregnancy.

X-Irradiation and antineoplastic drugs are known to abortion. X-ray exposure is a risk of abortion,
so it is avoided or minimized in the pregnancy period.

Contraceptive agents -
IUD (Intrauterine device) increases the risk whereas oral pill do not.

Drugs, chemicals and noxious agents -
Anaesthetic gases, arsenic, lead, formaldehyde increases the risk.

Miscellaneous - 
Exposure to electro-megnetic radiation from video display terminals does not increase the risk. Woman can safely use hair dyes, watch television and fly in airlines during pregnancy.

How the genetic factor is responsible for abortion

Majority (50%) of early miscarriage are due to chromosomal abnormality in the conceptus.

Autosomal trisomy is the commonest cytogenetic abnormality about 50%. Trisomy for 

every chromosome except chromosome 1 has been reported. 

Trisomy 16 is the most common trisomy in human pregnacies, occuring in more than 

1% of pregnancies. Only those pregnancies in which some normal cells occur in addition 

to the trisomy cells, survive. This condition usually results in spontaneous miscarriage in 

the first trimester. 

Structural chromosomal rearrangements are observed in 2-4% of abortuses.  These includes 

translocation, deletion, inversion and ring formation. Other chromosomal abnormalities 

like mosaic, double trisomy etc are found in about 4% of abortuses.

Mechanism of abortion process

In the early weeks, death of the ovum occurs first, followed by its expulsion. In later weeks, maternal environmental factors are involved leading to expulsion of the fetus which may have signs of life but is too small to survive.

• Before 8 weeks :- The ovum, surrounded by the villi with the decidual coverings, is expelled out intact. Sometimes, the external opening of cervix fails to dilate so that the entire mass is accommodated in the dilated cervical canal and is called cervical abortion.

• 8-14 weeks :- Expulsion of the fetus commonly occur leaving behind the placenta and the membranes. A part of it may be partially separated with brisk haemorrhage or remains totally attached to the uterine wall.

• Beyond 14th week :- The process of the expulsion is similar to that of a ''mini labour''. The fetus is expelled first followed by expulsion of the placenta after a varying interval.

What is spontaneous abortion (miscarriage)

According to WHO ''Abortion is the expulsion or extraction from its mother of an embryo
or fetus weighting 500 gm or less when it is not capable of independent survival.''
This 500 gm of fetal development is attained approximately at 22 weeks of gestation.
The expelled embryo or fetus is called abortus. The term miscarriage, which is mostly used,
is synonymous with spontaneous abortion.

Incidence -: 10-20% of all clinical pregnancies.

Common causes of abortion -

In first trimester :-

• Genetic factors
• Endocrine disorders
• Immunological disorders
• Infection

In second trimester :-

• Anatomical abnormalities
• Cervical incompetence
• Maternal medical illness
• Unexplained

Haemorrhage in early pregnancy

In early pregnancy, woman might get some light bleeding called 'spotting', when the foetus 
plants itself into the wall of uterus. This is also known as implantation bleeding and it often 
occurs after the missed period.

During the first three months of pregnancy, vaginal bleeding can be a sign of miscarriage or 
ectopic pregnancy (when the foetus starts to grow inside fallopian tubes instead of womb). 
Most miscarriages occur during the first 12 weeks of pregnancy and, most cannot be prevented. 

The causes of bleeding in early pregnancy are broadly divided into two groups.

• Those related to pregnant state :- This group relates to abortion (95%), ectopic pregnancy and implantation bleeding.
• Those associated with pregnant state :- The lesions are unrelated to pregnancy. Cervical lesions such as vascular erosion, polyp, ruptured varicose vein and malignancy are important causes.

Abruptio placentae (Early separation of placenta)

Abruptio placenta is defined as one form of antepartum haemorrhage where the bleeding
occurs due to premature separation of normally situated placenta. It is also called
placental abruption.

Varieties -
1. Revealed - Following separation of the placenta, the blood insinuates downwards
between the membranes and the decidua. Ultimately, the blood comes out of the cervical
canal to be visible externally. This is the commonest type.

2. Concealed - The blood collects behind the separated placenta or collected in between
the membranes and decidua. The collected blood is prevented from coming out of the
cervix by the presenting part which presses on the lower segment. At this times,
the blood may percolate into the amniotic sac after rupturing the membranes. In any of
the circumstances blood is not visible outside. This type is rare.

3. Mixed - In this type, some type of the blood collects inside (concealed) and a part is
expelled out (revealed).

Incidence - The overall incidence is about 1 in 150 deliveries.

Etiology -
- Hypertension in pregnancy.
- Trauma.
- Sudden uterine decompression.
- Short cord.
- Sick cord.
- Folic acid deficiency.
- cocaine abuse.

Clinical classification -

Depending upon the degree of placental abruption and its clinical effects, clinical classification 

is as follows:

Class 0 (Asymptomatic) - characteristics include the following:

• - Clinical feature may be absent.
• - The diagnosis is made after inspection of placenta following delivery.

Class 1 (Mild) - characteristics include the following:

• - External bleeding is slight.
• - Slightly tender uterus.
• - Normal maternal BP and heart rate.
• - No fetal distress.

Class 2 (Moderate) - characteristics include the following:

• - Vaginal bleeding mild to moderate.
• - Uterine tenderness is always present.
• - Maternal tachycardia.
• - Fetal distress.
• - Shock is absent.

Class 3 (Severe) - characteristics include the following:

• - Bleeding is moderate to severe or may be concealed.
• - Very painful tetanic uterus.
• - Maternal shock is pronounced.
• - Fetal death.
• - Shock is pronounced.

Sign and symptoms -

- Dark red bleeding.

- Abdominal pain and bleeding.

- Shock.

- PIH (pregnancy induced hypertension).

- Anemia.

- Pre-eclampsia.

- Uterine tenderness and hard.

- Low Hb level.

- Headache and vomiting may be present.

Management - 

Prevention -

- To detect the causes which produce placental separation. 

- To minimize and correct the anemia during antenatal period.

- Avoidance of trauma.

- To avoid sudden decompression of the uterus.

- Routine administration of folic acid.

Cause of bleeding in placenta previa

As the placenta growth slows down in later months and the lower segment
progressively dilates, the inelastic placenta is sheared off the wall of the lower
segment. This leads to opening up to utero-placental vessels and leads to an 
episode of bleeding. As it is a physiological phenomenon which leads to the
separation of the placenta, the bleeding is said to be inevitable. However,
the separation of the placenta may be provoked by trauma including vaginal
examination, coital act, external version or during high rupture of the membranes.
The blood is almost always maternal, although fetal blood may escape from the
torn villi specially when the placenta is separated during trauma.

The mechanisms of spontaneous control of bleeding are :
1. Thrombosis of the open sinuses.
2. Mechanical pressure by presenting part.
3. Placental infarction.

Cause of implantation of placenta in lower uterine segment

The exact cause of implantation of the placenta in the lower segment is not known.
The following theories are postulated :

1. Dropping down theory - The fertilized ovum drops down and is implanted in the
lower segment. Poor decidual reaction in the upper uterine segment may be the cause.
This explains the formation of central placenta praevia.

2. Defective decidua, resulting in spreading of the chorionic villi over a wide area in
the uterine wall to get nourishment. During this process, not only the placenta becomes
membranous but encroaches onto the lower uterine segment.

3. The formulation of capsular placenta - For chorion coming in contact with decidua
vera of the lower segment.

4. Big surface area of the placenta as in twins may encroach onto the lower segment.

The predisposing factors for placenta praevia -
- Multiparity.
- Increased maternal age (more than 35 years).
- History of previous caesarean section.
- Placental size.
- Smoking causes placental hypertrophy.

Placenta previa (Implantation of placenta in lower uterus)

When the placenta is implanted partially or completely over the lower uterine segment,
it is called placenta previa. When the inelastic placenta sheared off by the dilation of
lower uterine segment for expulsion of fetus, leads to bleeding.

Incidence - 1 in 200 deliveries in the hospital.

Cause -
The exact cause of implantation of the placenta in the lower segment is not known.
It is more common in women who have:
- Abnormally shaped uterus 
- Many previous pregnancies
- Multiple pregnancy (twins, triplets, etc.)
- Due to history of surgery, c-section, previous pregnancy, or abortion.

Women who smoke or have their children at an older age may also have an increased risk.

Types or degrees -
There are 4 types of placenta previa depending upon the degree of extension of placenta
to the lower segment.

1. Type I (low lying) - The major part of the placenta is attached to the upper segment
   and only the lower margin encroaches to the lower segment but not upto the cervical
   os (opening).

2. Type II (marginal) - The placenta reaches the marginal of the internal os but not cover it.

3. Type III (incomplete or partial central) - The placenta cover the internal os partially.

4. Type IV (central or total) - The placenta completely covers the internal os even after
    it is fully dilated.

Symptoms -
The only symptoms of placenta previa is vaginal bleeding. The classical features of bleeding
are sudden onset, painless, apparently causeless and recurrent.

Diagnosis -
This condition is diagnosed by ultrasonography.