threatened abortion
TRANSCRIPT
MANAGEMENT OF THREATENED ABORTION
Dr. Bushra Hasan Khan
JR-1
Department of Pharmacology
JNMC, AMU, Aligarh.
Threatened Abortion
A clinical entity where the process of abortion has
started, but has not progressed to a state where recovery
is impossible.
The clinical diagnosis of threatened abortion is
presumed when a bloody vaginal discharge appears
through a closed cervical os during the first half of
pregnancy.
Threatened Abortion is the most common complication
in the first half of pregnancy.
Its incidence varies between 20-25%.
Miscarriage is 2.6 times as likely
17% of cases are expected to present complications later
in pregnancy.
ETIOLOGY
Embryonic abnormalities
Maternal factors
Anatomic factors
Endocrine factors
Infectious factors
Immunologic factors
CLINICAL FEATURES
The pregnant patient complains of :
• Bleeding per vaginum
• Pain
INVESTIGATIONS
Blood
Urine
Pelvic examination
Ultrasonography
Transvaginal Sonography
Well formed gestational sac
Observation of fetal cardiac activity
With these there is about 98% chance of continuation of
pregnancy.
Sonography can usually differentiate between an intrauterine
pregnancy (viable or non-viable), a molar
pregnancy, or an inevitable abortion.
Serum Progesterone value
25 ng/ml or more – a viable pregnancy in about
95% cases
Serial serum beta HCG level
20 ng/ml or more – viable pregnancy
To assess the level of fetal well being
Adverse Prognostic factors in cases of Threatened Abortion
A large empty gestational sac
Discrepancy : gestational age and crown to rump length
Fetal bradycardia or absence of fetal heart activity
Advanced maternal age
History of recurrent pregnancy loss
Maternal serum Progesterone < 25 ng/ml or
low maternal serum hCG
Complications
These fetuses are at increased risk for intrauterine
growth retardation, preterm delivery, low birthweight,
and perinatal death.
Maternal risks include antepartum hemorrhage, manual
removal of the placenta, and cesarean delivery.
Management
Bed rest
Paracetamol
Progesterone therapy
hCG therapy
Tocolytic agents
“There is insufficient evidence of high quality that
supports a policy of bed rest in order to
prevent miscarriage in women with confirmed fetal
viability and vaginal bleeding in first half of pregnancy”.
Progesterone therapy
Oral micronized Progesterone : 200mg OD or BD.
Vaginal progesterone suppositories : 200mg OD or BD.
Progesterone vaginal gel : 100mg two or three times/day
Intramuscular Progesterone : Injection in oil given as
50mg /day.
• “Use of progestogens is effective in the treatment of threatened
miscarriage with no evidence of increased rates of pregnancy-
induced hypertension or antepartum haemorrhage as harmful
effects to the mother, nor increased occurrence of congenital
abnormalities on the newborn”.
•“However, the analysis was limited by the small number and
the poor methodological quality of eligible studies (four studies)
and the small number of the participants (421), which limit the
power of the meta-analysis and hence of this conclusion”.
“The current evidence does not support the routine use
of hCG in the treatment of threatened miscarriage”.
Tocolytics
Adrenergic receptor agonists
Ca2+ channel blockers
Oxytocin-receptor antagonist: Atosiban
Nitric oxide donors
Magnesium sulphate
Cycloxygenase inhibitors
Sites of action of tocolytic drugs in the uterine myometrium
Ritodrine
Started as 50 µg/min i.v. infusion
Rate of infusion is increased every 10 minutes till
uterine contractions cease or maternal heart rate
rises to 120/min.
Contractions can also be kept suppressed by 10 mg i.m.
4-6 hourly followed by 10 mg oral 4-6 hourly.
Side effects & contraindications
Tachycardia, Hypotension, Pulmonary Edema.
Hypergylycemia, Hypokalemia.
Anxiety, Restlessness, Headaches.
Fetal pulmonary edema.
Neonate may develop hypoglycemia and ileus.
Its use is contraindicated if mother is diabetic, having
heart disease, or receiving beta blockers.
Ca2+ channel blockers
Relative to Beta2 adrenergic agonists, Nifedipine is more
likely to improve fetal outcomes and less likely to cause
maternal side effects.
Oral Nifedipine 10 mg repeated once or twice after
20-30 min, followed by 10 mg, 6 hourly has been used.
Nifedipine: side effects
Maternal flushing
Headache, Dizziness, Nausea
Transient hypotension and Tachycardia, Palpitations.
Fetal hypoxia associated with maternal
Hypotension.
Oxytocin receptor antagonists
Atosiban : a peptide analogue of Oxytocin
Competitively inhibits the interaction of Oxytocin with
its membrane receptor on uterine cellsdecreases the
frequency of uterine contractions.
Intravenous use
6.75 mg bolus, followed by 300µg/min infusion for 3
hours. Then 100µg/hour for upto 45 hours.
Nitroglycerine
Nitric oxide is a potent vasodilator and smooth muscle
relaxant.
The major adverse effect is maternal hypotension.
Dose; 50-200µg intravenously.
Can consider repeating dose after 1-4 minutes if
inadequate response occurs.
Magnesium Sulphate
Administered intravenously ; 4-6 g loading dose,
then 2-4 g/hour titrated to uterine response and
maternal toxicity.
Two reviews demonstrate magnesium sulphate to be
ineffective as a tocolytic.
Side effects of magnesium sulphate
Maternal flushing,
Sweating,
Respiratory depression,
Bradycardia,
Myocardial depression,
Loss of deep tendon reflexes,
Neuromuscular blockade.
“There is insufficient evidence to support
the use of uterine muscle relaxant drugs
for women with threatened miscarriage”.
“Any such use should be restricted to the
context of randomised trials”.
Cycloxygenase inhibitor
Indomethacin
Use is controversial.
Anti-D Immunoglobulin
The Rh-negative woman is given anti-D
immunoglobulin following abortion.
This practice is controversial with threatened abortion
because it lacks evidence-based support (American
College of Obstetricians and Gynecologists, 1999;
Weissman and associates, 2002).