Types of abortions & Theatened abortion

Types of abortion:

There are two main groups and seven subgroups in abortions.

Spontaneous abortions: threatened, inevitable, incomplete, missed, recurrent

Induced abortions: therapeutic, elective.

Legally induced abortion is a relatively safe procedure, especially when performed during first 2 months of pregnancy.

In it the risk of death is 0.7/100,000 procedures.

This risk doubles with each 2 weeks of delay after 8 weeks of gestation.

Threatened abortion:

-          When any bloody vaginal discharge or bleeding appears during the first half of the pregnancy the possibility of threatened abortion can be presumed.

-          In it bleeding usually begins first followed by cramping abdominal pain a few hours to several days later.

-          Threatened abortion is commonly seen in one out of four or five women with vaginal spotting or bleeding in early pregnancy.

-          Half of these women will abort.

-          The unaborted women will have increased risk of suboptimal pregnancy outcomes such as preterm delivery, low birth weight and perinatal death.

-          The risk of malformed infant does not increase usually.

Differential diagnosis:

-          Patient should be carefully examined to rule out the possibility of dilated cervix., which will make the abortion inevitable.

-          To rule out ectopic pregnancy or torsion of unsuspected ovarian cyst.

Treatment:

-          Bed rest at home.

-          Analgesia to relieve the pain.

-          If bleeding becomes serious and persistent reexamination and hematological evaluation should be done.

-          If blood loss is more and causing anemia or hypovolemia etc. evacuation of the pregnancy is indicated generally.

-          Sometimes slight bleeding may persist for weeks. In that case vaginal sonography, estimation of serial serum quantitative hCG levels, serum progesterone levels in alone or in various combinations help in ascertaining a live intrauterine pregnancy.

-          Rh-ve pregnancy with a threatened abortion should receive anti-D immunoglobulin. Because more than 10% of such women have significant fetomaternal hemorrhage.

Early pregnancy loss (abortion or miscarriage)

Definition:

-          Abortion is defined as termination of pregnancy either spontaneously or intentionally before 20 weeks based upon the date of the first day of the last normal period.

-          One more definition is delivery of a fetus – neonate that weighs less than 500gms.

-          Definitions can vary according to state laws.

Usually more than 80% of abortions occur in the first 12 weeks.

In them chromosomal anomalies are responsible for at least half of the cases.

Causes :
- Defective implantation.
-Defective development of the embryo.
-Nonembryonic pregnancy or blighted ovum.
Above two can occur due to defective sperm or defective ovum or both.
- Maternal infections like rubella, chlamydia etc.
- Deficiency of progesterone or human chorionic gonadotropin etc.
- Traumatic causes like fall etc.

Risk factors:

-          The risk of spontaneous abortion increases with parity, maternal and paternal age.

-          The risk of clinically recognized abortion is 12% in women with age less than 20 years, whereas the risk increases to 26% in women with age more than 40 years.

-          The incidence increases if a women conceives within three months of a term birth.

The impact of abortion on future pregnancies and possible complications:

-          Usually fertility is not altered by an abortion.

-          There is some possibility for pelvic infection.

-          Multiple sharp curettage abortion procedures may result in increased risk of placenta previa.

-          But usually vaccum aspiration may not lead to future complications.

-          Septic abortion:

Ø      It is a serious complication most often associated with criminal abortion.

Ø      Usually severe hemorrhage, sepsis, bacterial shock and acute renal failure etc features can be seen.

Ø      These can develop in legal abortions also but with very less frequency.

Ø      Metritis can be seen. Sometimes parametritis, peritonitis, endocarditis, septicemia etc can also occur.

Ø      Usually two thirds of the septic abortions occur due to anaerobic bacteria.

Ø      Coliforms, haemophilus influenzae, campylobacter jejuni, Group-A streptococcus etc are other organisms.

Treatment:

Ø      Broad spectrum antimicrobials intravenously.

Ø      If sepsis and shock supervenes supportive care is needed.

Ø      Disseminated intravascular coagulopathy  can occur sometimes.

Ovulation resumption after abortion:

-  Sometimes ovulation can resume as early as 2 weeks after an abortion.

-  So effective contraception should be initiated soon after abortion.


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HIV - Pregnancy - 3

Laboratory evaluation:

-          In every 3 to 4 months or approximately in each trimester T-lymphocyte counts or HIV-1 RNA levels should be measured.

-          This will help in altering the therapy, to decide the route of delivery, in starting prophylaxis for pneumocystis carinii pneumonia.

-          Testing for tuberculosis and other STDs should be done.

Prevention of opportunistic infections:

-          Vaccination should be given for hepatitis B, influenza, pneumococcal infections.

-          If CD4+ count falls below 200/micro lit, primary prophylaxis for P.carinii pneumonia is recommended with either sulfamethoxazole – trimethoprim DS 1 tab/day or aerosolized pentamidine.

Prevention of HIV transmission to the infant:

-Preventive measures include – antiretroviral therapy, cesarean delivery and withholding breast feeding.

-With combination antiretroviral therapy transmission rates can be reduced to 1 to 2%.

-If no therapy is used the transmission rate is 10 to 28%.

-Scheduled cesarean delivery is recommended for HIV – infected women with an HIV-1 RNA load of more than 1000 copies/ml regardless of antiretroviral therapy.

-Better to do scheduled cesarean delivery at around 38 weeks o lessen the chances of spontaneous membrane rupture or the onset of labor.

-Some authors contradict the scheduled cesarean delivery as antiviral therapy itself can reduce the risk to 1 to 2%.

-Breast feeding increases the risk of neonatal transmission. As around 16% of breast-fed infants develop infection it is not recommended generally.

Measures to prevent HIV transmission to health-care providers:

-          As history and clinical examination cannot identify reliably all HIV infected patients, better to take blood and body-fluid precautions consistently in all patients.

-          Gloves, surgical masks, protective eyewear, fluid resistant gowns must be worn for all deliveries.

-          While handling the placenta or infant gown and gloves should be used.

-          Mouth-suction devices to clear the airway should be avoided.

-          If a glove is torn or neddlestick or any other  injury occurs glove should be changed as early as possible. That needle or instrument should be removed from sterile field.

-          The health-care workers who got exposed to contaminated fluids like needlestick injury should take post exposure prophylaxis with zidovudine, 200mg thrice a day and lamivudine, 150mg thrice a day for 4 weeks.

-          If the source patient has advanced AIDS or a high load HIV or has been treated with nucleoside analogues, then a protease inhibitor such as Indinavir, 800mg thrice a day should be added.

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HIV - Pregnancy - 2

Serological testing:

-EIA (Enzyme immunoassay) is used as a screening test to detect HIV antibodies.

-A repeated positive screening test is having 99.5% sensitivity.

-For confirmation Western blot or immuno fluorescence assay can be used.

-Usually antibody can be detected in 95% of patients within one month of infection.

-So antibody serotesting does no exclude early infection.

-Early infection can be diagnosed using viral P24 core antigen or viral RNA, DNA.

Mother to infant transmission:

-          Mother to infant transmission is the most common cause of HIV infections among children.

-          Transplacental transmission is possible.

-          Bu usually transmission occurs in peripartum period.

-          Around 15 to 25% of infants born to untreated HIV- infected mothers can get infected.

-          According to the severity of infection and CD4+ cell proportion (<15%) pregnancy complications like preterm delivery, fetal growth restriction, stillbirth etc can occur.

Risk factors for fetus – infant transmission:

-          Maternal plasma HIV -1 RNA viral burden

-          Preterm birth

-          Prolonged rupture of membranes

-          Concurrent genital ulcer disease

-          Breast – feeding

-          Invasive intrapartum monitoring

-          Chorioamnionitis

-          Plasma viral HIV-1 RNA levels have proven to be the best predictor of risk for transmission to the infant.

-          A viral load of less than 1000 copies/ml is associated with lowest risk of transmission. But actually transmission can occur at any threshold level.

Management:

Antiretroviral therapy should be offered to all HIV- infected pregnant women to treat the women and also to reduce the risk of perinatal transmission.

It should be given regardless of CD4+ T cell count or HIV RNA levels.

The approved antiretroviral drugs are categorized into 4 groups.

o       Nucleoside reverse transcriptage inhibitors(NRTI): eg. Abacavir, Zidovudine, Lamivudine.

o       Non nucleoside reverse transcriptage inhibitors(NNRTI): eg. Efavirenz, Nevirapine.

o       Protease inhibitors(PI): eg. Lopinavir/ritonavir, Ritonavir.

o       Fusion inhibitors(FI): eg. Enfuvirtide.

      Most of these drugs belongs to category B,C drugs according to FDA.

      Antiretroviral regimens recommended for HIV-1 treatment in pregnancy are:

v     Protease inhibitor based HAART regimen (NNRTI & FI sparing): eg. Lopinavir/ritonavir + Zidovudine etc.

v     NNRTI based HAART regimen (PI and FI sparing): eg. Nevirapine + lamividine etc.  Efavirenz should be avoided in the first trimester.

v     Triple nucleoside reverse transcriptage inhibitors regimen (NNRTI, PI and FI sparing): eg. Abacavir + lamivudine + zidovudine

It should be used only when an NNRTI or a PI based regimen cannot or should not be used as first-line therapy.

With treatment survival improves and morbidity reduces.

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HIV – Pregnancy - 1

-There are around 40 million HIV/AIDS infected people in the world.

-Around one third of the new cases are resulting from heterosexual transmission. And in them two-thirds are women.

-Incidence of HIV/AIDS in pregnancy varies from 0.3% to 2%.

Causative organisms:

-Acquired immunodeficiency syndrome(AIDS) is caused by DNA retroviruses termed as human immunodeficiency virus, HIV-1 and HIV-2.

-Worldwide most of the cases are caused by HIV-1.

-Whereas HIV-2 infection is endemic in West Africa.

-These retroviruses contain genome that encodes reverse transcription of DNA from RNA.

-So the virus can make its own DNA copies in host cells.

Transmission:

-By infected blood and blood products.

-Sexual transmission by saliva, vaginal secretions and semen.

-It is the major mode of transmission.

-Vertical transmission possibly by placenta and membranes can occur.

-The baby can acquire the infection mainly during labor or after delivery through breast milk.

Clinical features:

Acute illness or acute retroviral syndrome:

-It usually starts within days o weeks after exposure.

-Generally it is similar o other viral syndromes.

-It usually lasts less than 10 days.

-Presenting symptoms:

  Fever

  Nigh sweats

  Fatigue

  Rash

  Headache

  Lymphadenopathy

  Pharyngitis

  Myalgias

  Arthralgias

  Nausea,

  Vomitings & diarrhea etc.

Chronic viremia begins after symptoms abated.

The stimulating factors which lead to further progression of asymptomatic viremia to the immunodeficiency syndrome are not well defined.

Usually the median time is about 10 years.

AIDS:

-HIV positivity in association with any number of clinical findings can be considered as AIDS.

-Generalized lymphadenopathy, oral hairy leukoplakia, opthous ulcers and thrombocytopenia are commonly seen clinical features.

-The opportunistic infections that may herald AIDS are:

Ø      Esophageal or pulmonary candidiasis

Ø      Persistent herpes simplex or zoster

Ø      Condylomata accuminata

Ø      Tuberculosis

Ø      Cytomegalovirus infection

Ø      Molluscum contagiosum

Ø      Pneumocysis infections

Ø      Toxoplasmosis etc.

-Neurological disease is common. About half of patients will have central nervous system symptoms.

-CD4+ count of less than 200/micro lit is also considered diagnostic for AIDS.

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