Obstetrics Marrow Pg 425-434 (Obstetrics Complications)

Perforation during SFE

• Perforation during SFE can occur when using a dilator or KC (likely a medical abbreviation).
• Signs of perforation include:
  • Loss of resistance.
  • KC going deep inside the uterus.
  • Patient experiencing a rise in pulse rate and a drop in blood pressure, indicating shock.
  • Patient complaining of severe abdominal pain.
• Management of perforation includes:
  • Immediately stopping the procedure.
  • Not removing the KC.
  • Informing a senior consultant.
  • Checking the patient's vital signs.
• If the patient is stable, a diagnostic laparoscopy is performed.
• If the patient is unstable, resuscitative measures are taken followed by a diagnostic laparotomy.

Manual Vacuum Aspiration (MVA) & Menstrual Regulation (MR)

• MVA is an alternative to suction and evacuation (S&E) in rural areas where electricity is not available.
• MR is considered outdated.
• MVA requires a specific syringe with two pinch valves and a KC, while MR requires a single pinch valve syringe.

Obstetric Complications Based on Gestational Age

T1

• Medical abortion options include:
  • Mifepristone + Misoprostol.
  • Suction evacuation.
  • Manual vacuum aspiration (MVA).

T2

• Medical abortion options (require inpatient procedures) include:
  • Prostaglandins: misoprostol/Carboprost/Dinoprostone.
  • Oxytocin.
  • Extra-amniotic Ethacridine instillation.
  • Intra-amniotic saline.
• Other options for T2 complications include:
  • Suction evacuation.
  • Dilatation & Evacuation (D&E).
  • Hysterotomy: A procedure to open the uterus to remove the products of conception.

1st Trimester Abortions: Medical Abortions

• Timing: Up to 9 weeks (63 days)
• Drugs used:
  • Mifepristone: Oral
  • Misoprostol: Oral/sublingual/per-vaginal/per-rectal.
• Mechanism of Action:
  • Mifepristone (RU 486): Progesterone antagonist leading to detachment of the implanted embryo.
  • Misoprostol: Promotes uterine contraction, cervical ripening and softening, leading to the expulsion of the detached embryo.
• Bleeding typically occurs after misoprostol.
• Protocol:
  • Day 1: Tab.mifepristone 200mg - single tablet orally
  • Day 3: Tab.misoprostol 800 mcg - Vaginal > Sublingual (OTC) >> Oral (ISE)
  • Bleeding occurs within 14-6 hours
  • Day 15: Follow-up to ensure complete abortion. USG in MTP - Not routinely required
• Indications:
  • Patient uncertain of last menstrual period (LMP).
  • Size of uterus doesn't match the gestational period.
  • Patient experiencing pain/continuous spotting with the internal os open on day 15.

Outcome of Tubal Abortion and Tubal Rupture

• Tubal abortion: Occurs in the fimbrial end of the fallopian tube.
  • Most common site: Ampulla.
• Tubal rupture: Occurs due to continuous growth of the ectopic pregnancy.
  • Most common site: Isthmus.

Criteria for Various Sites of Ectopic Pregnancy

Risk Factors and Clinical Features of Ectopic Pregnancy

Risk Factors

• PID/Salpingitis: most common.
• Previous history of ectopic/tubal surgeries - Highest risk.
• Cervicitis.
• Multiple partners.
• Smoking.
• Risk factors for PID.
• Previous history of C-section.
• Infertility & ART (Assisted reproductive techniques).
• Contraceptives: Increased risk of ectopic pregnancy.
  • Lower absolute risk (chance of pregnancy).
  • Higher relative risk (chance of ectopic pregnancy if pregnancy occurs).
  • Highest risk is associated with:
    • Tubal ligation > Progesterone IUD (mirena, progestasert) > Cu-IUD.
    • POP > OCP (Progesterone - smooth muscle relaxant leading to decreased peristalsis).

Medical Termination of Pregnancy (MTP) Act & Methods

• Amendments 2021:
  • MTP for Congenital Anomalies: Up to 24 weeks.
  • MTP for Contraceptive Failure: Up to 20 weeks.
  • Severe Congenital Anomalies: No upper limit. Requires approval by a medical board.
• Composition of Medical Board:
  • Gynecologist.
  • Radiologist.
  • Paediatrician.
  • Person assigned by the State.
• Indications for MTP:
  • Rape.
  • Contraceptive Failure.
  • Saving the life of the pregnant female.
  • Preventing serious physical or mental injury to the mother.
  • Preventing a fetus with physical or mental abnormalities from being born.
• Consent Requirements for MTP:
  • For patients under 18 years old: Guardian required.
  • For patients with mental instability: Guardian required.
• Approval Requirements for MTP:
  • Up to 20 weeks: Single doctor's approval.
  • 20-24 weeks: Approval required from two doctors.
• Records Required for MTP:
  • Marriage proof (Not required).
  • FIR report of rape (Not required).
• Qualifications for Performing MTP:
  • MD/MS/DGO/DNB in Obstetrics & Gynaecology (OBG).
  • Registered medical practitioner.
  • Assisted in 25 MTPs + primary surgeon in 5 of them.
  • House job in OBG x 6 months.
  • Worked in the OBG department of a multispecialty hospital for 1 year.
• Methods of MTP Based on Technique:

  	Medical Abortion	Surgical Abortion
  Advantages	* Non-invasive * Surgical expertise not required * No surgical/anaesthetic complications	* Fast procedure * One time completion * One step procedure
  Disadvantages	* Surgical option on failure * Multiple step, longer procedure	* Invasive * Surgical & anaesthetic complications

Types of Abortion

• Abbreviations:
  • POC: Products of conception.
  • POG: Period of gestation.
  • UPI: Unexplained Pregnancy Issue.
  • UPT: Urine Pregnancy Test.
  • LSCS: Lower Segment Cesarean Section.
  • APS: Antiphospholipid Syndrome.

Missed Abortion

Abortion + Features of Shock

• Most common cause: Septic abortion > Incomplete abortion.
• History of abortion + ↑ APTT: APLA syndrome.

Septic Abortion

• Septic foci in any abortion.
• Symptoms:
  • Fever, chills.
  • Abdominal pain.
  • Diarrhea, vomiting.

Grading of Septic Abortion

• Note: TSS (Toxic Shock Syndrome) is never caused by E.coli.

Management of Septic Abortion

• Features of septic abortion include:
  • Purulent vaginal discharge.
  • May present as shock (Toxic shock syndrome).
• Management includes:
  • Ampicillin + Gentamycin + metronidazole.

Medical Abortion in Second Trimester

• Drugs: Prostaglandins (Best)
  • i. misoprostol (PGE1) - Best
  • ii. Dinoprostone (PGE2)
  • iii. Carboprost (PGF2α)
• Dose: misoprostol 400mcg every 3 hours
• Maximum doses: 5 doses
• Patient admission: Required.
• Potential Complications: Patient may experience miniature labor. Products of conception are expelled out.
• Note: Mifepristone should not be used in second trimester pregnancy.

Surgical Abortion in Second Trimester

• Methods:
  • Dilatation & Evacuation (D&E):
    • Most common method.
    • Instruments used:
      • Ovum forceps/Sponge holding forceps.
  • After procedure: Blunt curettage.
    • Spoon-shaped forceps (with ratchet locks).
• Additional Note:
  • Always perform blunt curettage in a pregnant uterus.
  • Exception: After severe molar pregnancy or failed medical abortion using misoprostol.
    • Misoprostol (Teratogenic) → Moebius Syndrome.
    • Pregnancy will likely not continue.

Management of Certain Conditions

• If history of thrombosis or abortion: Heparin + Aspirin.
• If history of preterm labor (due to UPI): Aspirin.
• Aspirin started when intrauterine pregnancy is diagnosed (UPT +ve).
• Heparin started once intrauterine pregnancy confirmed.
• Anticoagulants are stopped intrapartum.
• Continued post-partum:
  • a. 6 hours after vaginal delivery.
  • b. 12 hours after LSCS.
• APS in non-pregnant female with history of thrombosis: Warfarin (DOC).

Role of Progesterone & Basics of Ectopic Pregnancy

• Role of Progesterone:
  • Corpus luteum secretes progesterone.
  • Progesterone levels are higher in ectopic pregnancy compared to the non-pregnant state, but lower than in intrauterine pregnancy.
  • Decidualization of the endometrium:
    • USG - Pseudogestational sac.
    • Decidua vera +: Not differentiated into decidua basalis/capsularis/parietalis.
• Anatomy of fallopian tube:
  • Parts (medial to lateral): Interstitium (Intramural) > Isthmus > Ampulla > Infundibulum.
  • Narrowest part: Interstitium > Isthmus.
  • Sphincters:
    • Anatomical: Interstitium.
    • Physiological: Isthmus.
• Duration of Ectopic pregnancy:
  • Lasts longest: Interstitium (due to myometrial support).
  • Most dangerous site of ectopic pregnancy (↑ bleeding): Interstitium.
  • Ends earliest: Isthmus.
• Site of Ectopic pregnancy:
  • Fallopian tube: most common.
    • Most common part: Ampulla (a site of fertilization, maximum number of plicae (mucosal folds)).
  • Non-tubal sites:
    • Most common non-tubal site: ovary.
    • Less common: C-section scar > Cervical ectopic > Abdominal ectopic (lasts longest; derives blood supply from adjacent organs).
• Other details:
  • Decidual cast +/- (Shedding of decidua).
  • Placenta.

Instrument Details (Suction and Evacuation)

• Karman's Cannula:
  • Description: Plastic cannula with triangular openings.
  • Number: No. of the cannula = Diameter of cannula (in mm).
  • Size: Size = Period of gestation (Or 1 less).
  • Uses: Suction & Evacuation (SEE).
• Other Instruments/Procedures:
  • Vulsellum: Hold the cervix.
  • Sponge Holding Forceps: Hold the cervix.
  • Paracervical Block: Anesthesia for SSE.
  • Uterine Sound: Measures uterocervical length and confirms the position of the uterus. Acts as a first dilator.
  • Olive Tipped Calibrated Uterine Sound: Measures uterocervical length.
  • Hegar's Dilator: Used to dilate the internal os.
  • Injection Sites:
    • 12 o'clock position: Site to hold cervix (and 2, 4, 8, 10 o'clock positions).
    • Not given: 3 & 9 o'clock.
  • Injection site for tenaculum: 12 o'clock.
  • Injection Sites (Other): 2, 4, 8, 10 o'clock.
• Anesthesia: Paracervical block with 1% lignocaine.
• Maximum number of KC used for SSE: 16.
• Pressure Generated during SSE: ≥ 600 mmHg.
• End Point: Blood loss, Air bubbles in KC, Grating sensation over uterus, Internal os starts closing → Gripping sensation over the KC.
• Possible Complications: Incomplete abortion, missed abortion, endometrial biopsy.

Treatment of Absent Cardiac Activity

• Repeat 400-800 mcg misoprostol after 7 days.
• Follow up with a medical professional.

Suction & Evacuation (S&E)

• Best method of medical termination of pregnancy (MTP): Between 9-12 weeks.
• Performed until 16 weeks.

Pre-requisites for Suction & Evacuation (S&E)

• ABO/Rh grouping.
• Pregnancy test (if not done with Nischay card).
• Confirm Size & Position (Anteverted):
  • Empty bladder.
  • Pelvic examination in lithotomy position.
  • Posterior vaginal wall: Sim's speculum.
  • Anterior vaginal wall: Anterior vaginal wall retractor.

Procedure for Suction & Evacuation (S&E)

1. Empty bladder.
2. Pelvic/Vaginal (P/V) examination in lithotomy position (confirm size & position - anteverted/retroverted).
3. Retract vaginal walls.
4. Use Hegar's dilators to dilate the internal os.
5. Insert a triangular Karman's Cannula.
6. Attach to a suction machine to evacuate products of conception.

This quiz covers critical knowledge on managing perforation during SFE, including signs, immediate actions, and further procedures. Additionally, it explores the Manual Vacuum Aspiration (MVA) method and its relevance compared to menstrual regulation. Test your understanding of these important medical practices.