Obstetrics Marrow Pg 425-434 (Obstetrics Complications)

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Questions and Answers

What is an initial step to take if perforation occurs during SFE using a dilator?

Stop procedure and proceed to remove the dilator

Continue the procedure

Inform the senior consultant immediately

Stop procedure and wait & watch (correct)

If a patient shows loss of resistance and severe abdominal pain during the use of KC, it's recommended to continue the procedure without informing anyone.

False

What equipment is required for Manual Vacuum Aspiration (MVA)?

MVA syringe and KC

During an episode of shock, the patient's _____ will typically show an increase in pulse rate and a decrease in blood pressure.

vitals Signup and view all the answers

Match the following procedures with their characteristics:

MVA = Alternative to S&E in rural areas MR = Outdated procedure Stable = Diagnostic laparoscopy Unstable = Resuscitative measures + Diagnostic laparotomy Signup and view all the answers

What is the primary mechanism of action of Mifepristone?

Acts as a progesterone antagonist Signup and view all the answers

Medical abortions using Mifepristone and Misoprostol can be performed safely up to 12 weeks of gestation.

False Signup and view all the answers

What is the follow-up time after administering Mifepristone and Misoprostol to ensure complete abortion?

Day 15 Signup and view all the answers

The drug _____ is used orally for medical abortion in the first trimester.

Mifepristone Signup and view all the answers

Match the following drugs with their primary purposes:

Mifepristone = Progesterone antagonist Misoprostol = Promotes uterine contractions Oxytocin = Stimulates contractions during labor Carboprost = Used for managing postpartum hemorrhage Signup and view all the answers

What is the most common site for a tubal abortion?

Ampulla Signup and view all the answers

Cervicitis is a risk factor for ectopic pregnancy.

True Signup and view all the answers

What is the highest risk factor for ectopic pregnancy?

Previous history of ectopic/tubal surgeries Signup and view all the answers

The most common cause of ectopic pregnancy is __________.

PID/Salpingitis Signup and view all the answers

Match the risk factors with their descriptions:

PID/Salpingitis = Most common risk factor for ectopic pregnancy Previous C-section = Increases the risk of future ectopic pregnancies Smoking = Contributes to higher chances of ectopic pregnancy Multiple partners = Associated with the risk of PID Signup and view all the answers

What is the recommended best method for medical termination of pregnancy between 9-12 weeks?

Suction & Evacuation Signup and view all the answers

Patients with an Hb level of 9 g/dL require follow-up after the medical termination procedure.

False Signup and view all the answers

What is the first step in the procedure for Suction & Evacuation?

Empty bladder Signup and view all the answers

After confirming the size and position of the uterus, the next step is to insert a triangular _______ after dilating the internal os.

Karman's Cannula Signup and view all the answers

Match the following complications with their corresponding criteria for follow-up:

Excessive bleeding = Hb < 8 g/dL Incomplete abortion = Patient not compliant to follow up Uncontrolled Hypertension = BP ≥ 160/100 mmHg Uncontrolled seizures = Presence of seizures Signup and view all the answers

What is the primary use of Karman's Cannula?

Suction & Evacuation (SEE) Signup and view all the answers

The maximum number of Karman's Cannula used for suction and evacuation is 12.

False Signup and view all the answers

What is the pressure generated during suction and evacuation (SSE) using Karman's Cannula?

≥ 600 mmHg Signup and view all the answers

The injection site for the tenaculum is at the _____ o'clock position.

12 Signup and view all the answers

Match the instruments with their uses:

Vulsellum = Used to hold the cervix Hegar's Dilator = Used to dilate the internal os Uterine Sound = Measures uterocervical length Sponge Holding Forceps = Used to hold the cervix Signup and view all the answers

What is the maximum period for MTP in cases of congenital anomalies according to the 2021 amendments?

Up to 24 weeks Signup and view all the answers

Only one doctor's approval is required for an MTP procedure up to 24 weeks.

False Signup and view all the answers

What is required for patients under 18 years old to consent for an MTP?

Guardian consent Signup and view all the answers

MTP for severe congenital anomalies requires __________ from a medical board.

approval Signup and view all the answers

Match the MTP methods with their characteristics:

Medical Abortion = Non-invasive, longer procedure Surgical Abortion = Invasive, fast procedure Signup and view all the answers

What is the most common cause of abortion-related complications?

Septic abortion Signup and view all the answers

Toxic shock syndrome can be caused by E. coli.

False Signup and view all the answers

What are the symptoms of septic abortion?

Fever, chills, abdominal pain, diarrhea, vomiting Signup and view all the answers

The most effective management for septic abortion includes _____, Gentamycin, and metronidazole.

Ampicillin Signup and view all the answers

Match the grades of septic abortion with their descriptions:

Grade 1 = Infection limited to uterus Grade 2 = Infection spreads to pelvic organs Grade 3 = Peritonitis/shock/renal failure Signup and view all the answers

What is the initial treatment for a patient with a history of thrombosis and abortion?

Heparin and Aspirin Signup and view all the answers

A threatened abortion requires immediate surgical intervention.

False Signup and view all the answers

What is the standard time to restart anticoagulants after a vaginal delivery?

6 hours Signup and view all the answers

In the case of a complete abortion, the status of the uterus is typically _____ and will show no current bleeding.

empty Signup and view all the answers

Match the type of abortion with its appropriate management:

Threatened abortion = Reassurance and avoid intercourse Inevitable abortion = Expedite abortion process Incomplete abortion = Maintain vitals and expedite abortion Complete abortion = Reassurance and Anti-D if Rh +ve Signup and view all the answers

Which part of the fallopian tube is the most common site for ectopic pregnancies?

Ampulla Signup and view all the answers

Progesterone levels in ectopic pregnancy are higher than in a non-pregnant state.

True Signup and view all the answers

What is the least dangerous site of ectopic pregnancy?

Isthmus Signup and view all the answers

The __________ is the most common non-tubal site for ectopic pregnancy.

ovary Signup and view all the answers

Match each part of the fallopian tube with its characteristic:

Interstitium = Narrowest part of the fallopian tube Isthmus = Most dangerous site for ectopic pregnancy Ampulla = Most common site for fertilization Infundibulum = Funnel-shaped end of the fallopian tube Signup and view all the answers

Which drug is considered the best for medical abortion?

Misoprostol Signup and view all the answers

Blunt curettage should never be performed in a pregnant uterus.

False Signup and view all the answers

What is the maximum number of doses of misoprostol that can be administered for medical abortion?

5 Signup and view all the answers

The most common surgical method for abortion is __________.

Dilatation & Evacuation (D&E) Signup and view all the answers

Match the following drugs with their associated risks or characteristics:

Misoprostol = Teratogenic effects leading to Moebius Syndrome Mifepristone = Not used in 2nd trimester pregnancy Dinoprostone = Prostaglandin PGE2 Carboprost = Prostaglandin PGF2α Signup and view all the answers

Study Notes

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

Site	Criteria
Cervical	Paalman (New), Rubin (Obsolete)
1° Abdominal	Studdiform, Spiegelberg
Ovarian
2° Abdominal	From fimbrial end

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

Type	c/o	Height of uterus P/A	Internal OS	USG	Management
Threatened abortion	Spotting P/v.	Equal to POG	Closed	Cardiac activity +	Reassurance. Advice to avoid intercourse.
Inevitable abortion	Bleeding P/v.	Equal to POG	Open	Cardiac activity absent	Expedite abortion process by medical abortion/suction & evacuation.
Incomplete abortion	Bleeding + Pain abdomen + H/o expelled POC	< POG	Open + POC seen coming	Incomplete POC	Maintain vitals if in shock. Expedite abortion.
Complete abortion	H/o bleeding + POC expelled with no current bleeding	< POG	Closed	Empty uterus	Reassurance. Anti-D if Rh +ve.

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

Type	c/o	Height of uterus P/A	Internal OS	USG	Management
Missed abortion: USG based diagnosis	No symptoms; may have brown discharge	≤ POG	Closed	mean sac diameter ≥25 mm + no fetal pole; OR Crown rump length 27mm + Absent cardiac activity; OR Cardiac activity present earlier, absent now	Medical abortion; OR Suction evacuation

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

Grade	Description
1	Infection limited to uterus.
2	Infection spreads to pelvic organs.
3	Peritonitis/shock/renal failure.

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)

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

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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.