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Pelvic Inflammatory Diseases (PID)

Pelvic inflammatory disease (PID) refers to various inflammatory conditions affecting the upper genital tract in females.

Pelvic inflammatory diseases are diseases of the upper genital tract.

It is a spectrum of infection and inflammation of the upper genital tract organs involving the endometrium, fallopian tubes, ovaries, pelvic peritoneum and surrounding structures.

Infections, often ascending from the vagina, can lead to salpingitis, endometritis, pelvic peritonitis, or the formation of tubo-ovarian abscesses.

Aetiology of Pelvic Inflammatory Diseases

Exact cause is unknown but PID is often attributed to multiple pathogens, including

Neisseria Gonorrhoeae: A bacterium that causes the sexually transmitted infection gonorrhoea. If left untreated, gonorrhoea can ascend from the cervix to the upper reproductive organs, leading to PID.
Chlamydia Trachomatis: The bacterium responsible for chlamydia, another common sexually transmitted infection. Chlamydia can infect the cervix and ascend to the uterus and fallopian tubes, leading to PID.
Mycoplasma: Certain species of Mycoplasma, such as Mycoplasma genitalium, have been implicated in PID. These bacteria can cause inflammation and infection in the reproductive tract.
Gardnerella Vaginalis: An overgrowth of Gardnerella vaginalis can lead to bacterial vaginosis, an imbalance of vaginal bacteria that can contribute to the development of PID.
Bacteroides: Bacteroides species are anaerobic bacteria that can be involved in the polymicrobial infection associated with PID.
Gram-Negative Bacilli like Escherichia Coli: Certain gram-negative bacteria, including Escherichia coli, commonly found in the gastrointestinal tract, can cause infections in the reproductive organs, contributing to the development of PID.

Risk Factors/Other Factors.

The aetiology of pelvic inflammatory diseases (PIDs) can be attributed to several other factors, including:

Sexually Transmitted Infections (STIs): Infections such as chlamydia and gonorrhoea are common causes of PID. These bacteria can travel from the cervix to the upper genital tract, leading to inflammation and infection.
Bacterial Vaginosis: Imbalance of normal vaginal bacteria can increase the risk of developing PID. The overgrowth of harmful bacteria can lead to inflammation and infection of the reproductive organs.
Postpartum or Post-Abortion Infections: Infections following childbirth or abortion can lead to inflammation of the reproductive organs, increasing the risk of PID.
IUD Insertion: Insertion of intrauterine devices (IUDs) for contraception can introduce bacteria into the reproductive tract, potentially leading to PID.
Endometrial Procedures: Certain medical procedures, such as endometrial biopsy or dilation and curettage (D&C), can introduce bacteria into the uterus, increasing the risk of PID.
Unprotected Sexual Activity: Engaging in unprotected sexual activity with multiple partners can increase the risk of acquiring STIs, which can lead to PID.
Douching: Douching is the practice of washing or flushing the vagina with water or other fluids. It can disrupt the natural balance of bacteria in the vagina, increasing the risk of developing PID.
Previous PID Infections: Individuals with a history of pelvic inflammatory disease are at an increased risk of developing recurrent episodes of PID.
Multiple or New Sexual Partners: Engaging in sexual activity with multiple partners or having a new sexual partner can elevate the risk of acquiring sexually transmitted infections (STIs) that can lead to PID.
History of STIs in the Patient or Her Partner: A history of sexually transmitted infections, such as chlamydia or gonorrhea, in either the patient or her partner can increase the likelihood of developing PID.
History of Abortion: Previous induced abortions can be a risk factor for PID, particularly if the procedure leads to infections in the reproductive tract.
Young Age (Less Than 25 Years): Younger individuals, particularly adolescents, are at a higher risk of PID, possibly due to increased sexual activity and immature cervix, which may facilitate the spread of infections.
Postpartum Endometritis: Infections following childbirth, particularly involving the lining of the uterus (endometritis), can increase the risk of developing PID.

Clinical Manifestations of Pelvic Inflammatory Diseases (PID)

Lower Abdominal Pain (usually <2 weeks): Patients with PID commonly experience pain in the lower abdominal region, usually lasting for less than two weeks. This pain is often a result of the inflammation and infection affecting the pelvic organs. The nature of the pain is bilateral, affecting both sides of the lower abdomen.
Dysuria, Fever: Dysuria (painful or difficult urination) and fever are indicative symptoms of PID. These manifestations result from the inflammatory response and the body’s attempt to combat the infection.
Smelly Vaginal Discharge Mixed with Pus: PID can lead to an alteration in vaginal discharge, which may become malodorous and contain pus. This change is a consequence of the infection affecting the reproductive organs and the discharge’s composition.
Painful Sexual Intercourse (Dyspareunia): Dyspareunia, or pain during sexual intercourse, is a common symptom of PID. Inflammation and infection can make sexual activity uncomfortable or painful.
Cervical Motion Tenderness: Cervical motion tenderness is a clinical sign observed during a pelvic examination. It involves pain or discomfort when the cervix is moved, indicating inflammation in the pelvic region, specifically around the cervix.
Abnormal Uterine Bleeding: PID may cause irregular or abnormal uterine bleeding. The inflammatory processes can disrupt the normal menstrual cycle, leading to unusual bleeding patterns.
Palpable Swellings in Severe Cases: In severe cases of PID, palpable swellings may be detected, indicating the presence of pus in the fallopian tubes or the development of a pelvic abscess. Signs of peritonitis, such as rebound tenderness (pain upon release of pressure), suggest an advanced and serious stage of the disease.
Urinary Symptoms: PID can sometimes affect the nearby urinary structures, leading to symptoms like increased frequency or urgency of urination. This occurs due to the proximity of the reproductive and urinary organs in the pelvic region.
Gastrointestinal Symptoms: PID’s inflammatory processes can extend to the gastrointestinal tract, causing symptoms such as nausea, vomiting, or diarrhoea. These symptoms may result from the proximity of the reproductive and digestive organs in the pelvic cavity.
Painful Bowel Movements: PID can cause inflammation around the pelvic organs, leading to pain during bowel movements. This symptom is a consequence of the infection affecting the nearby structures.
Adnexal Mass: The presence of an adnexal mass, indicating swelling or enlargement in the region near the uterus and ovaries, can be detected in PID cases. This mass is a clinical finding associated with pelvic inflammation.
Speculum Examination: A speculum examination may reveal a congested cervix with purulent discharge, providing visual evidence of cervical involvement in PID.
Intermenstrual Bleeding: Intermenstrual bleeding, occurring between regular menstrual cycles, is another symptom associated with PID, contributing to the spectrum of abnormal bleeding patterns.
Post-coital Bleeding: Post-coital bleeding, or bleeding following sexual intercourse, is highlighted as a distinctive symptom of PID, reflecting the impact of inflammation on the reproductive organs.

Diagnosis and Investigations for Pelvic Inflammatory Diseases (PID)

Gram Staining: Gram staining to detect intracellular diplococci, providing microscopic evidence of bacterial presence. This method aids in identifying pathogens like Neisseria gonorrhoeae.
Cervical Culture and Sensitivity: Collecting pus samples for culture and sensitivity from the cervix helps identify the specific microorganisms causing the infection and their sensitivity to antibiotics.
Abdominal Pelvic Ultrasound Scan: An ultrasound scan assesses the abdominal and pelvic regions. While it may appear normal in some cases, it is crucial for detecting complications such as pelvic tubo-ovarian abscess or hydrosalpinx.
Pelvic Tubo-Ovarian Abscess: Visualization of a pelvic tubo-ovarian abscess is a diagnostic indicator, revealing a localized collection of pus and inflammatory tissue within the pelvic region.
Physical Examination – Must Include:

Lower Abdominal Pain (LAP): Assessment of lower abdominal pain,, as PID commonly presents with pelvic discomfort.
Cervical Motion Tenderness: Tenderness observed during movement of the cervix is a clinical sign of PID.
Adnexal Tenderness: Tenderness in the adnexal region (near the uterus and ovaries).

6. Speculum Examination: A speculum examination assists in assessing the cervix and vaginal canal.

7. Pregnancy Test: Conducting a pregnancy test is essential to rule out pregnancy-related causes of pelvic symptoms.

Management of Pelvic Inflammatory Diseases

Aims of Management

To eliminate the infection.
To relieve symptoms.
To prevent complications.

Medical Management:

Outpatient treatment involves a combination of medications covering multiple microorganisms.

Ceftriaxone 250 mg IM (or cefixime 400 mg stat if ceftriaxone is not available)
Doxycycline 100 mg orally every 12 hours for 14 days
Metronidazole 400 mg twice daily orally for 14 days
In pregnancy, erythromycin 500 mg every 6 hours for 14 days replaces doxycycline.
Do not use doxycycline during pregnancy and breastfeeding.

For severe Cases, Admission is considered.

Severe cases or those not improving after 7 days require referral for ultrasound scan and parenteral treatment.
Patients with severe PID should be admitted and injectable antibiotics should be given for at least 2 days then switch to the oral antibiotics.
IV Clindamycin 900 mg 8 hourly plus gentamycin 2 mg/kg loading dose then 1.5mg/kg 8 hourly. OR Ceftriaxone 1 g IV daily plus metronidazole 500mg IV every 8 hours until clinical improvement, then continue oral regimen.
Note: A number of patients have repeated infection resulting from inadequate treatment or re-infection from untreated partners.
Therefore: Male sexual partners should be treated with drugs that cover N.gonorrhoeae and C. Trachomatis to avoid reinfection.ie. Cefixime 400 mg stat Plus Doxycycline 100mg 12 hourly for 7 days.

Nursing Interventions for Pelvic Inflammatory Disease (PID):

Assessment (History and Physical Examination): Thorough assessment, including a detailed history and physical examination, helps identify specific symptoms, risk factors, and the extent of pelvic involvement.
Fever Management: Effective management of fever involves monitoring temperature regularly and implementing interventions such as antipyretic medications and cooling measures to ensure patient comfort and prevent complications.
Pain Management: Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, can alleviate pelvic pain and inflammation. Prescription pain medications may be considered for severe cases.
Anxiety Alleviation: Addressing emotional well-being is crucial. Provide support and information to alleviate anxiety related to the diagnosis, treatment, and potential complications of PID.
Health Education: Patient education focuses on understanding PID, its causes, and the importance of compliance to prescribed medications. Information on preventive measures, symptom recognition, and follow-up care is also provided.
Rest and Sleep Promotion: Encouraging adequate rest and sleep aids in the body’s recovery process. Assist in creating a conducive environment for rest, addressing discomfort and promoting relaxation.
Hygiene (Bowel and Bladder Care): Maintaining proper hygiene, especially regarding bowel and bladder care, is emphasized to prevent infections and promote overall well-being during the recovery phase.
Dietary Guidance: Provide dietary recommendations to support healing. Adequate nutrition is essential for recovery, and guidance may include hydration, balanced meals, and nutritional supplements if necessary.
Discharge Advice: Comprehensive discharge instructions cover post-treatment care, prescribed medications, and potential signs of complications. Patients are educated on when to seek medical attention and the importance of completing the entire course of antibiotics.
Sexual Partners: Educating and treating sexual partners exposed to the same STIs is A MUST. This preventive measure aims to interrupt the cycle of reinfection and reduce the transmission of STIs.
Follow-up Care: Post-treatment follow-up ensures the effectiveness of antibiotic therapy. Recommend additional tests or visits to confirm resolution and assess for any complications.
Prevention: Emphasize preventive measures, including safe sex practices, consistent condom use, regular STI testing, and limiting sexual partners. Vaccination against specific STIs, such as HPV and hepatitis B, is promoted to reduce the risk of PID. Education on maintaining a healthy sexual lifestyle is also provided.

Complications of Pelvic Inflammatory Disease (PID)

Infertility: PID poses a high risk of infertility by causing scarring and damage to the reproductive organs. This can impair fertility by obstructing the fallopian tubes, disrupting normal ovulation, or affecting the uterus.
Ectopic Pregnancy: The increased likelihood of scarring in the fallopian tubes from PID raises the risk of ectopic pregnancies. An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes, posing a serious medical emergency.
Chronic Pelvic Pain: Persistent or recurrent pelvic pain may develop as a long-term consequence of PID.
Pelvic Abscess: In some cases, untreated or severe PID can lead to the formation of a pelvic abscess—a collection of pus within the pelvic cavity.
Pelvic Peritonitis: Pelvic peritonitis refers to inflammation of the peritoneum, the lining of the pelvic cavity. It can result from the spread of infection within the pelvis, leading to severe abdominal pain, tenderness, and potential complications.
Tubo-ovarian Abscess (TOA): A tubo-ovarian abscess is a localized collection of infected fluid involving the fallopian tubes and ovaries. This serious complication may necessitate surgical intervention, such as drainage or removal of the abscess.
Adhesions and Scarring: PID can contribute to the formation of adhesions and scarring within the pelvic organs. These adhesions may lead to structural changes, increasing the risk of complications such as bowel obstruction or chronic pain.

Images Reference: https://www.invitra.com/en/pelvic-inflammatory-disease

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CERVICAL ECTROPION (CERVICAL EROSION)

Cervical ectropion is a condition where cells from inside the cervix form a red, inflamed patch on the outside the cervix.

Cervical ectropion is a condition in which there is a raw-looking area on the cervix.

Cervical ectropion happens when cells from inside the cervical canal grow onto the outside of the cervix. These cells are called glandular cells. Glandular cells are red, so the area may look red. Cervical ectropion is sometimes called cervical erosion or cervical ectopy.

This is a benign (non-cancerous) condition and does not lead to cervical cancer.

The cervix is the lower portion of the uterus. It is composed of two regions; the ectocervix and the endocervical canal.

Endocervical canal (endocervix) – the more proximal, and ‘inner’ part of the cervix. It is lined by a mucus-secreting simple columnar epithelium.
Ectocervix – the part of the cervix that projects into the vagina. It is normally lined by stratified squamous non-keratinized epithelium. A cervical ectropion is the presence of everted endocervical columnar epithelium on the ectocervix. This change is thought to be induced by high levels of oestrogen and does not represent metaplasia.

Etiology

The most common cause of a Cervical Ectopy is hormonal changes. Women who are taking oral contraceptives often have cervical ectopy. This is thought to be a response to high levels of oestrogen in the body. The cells which line the inside surface of the cervix often travel and sit on the exterior surface of the cervix. This can be seen when examination with a speculum is performed.

It is thought that cervical ectropion is induced by high levels of oestrogen. Therefore, factors that increase the risk of ectropion are related to those that increase levels of oestrogen:

Use of the combined oral contraceptive pill
Pregnancy
Adolescence
Menstruating age (it is uncommon in postmenopausal women)

Clinical Features of Cervical Erosion

Cervical ectropion is most commonly asymptomatic. It can occasionally present with post-coital bleeding, intermenstrual bleeding, or excessive discharge (non-purulent). On speculum examination, the everted columnar epithelium has a reddish appearance – usually arranged in a ring around the external os.

Unexpected Vaginal Bleeding: Cervical ectropion can lead to unexpected vaginal bleeding, which may occur spontaneously or be triggered by factors like sexual intercourse. The raw area on the cervix, exposed due to ectopy, is more susceptible to irritation and bleeding.
Spotting or Blood-Streaked Discharge: Women with cervical ectropion may experience spotting or a discharge with streaks of blood. This is a result of the fragile blood vessels in the exposed glandular cells, which can rupture easily, causing small amounts of bleeding.
Common Occurrence During or After Sexual Intercourse: Bleeding is often associated with sexual intercourse. The friction and pressure exerted during penetration can irritate the raw area on the cervix, leading to bleeding. This may not happen every time but can be a recurring issue for some women.
Association with Vaginal Infections (Thrush or Bacterial Vaginosis): Presence of vaginal infections such as thrush or bacterial vaginosis can exacerbate the symptoms of cervical ectropion. These infections cause additional irritation to the already sensitive area, leading to increased risk of bleeding.
Possibility of Asymptomatic Cases: Some women may have cervical ectropion without experiencing noticeable symptoms. The condition may only be identified during routine examinations, such as Pap smears.

Investigations of Cervical Erosion.

Cervical erosion/ectropion is diagnosed through a clinical examination. The main role of any investigation is to exclude other potential diagnoses:

Pregnancy test: To rule out pregnancy as a cause of cervical erosion
Triple swabs – if there is any suggestion of infection (such as purulent discharge), endocervical and high vaginal swabs should be taken. (A triple swab refers to the collection of three separate swab samples from different areas of the reproductive system during a medical examination)
Cervical smear – to rule out cervical intraepithelial neoplasia. If a frank lesion is observed, a biopsy should be taken (note that biopsies are not performed as routine).

Management of Cervical Erosion

Cervical ectropion is not a harmful condition and does not usually require treatment unless symptomatic.

First-line treatment is to stop any oestrogen-containing medications – most commonly the combined oral contraceptive pill. This is effective in the majority of cases.
If symptoms persist, the columnar epithelium can be ablated, using cryotherapy or electrocautery. This will result in significant vaginal discharge until healing is completed.
Medication to acidify the vaginal pH has been suggested, such as boric acid pessaries.
Mostly cervical erosion is present in women who do not have any symptoms and thus no specific treatment is advised.

There are three different versions of cauterization therapy:

Diathermy: This uses heat to cauterize the affected area.
Cryotherapy: This uses very cold carbon dioxide to freeze the affected area. A 2016 Study found this to be an effective treatment for women with cervical ectropion who were experiencing a lot of discharge.
Silver nitrate: This is another way to cauterize the glandular cells.

After the treatment, the doctor may recommend that a woman avoids sexual activity and using tampons for up to 4 weeks. After this time, her cervix should have healed.

If a woman experiences any of the following after the treatment, she should go back to the doctor:

Discharge that smells bad
Heavy bleeding (more than a average period)
Ongoing bleeding

CERVICAL POLYPS

Cervical polyps are benign growths protruding from the inner surface of the cervix.

They are benign tumours arising from the endocervical epithelium and may be seen as smooth reddish protrusion in the cervix.

They are usually asymptomatic, but a very small minority can undergo malignant change. They are estimated to be present in 2-5% of women.

Types of Cervical Polyps

Ectocervical Polyps:

Location: Ectocervical polyps originate from the outer surface of the cervix, protruding into the vaginal canal.
Characteristics: These polyps typically emerge from the stratified squamous non-keratinised epithelium of the ectocervix. Due to their external location, they are readily visible during routine gynecological examinations.
Appearance: Ectocervical polyps often present as finger-like or grape-like growths extending from the cervix. Their appearance may vary in size, and they are usually distinguishable by their pedunculated or stalk-like structure.
Symptoms: While ectocervical polyps are frequently asymptomatic, they can cause abnormal vaginal bleeding, spotting, or post-coital bleeding when symptoms are present. Their visibility facilitates diagnosis during speculum examinations.

Endocervical Polyps:

Location: Endocervical polyps develop within the endocervical canal, the more proximal and inner part of the cervix.
Characteristics: These polyps arise from the mucus-secreting simple columnar epithelium lining the endocervical canal. Unlike ectocervical polyps, their location within the canal makes them less visible during routine examinations.
Appearance: Endocervical polyps are less noticeable externally but may be detected through imaging techniques like ultrasound or hysteroscopy. They may obstruct the cervical canal, leading to symptoms like infertility or irregular bleeding.
Symptoms: Similar to ectocervical polyps, endocervical polyps may cause abnormal bleeding or spotting. However, their impact on fertility or interference with cervical smears may be more pronounced due to their location.

Clinical Features of Cervical Polyps

Often asymptomatic, identified only through routine cervical screening.

Abnormal vaginal bleeding:

Menorrhagia (heavy menstrual bleeding)
Intermenstrual bleeding (bleeding between periods)
Post-coital bleeding (bleeding after sex)
Post-menopausal bleeding
Increased vaginal discharge
Rarely, large polyps can block the cervical canal, causing infertility.
On speculum examination, cervical polyps are usually visible as polypoid growths projecting through the external os.

Aetiology

The aetiology of cervical polyps remains unknown. Some of the risk factors are:

Premenopausal women
Multigravida
Sexually transmitted infections
Previous history of cervical polyps
Chronic cervicitis.
Chronic inflammation
Abnormal response to oestrogen (cervical polyps are associated with endometrial hyperplasia)
Localized congestion of the cervical vasculature

Investigations

The definitive diagnosis for a cervical polyp is histological examination after its removal. Therefore, the main role of any other investigations is to exclude alternative causes of the symptoms:

Triple swabs – if there is any suggestion of infection (such as purulent discharge), endocervical and high vaginal swabs should be taken.
Cervical smear – to rule out cervical intraepithelial neoplasia (CIN). Sometimes the polyp can prevent the smear being taken, in which case the smear should be repeated after the polyp has been removed.

Management

Cervical polyps have a small (less than 0.5%) risk of malignant transformation – and so it is common practice to remove them whenever they are identified (even if asymptomatic).
Polyps are easily removed in the doctor’s office, without anaesthesia.
They’re simply held and twisted off gently or taken off with polypectomy forceps or ring forceps. Any resulting bleeding can be cauterized with silver nitrite. They’re then sent to the laboratory to make sure that there’s no sign of cancer.
If the polyps is infected antibiotics may be prescribed.
Larger polyps, or those that are more difficult to access can be removed by diathermy loop excision in the colposcopy clinic, or under general anaesthesia if the base of the polyp is broad.
Any excised polyps should be sent for histological examination to exclude malignancy. They have a recurrence rate of 6-12%.

CERVICAL TRAUMA

Cervical trauma refers to any injury occurring on the cervix.

Etiology

It is caused by

Childbirth: Trauma during childbirth, especially prolonged or difficult deliveries, can result in cervical injuries.
Rough Sexual Intercourse: Forceful or rough sexual activities may cause trauma to the cervix.
Surgical Procedures: Gynaecological surgeries or procedures involving the vaginal canal can lead to cervical trauma.
High Vaginal Fluid Acidity: Elevated acidity levels in vaginal fluids can contribute to irritation and potential trauma.
Tampon Usage: Improper or forceful tampon insertion and removal may cause cervical injuries.
Criminal Abortion: Unregulated and unsafe abortion practices, including the use of inappropriate instruments, can result in cervical trauma.
Gynaecological Procedures: Certain medical interventions, such as dilation and curettage (D&C), may pose a risk of cervical trauma.

Clinical Features

Dyspareunia: Pain during sexual intercourse is a common symptom of cervical trauma.
Postcoital Bleeding: Bleeding following sexual activity is a notable clinical feature.
Vaginal Bleeding: Unexplained or persistent vaginal bleeding may indicate cervical trauma.
Lower Abdominal Pain: Discomfort or pain in the lower abdominal region can be associated with cervical injuries.

Investigations

Speculum Examination: A thorough examination using a speculum helps visualize any visible signs of trauma.
High Vaginal Swab: Swabs may be taken to assess for infections or abnormal discharge.
Cryotherapy: In some cases, cryotherapy may be used to evaluate and treat cervical trauma.
History Taking: Understanding the patient’s medical history and the context of the symptoms is crucial.

Management

Antibiotics: Prescribe broad-spectrum antibiotics to prevent or address potential infections resulting from cervical trauma.
Analgesics: Provide analgesic medications to manage pain associated with cervical trauma. Nonsteroidal anti-inflammatory drugs (NSAIDs) or other suitable pain relievers may be recommended.
Restrictions for Sexual Intercourse: Emphasize the importance of abstaining from sexual activity until the cervical trauma has adequately healed. Educate the patient on the potential risks of premature resumption of sexual intercourse.
Rest and Sleep: Advice on sufficient rest and sleep to support the body’s natural healing processes. Stress the importance of avoiding activities that could strain the pelvic region during the recovery period.
Follow-up Examinations: Schedule regular follow-up examinations to monitor the progress of cervical healing. Adjust the management plan based on the findings.
Pelvic Floor Exercises: Recommend simple pelvic floor exercises to promote muscle tone and support the healing of cervical tissues.
Hygiene Practices: Emphasize proper hygiene practices to prevent infections in the healing cervix.
Avoidance of Vaginal Products: Instruct the patient to refrain from using irritant vaginal products, such as douches, tampons or harsh soaps, during the recovery phase.
Psychological Support: Acknowledge the potential psychological impact of cervical trauma and provide emotional support. Encourage open communication about any concerns or anxieties related to the injury.
Patient Education: Educate the patient about the causes of cervical trauma and preventive measures. Provide information on recognizing warning signs that may necessitate immediate medical attention.
Monitoring for Complications: Monitor for any signs of complications, such as persistent bleeding, worsening pain, or signs of infection.

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HABITUAL ABORTION (RECURRENT ABORTION)

Habitual abortion refers to the occurrence of spontaneous abortion in three or more consecutive pregnancies.

Recurrent abortion is the consecutive loss of 3 or more fetuses weighing less than 500g.

It usually occurs before 20 weeks of gestation and the risk of further abortion increases with further pregnancy loss.

Approximately 1% of women experience this, with an increased risk of further abortion with each pregnancy loss. The high incidence suggests underlying causes.

Causes of Habitual Abortion

Genetic causes: Abnormal parental karyotype, commonly translocation.
Immunological factors: Women with a history of pregnancy loss lack immunological G (1gG) locking agent (rhesus incompatibility).
Endocrine factors: Hypersecretion of Luteinizing hormone may affect the oocyte or endometrium, leading to errors in implantation.
Polycystic ovaries in mothers increase the risk of early pregnancy loss.
Infections (TORCHES): Toxoplasmosis, Rubella, Syphilis, Herpes Simplex Virus, and Cytomegalovirus.
Structural abnormalities:

Uterine abnormalities like bicornuate uterus.
Cervical incompetence.

Management of Habitual Abortion

Mothers should be referred to specialized clinics for screening services.
The treatment of recurrent abortion depends on the cause.
Recurrent abortion due to cervical incompetence is treated with cervical suture/ cerclage at the 14th week of pregnancy and remains in place until the 38th week of pregnancy.
Specific treatment for any identified cause, e.g., cervical cerclage at 14 weeks using Shirodkar’s or McDonald’s method.
An absorbable suture is inserted at the level of the cervical os, remaining until 38 weeks or the onset of labour when it is removed.

CRIMINAL ABORTIONS

Criminal abortions are intentionally performed to end pregnancy, violating the law.

Implements like knives, sticks, and oxytocin drugs are used, often leading to septic abortion.

Treatment

Treatment follows the protocol for septic abortion.

At the medical Centre.

Mother is received and put in bed.
Counselling but she must be sent to the hospital
She should be started on Antibiotics for example ceftriaxone 1g stat IV or any other antibiotics available but in large doses.
Resuscitate the mother depending on her condition
Refer to hospital for further management
A full report will be received plus the general examination of the mother.
Re-assurance is necessary

At the Hospital.

The mother is admitted and preferably isolation done due to the fear of infection
Doctor is informed, Meanwhile the following should be done:
Histories are obtained from the mother.
General examination will be done and Vaginal examination too.
If sepsis has set in, she will be put on IV drugs immediately (antibiotics) like Gentamycin 160 mg o.d for 5/7 and metronidazole 500 mg 8 hourly for 5/7 then the evacuation of the products.

Dangers of Criminal Abortions:

Death due to haemorrhage.
Pelvic Sepsis.
Pelvic peritonitis.
General peritonitis.
Sterility.
Acute renal failure.

THERAPEUTIC ABORTION

Therapeutic abortion consists of evacuating the uterus and is undertaken as a treatment to save the life of the mother.

It is performed only by a doctor, with the consent of the woman and her husband.

Indications for Therapeutic Abortion

Chronic nephritis.
Severe hypertension.
Heart defects.

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SEPTIC ABORTION

Septic abortion is characterized by micro-organisms invading the retained products of conception in the uterus.

It commonly arises as a complication of induced or incomplete abortion.

Causative Organisms of Septic Abortion

Escherichia coli.
Non-hemolytic streptococci.
Staphylococcus aureus.
Streptococcus pyogenes.
Streptococcus pneumoniae.

Clinical Features of Septic Abortion

History of amenorrhea and incomplete abortion.
Pyrexia (fever).
Tender uterus on palpation.
Rapid pulse.
Patient’s awareness of interference with the pregnancy.
Headache.
General malaise.
Severe lower abdominal pain.
Profuse offensive brownish discharge from the vagina.
Mental confusion and endotoxic shock.

Management of Septic Abortion

In the Maternity Center:

Arrange transport to the hospital.
While waiting for transport, keep the patient isolated.
Examine the patient and record all particulars.
Send the patient to the hospital with a written note.

In the Hospital:

Admit the mother to a gynaecological ward in isolation.
Take a detailed history from the patient.
Nurse the patient in a sitting-up position to aid drainage of liquor or pus from the uterus.
Perform a general examination to rule out anaemia, shock, etc.
Monitor vital observations.
Inform the doctor.
Conduct necessary investigations, e.g., blood for HB, grouping, and cross-match, high vaginal swab for culture and sensitivity.
CBC indicates elevation of white blood cell count.
Vaginal swab may be recommended to identify the causative bacteria
Administer intravenous fluids for rehydration and electrolyte replacement.
Conduct blood transfusion if the patient is anaemic.
Provide a highly nutritious diet.
Administer broad-spectrum antibiotics based on laboratory results.
Avoid urine retention and oliguria indicating tubular necrosis.
Perform evacuation after the course of antibiotics.
Medical treatment includes injection penicillin, gentamycin, and hydrocortisone to counteract shock.
Treatment should start with IV antibiotics and then switch to oral antibiotics. Amoxicillin 500mg 8 hourly for 7 days plus metronidazole 400mg 8 hourly for 7 days.
Give IV fluids and tetanus toxoid.

Complications of Septic Abortion

Septicemia: Septic abortion can lead to the development of septicemia, a condition characterized by the systemic spread of infection, resulting in high fever, rapid heart rate, and altered mental status.
Renal Failure: In severe cases of septic abortion, the systemic infection can lead to acute renal failure, a condition marked by the loss of kidney function, resulting in decreased urine output, fluid retention, and electrolyte imbalances.
Uterine Perforation: Instrumentation or medical procedures associated with septic abortion can lead to uterine perforation, a serious complication that may result in internal bleeding, infection.
Pelvic Thrombophlebitis: Septic abortion can increase the risk of developing pelvic thrombophlebitis, a condition characterized by the formation of blood clots in the pelvic veins, leading to pain, swelling, and the risk of pulmonary embolism.
Anaemia: Prolonged or heavy bleeding associated with septic abortion can lead to anaemia, a condition marked by a low red blood cell count, resulting in fatigue, weakness, and shortness of breath.
Disseminated Intravascular Coagulation (DIC): In severe cases of septic abortion, the body’s response to infection can lead to disseminated intravascular coagulation, a condition characterized by abnormal blood clotting and bleeding.

MISSED ABORTION

Missed abortion occurs when the embryo dies or fails to develop, and the products of conception are retained in the uterus for weeks or months.

Missed abortion also refers to fetal death without expulsion of products of conception.

Death of the embryo usually occurs before 8 weeks gestation.

Cessation of symptoms of pregnancy usually prompts the mother to seek medical attention from a health facility. Symptoms include vaginal bleeding, abdominal pain, brown vaginal discharge and the cervix is usually closed.

Clinical Features of Missed Abortion

History of amenorrhea.
Symptoms of threatened abortion occur and cease.
Absence of usual signs of pregnancy progress.
Reduction in breast size.
Fundus loss for dates due to fetal non-growth.
Complete separation of products of conception from uterine walls without expulsion.
Uterus ceases to enlarge, and the cervix remains tightly closed.
After several weeks, brown discharge precedes bleeding, lower abdominal pain, and expulsion of a reddish-brown mass.

Management of Missed Abortion

In the Maternity Center:

Prepare transport to the hospital.
While waiting, obtain the patient’s history and conduct an examination.
Send the patient to the hospital with a written note.

In the Hospital:

Admit the patient to a gynaecological ward.
If spontaneous abortion doesn’t occur, intravenous infusion of prostaglandins or oxytocin may be given.
If the mole is not expelled, surgical emptying of the uterus using a suction curette is performed after cervix dilation.
Administer analgesics for pain relief.
Monitor vital observations: temperature, pulse, respiration, and blood pressure.

SEPTIC ABORTION Read More »

INCOMPLETE ABORTION

Incomplete abortion occurs when some products of conception, that is the placental tissues (chorionic membranes), are retained within the uterus.

Clinical Features of Incomplete Abortion

Heavy and Excessive Vaginal Bleeding: Incomplete abortion presents with heavy and profuse vaginal bleeding, which may be accompanied by the passage of blood clots and tissue fragments.
Abdominal Pain and Backache: Individuals experiencing incomplete abortion commonly report abdominal pain, which may be crampy or persistent, and backache, indicative of ongoing uterine contractions and tissue expulsion.
Cervical Changes: Physical examination may reveal a partially open and soft cervix, reflecting the incomplete nature of the abortion process and the presence of retained products of conception within the uterus.
Bulky Uterus: A palpable enlargement of the uterus may be observed, indicating the presence of retained tissue and blood within the uterine cavity.
Products of Conception Felt on Abdominal Palpation: May detect the presence of retained products of conception during abdominal palpation.
Signs of Anaemia: Symptoms such as fatigue, weakness, and pallor may indicate the development of anaemia due to prolonged or heavy bleeding associated with incomplete abortion.
Signs of Shock: In severe cases, incomplete abortion can lead to signs of shock, including rapid heart rate, low blood pressure, and cold, clammy skin, reflecting the body’s response to significant blood loss and compromised circulation.
Fever and Chills: The presence of fever and chills may indicate an infection, which can complicate incomplete abortion and necessitate immediate medical attention.
Foul-Smelling Vaginal Discharge: In cases of infection, individuals may experience a foul-smelling vaginal discharge, suggestive of uterine or pelvic involvement requiring evaluation and treatment.
Emotional Distress: Coping with the physical symptoms and emotional impact of incomplete abortion can lead to psychological distress, including feelings of grief, anxiety, and depression.

Management of Incomplete Abortion

Admit the mother to a gynaecological ward.
Take the patient’s history.
Reassure the patient and relatives to allay anxiety.
Notify the doctor for investigations such as HB, grouping, and cross-match.
Resuscitate the patient with intravenous fluids.
If in shock, keep the patient warm.
Monitor vital observations.
Obtain informed consent.
Administer oxytocin or misoprostol to contract the uterus and expel retained products, controlling bleeding.
If products are seen in the vagina, perform manual evacuation with sterile gloves.
Monitor airway, breathing, and circulation.
Transfuse according to laboratory HB results.
Shave and dress the patient in a clean theatre gown, informing theatre staff.
Evacuate the uterus under general anaesthesia in theatre when the mother is stable. Manual vacuum aspiration is recommended to remove retained products
Misoprostol 400-800 mcg every 6 hours orally OR Oxytocin may be recommended to control blood loss.
Rhesus negative mothers should receive Anti-D immunoglobulin 300 μg IM single dose.
Provide prophylactic antibiotics.
Administer ferrous/folic acid.
Ensure a good nutritious diet.

Provide advice on discharge:

Adequate rest at home.
Nutritious diet.
Report for scheduled reviews.
Take prescribed medications.
Attend antenatal care clinics as required.

Complications of Incomplete Abortion

Hemorrhagic Shock: Excessive bleeding associated with incomplete abortion can lead to hemorrhagic shock, a critical condition characterized by inadequate blood flow to vital organs. This can result in symptoms such as rapid heart rate, low blood pressure, and organ dysfunction.
Anaemia: Prolonged or heavy bleeding during incomplete abortion can lead to anaemia, a condition characterized by a low red blood cell count, which can result in fatigue, weakness, and shortness of breath.
Sepsis: Incomplete abortion can increase the risk of uterine infection, potentially leading to sepsis, a life-threatening condition characterized by the body’s extreme response to an infection. Symptoms of sepsis may include fever, rapid breathing, elevated heart rate, and altered mental status.
Uterine Perforation: In rare cases, instrumentation or medical procedures during incomplete abortion can lead to uterine perforation.
Retained Tissue: Incomplete abortion may result in the retention of fetal or placental tissue within the uterus, increasing the risk of infection, haemorrhage, and ongoing symptoms.
Future Fertility Concerns: In cases of recurrent or severe incomplete abortion, there may be concerns about its impact on future fertility and reproductive health.
Emotional and Psychological Impact: Coping with the physical and emotional aspects of incomplete abortion can lead to psychological distress, including feelings of grief, guilt, and anxiety.

COMPLETE ABORTION

Complete abortion occurs when all products of conception have been expelled spontaneously.

Clinical Features of Complete Abortion

Resolution of Pain: Following a complete abortion, patients experience a cessation of the previously reported abdominal pain and cramping, indicating the successful expulsion of all products of conception from the uterus.
Minimal Blood Loss: Scanty or minimal vaginal bleeding is commonly observed after a complete abortion, reflecting the natural cessation of uterine bleeding as the pregnancy-related tissues are fully expelled.
Well-Contracted Uterus: Physical examination may reveal a well-contracted uterus, indicating that the uterine muscles have effectively expelled all fetal and placental tissues, leading to the restoration of its normal size and tone.
Regression of Signs of Pregnancy: As the pregnancy-related tissues are expelled during a complete abortion, signs and symptoms of pregnancy, such as breast tenderness, nausea, and fatigue, usually regress, reflecting the resolution of the pregnancy.
Emotional Relief: Following a complete abortion, individuals may experience a sense of emotional relief and closure as they no longer experience the physical symptoms and uncertainty associated with an ongoing pregnancy complication.
Negative Pregnancy Test: A pregnancy test may return negative following a complete abortion, indicating the absence of pregnancy hormones in the bloodstream.

Management of Complete Abortion.

Evacuation of the uterus is NOT necessary.
Observe for heavy bleeding.
Ensure follow-up of the woman after treatment.
Recommend bed rest
Rhesus negative mothers should receive Anti-D immunoglobulin 300 μg IM single dose within 72 hours.
Advice the mother to come back if bleeding reoccurs or she develops fever which may be a sign of infection.

Note: If no active bleeding and ultrasound shows an empty uterine cavity, no further treatment is required, and hospital admission is unnecessary.

INCOMPLETE ABORTION Read More »

THREATENED ABORTION

Threatened abortion occurs when products of conception tend to be expelled before 28 weeks of gestation, but the disturbance is minor enough that the fetus can continue to term.

Clinical Features of Threatened Abortion

Symptoms:

History of amenorrhea.
Painless vaginal bleeding.
Slight or no abdominal pain.
Patient may complain of backache and abdominal discomfort.

Examination (Signs):

General condition is good; on Vaginal examination, the OS is closed.
No uterine contractions.
Membranes remain intact.
Slight bleeding per vagina.
Signs of pregnancy.
The size of the uterus corresponds with the weeks of amenorrhea.
On abdominal palpation, the height of the fundus usually corresponds to the period of amenorrhea.

NB: No vaginal examinations must be done unless the bleeding is severe with clots.

Management of Threatened Abortion

Maternity:

Admit the patient and ensure complete bed rest.
Take personal and obstetrical histories, including the last normal menstrual period.
Monitor vital signs: temperature, pulse, respiration, and blood pressure.
Conduct a general examination to rule out anaemia, dehydration, and jaundice.
Investigations include, Blood smear for malaria parasites, Urine for urinalysis
Aseptic vulval scrubbing, provide a clean pad, and save used pads.
Administer Phenobarbital tablets 30mg – 60 mg 8 hourly.
Observe for 4-6 hours.
Paracetamol 1 g every 6-8 hours prn for 5 days.
Provide lubricants such as liquid paraffin (30 ml) to lubricate the faeces.
No enema is provided.
Change vulval scrubbing pads and examine used ones for blood loss.
Record the amount of blood loss, including clots and membranes.
Ensure daily bath and oral hygiene.
Pay special attention to the bladder; ensure regular urination and bowel movements.
If bleeding stops, avoid strenuous activity and abstain from sex for at least 14 days.
Follow up in 2 days in the ANC clinic.
If bleeding persists, refer to the hospital.

Hospital:

Admit the mother in the gynaecological ward for complete bed rest.
Take personal and obstetrical histories, including the last normal menstrual period.
Monitor vital signs: temperature, pulse, respiration, and blood pressure.
Conduct a general examination to rule out anaemia, dehydration, and jaundice.
Order investigations: blood for HB, grouping and cross-match, blood smear for malaria parasites, urine for urinalysis.
Reassure and calm the mother.
Conduct vaginal inspection, clean the vulva with normal saline, and apply a clean pad.
Encourage frequent urination to avoid urine retention.
Provide roughages to prevent constipation.
Ensure a highly nutritious diet.
Administer prescribed mild sedatives if the patient is restless and anxious.
Treat the identified cause of abortion (e.g., malaria).
Administer Phenobarbital tablets 30mg – 60 mg 8 hourly as prescribed.
Observe for 4-6 hours.
Paracetamol 1 g every 6-8 hours prn for 5 days as prescribed.
Provide lubricants such as liquid paraffin (30 ml) to lubricate the faeces.
No enema is provided.
Change vulval scrubbing pads and examine used ones for blood loss.
Record the amount of blood loss, including clots and membranes.
Ensure daily bath and oral hygiene.
Pay special attention to the bladder; ensure regular urination and bowel movements.
Maintain hygiene by changing soiled linen, carrying out bed baths, and ensuring oral hygiene.
Provide clean clothing to the patient.

Advice on discharge:

Continue bed rest at home.
Avoid sexual intercourse for 3-6 weeks.
Avoid heavy work such as lifting heavy things.
Report immediately if bleeding reoccurs.
Attend antenatal clinics.
Take only prescribed drugs.

Note: If threatened abortion is not attended to properly, it may lead to inevitable abortion.

INEVITABLE ABORTION

Inevitable abortion occurs when no measures can be taken to stop the abortion, leading to the cessation of pregnancy.

Causes of Inevitable Abortion

Maternal Infections: Infections such as syphilis, especially during the mid-trimester, can significantly increase the risk of inevitable abortion. Syphilis can lead to complications that affect the developing fetus and the health of the pregnancy, potentially resulting in unavoidable pregnancy loss.
Congenital Abnormalities: Fetal congenital abnormalities, which may arise due to genetic factors or environmental influences, can contribute to inevitable abortion. These abnormalities can impact the fetus’s viability and development, leading to pregnancy complications that cannot be averted.
History of Induced Abortion: A previous history of induced abortion can be a risk factor for inevitable abortion in subsequent pregnancies. The uterine scarring or damage resulting from a previous abortion procedure may increase the likelihood of pregnancy loss in future gestations.
Incompetent Cervix: Also known as cervical insufficiency, this condition involves the cervix opening too early during pregnancy, potentially leading to inevitable abortion. The weakened cervix is unable to support the growing fetus, resulting in premature dilation and pregnancy loss.
Uterine Anomalies: Structural abnormalities of the uterus, such as a septate or bicornuate uterus, can predispose women to inevitable abortion. These anomalies can interfere with the implantation and development of the fetus, increasing the risk of pregnancy loss.
Hormonal Imbalances: Fluctuations in hormone levels, particularly progesterone, can impact the maintenance of a healthy pregnancy. Hormonal imbalances may lead to inadequate support for the developing fetus, contributing to inevitable abortion.

Clinical Features of Inevitable Abortion

History of amenorrhea.
Lower abdominal pain and backache.
Heavy vaginal bleeding with clots.
Dilated cervix.
Painful uterine contractions.
Rupture of membranes, with liquor visible, especially after 16 weeks.
On speculum examination, membranes and other products of conception may protrude through the cervix or vagina.
Signs and symptoms of shock in the mother.
Palpable uterus may be smaller than expected.

NB: Inevitable abortion may be either complete or incomplete.

Management of Inevitable Abortion

In the Maternity Center:

Considered a gynaecological emergency requiring swift actions.
Admit the patient and provide reassurance.
Take a history, including presenting complaints.
Perform a physical examination, including vital signs and general examination.
Rule out signs of shock.
Examine to determine the level of the fundus and estimate gestation.
For pregnancies above 12 weeks, conduct a speculum examination to remove blood clots or visible products of conception.
If bleeding is heavy, administer ergometrine 0.5mg IM or oxytocin IV to induce uterine contractions and expel products of conception.
Administer pethidine injection 100 mg if Blood Pressure is 100/80 mm/Hg or more.
Keep the mother on IV fluids to prevent shock.
After complete expulsion of products of conception, check the uterus for adequate contraction.
Measure and record all blood loss and observations accurately.
Allow the mother to rest comfortably.
Assess if abortion is complete or incomplete and manage accordingly.

In the Hospital:

Admit the mother to a well-equipped gynaecological ward.
Take a complete history, focusing on the onset and amount of bleeding and any history of infection or disease.
Reassure the patient and relatives.
Conduct a brief general examination to assess the mother’s condition and rule out anaemia, dehydration, and shock.
Palpate the mother’s abdomen to estimate weeks of gestation.
Take baseline vital observations.
Clean the vulva, prepare for a vaginal examination, and apply a sterile pad.
Attempt to remove parts of the placenta or fetus visible through the cervical os or vagina.
Inform the doctor.
Carry out investigations as requested by the doctor.
Doctor’s treatment includes IV oxytocin for pregnancies 16 weeks and below; blood loss control with oxytocin/ergometrine injection; possible blood transfusion according to lab results; administration of intravenous fluids to prevent shock.
Prescribe analgesics to reduce pain, haematinics such as ferrous, and ensure good hygiene.
Provide a nutritious diet to the patient.

Prevention of Inevitable Abortion

Regular Antenatal Care: Attending antenatal clinics is crucial for the early identification and management of potential risk factors for inevitable abortion. Regular prenatal check-ups allow healthcare providers to monitor the pregnancy closely and address any emerging issues promptly.
Prompt Reporting of Symptoms: Early detection of symptoms such as bleeding is vital in preventing inevitable abortion. Individuals experiencing any signs of potential pregnancy complications, such as abnormal bleeding, should promptly report to maternity centres for thorough evaluation and appropriate intervention.
Timely Medical Consultation: Seeking prompt medical advice and treatment in the event of any concerning symptoms or risk factors can significantly contribute to preventing inevitable abortion. Timely intervention by healthcare professionals can help mitigate potential complications and support the continuation of a healthy pregnancy.
Lifestyle Modifications: Adopting a healthy lifestyle, including proper nutrition, regular exercise, and avoiding harmful substances such as alcohol and tobacco, can contribute to reducing the risk of inevitable abortion. Maintaining a healthy weight and managing pre-existing medical conditions can also play a role in preventing pregnancy loss.
Addressing Underlying Health Conditions: Managing pre-existing health conditions such as diabetes, hypertension, and thyroid disorders through appropriate medical care and lifestyle modifications can help minimize the risk of inevitable abortion.
Genetic Counselling: For individuals with a history of genetic abnormalities or recurrent pregnancy loss, genetic counselling can provide valuable insights and guidance on family planning, prenatal testing, and potential interventions to reduce the risk of inevitable abortion.

Complications of Inevitable Abortion

Hemorrhagic Shock: Excessive bleeding associated with inevitable abortion can lead to hemorrhagic shock, a life-threatening condition characterized by inadequate blood flow to vital organs. This can result in symptoms such as rapid heart rate, low blood pressure, and organ dysfunction.
Anaemia: Prolonged or heavy bleeding during inevitable abortion can cause anaemia, a condition characterized by a low red blood cell count. Anaemia can lead to fatigue, weakness, and shortness of breath, impacting the overall health and well-being of the individual.
Dehydration: Significant blood loss and prolonged bleeding can lead to dehydration, potentially resulting in electrolyte imbalances and compromised organ function. Dehydration can manifest as dizziness, dry mouth, decreased urine output, and in severe cases, may necessitate medical intervention.
Infection: Incomplete evacuation of the products of conception during inevitable abortion can increase the risk of uterine infection. This can lead to symptoms such as fever, pelvic pain, and abnormal vaginal discharge, requiring prompt medical attention to prevent complications.
Psychological Distress: Coping with the emotional impact of inevitable abortion can lead to psychological distress, including feelings of grief, guilt, and anxiety. Providing appropriate emotional support and counselling is essential to address the mental health implications of pregnancy loss.
Uterine Perforation: In rare cases, instrumentation or medical procedures during inevitable abortion can lead to uterine perforation, a serious complication that requires immediate medical evaluation and intervention.
Long-term Reproductive Health Implications: In some instances, inevitable abortion may be associated with long-term reproductive health implications, including scarring of the uterus, which can impact future pregnancies.

THREATENED ABORTION Read More »

ABORTIONS

Abortion is defined as the expulsion of products of conception before 28 weeks of gestation.

Abortion is also defined as the termination of pregnancy prior to 28 weeks of gestation or delivery of a fetus weighing less than 500g.

It may be early or late abortion.

Early abortion is the termination of pregnancy before 12 weeks of gestation.
Late abortion is the termination of pregnancy between 12-24 weeks of gestation.

Causes of Abortion

Abortion can be categorized into

Fetal, Maternal, Uterine and Local causes.

Fetal Causes:

Malformation of the Zygote in Chromosomal Disorders: Abnormalities in the zygote’s chromosomal structure such as trisomy 21 (Down syndrome) or monosomy X (Turner syndrome) are examples of conditions that can result in fetal malformation and contribute to abortion.
Abnormal Implantation in the Uterus: Includes conditions like placenta previa, where the placenta attaches near the internal os, can impact normal fetal development and lead to complications that may result in abortion. Abnormal implantation can disrupt the supply of nutrients and oxygen to the fetus, affecting its growth and development.
Diseases of the Fertilized Ovum: Disorders affecting the fertilized ovum such as genetic or metabolic abnormalities, can compromise the viability of the embryo and contribute to spontaneous abortion. These diseases may interfere with the embryo’s ability to develop and thrive in the early stages of pregnancy.
Chromosome Abnormalities of the Fetus (30% – 40%): Genetic irregularities in the fetus including numerical and structural chromosomal abnormalities, are significant contributors to spontaneous abortion. These abnormalities can disrupt normal fetal development and increase the likelihood of pregnancy loss.

Maternal Causes:

Acute Illness with High Temperatures: Conditions like malaria, typhoid, rubella, etc., which can raise body temperatures.
Chronic Illnesses: Persistent conditions like anaemia, chronic nephritis, diabetes mellitus (DM), syphilis, etc.
Cervical Incompetence: Impaired cervical function leading to the inability to maintain a pregnancy.
Severe Malnutrition: Inadequate nutritional support impacting maternal health and fetal development.
Oxytocic Drugs: Medications that stimulate uterine contractions.
Hormonal Insufficiency: Such as insufficient production of progesterone before placental formation, affecting decidua development. Thyroid Deficiency and Hyperthyroidism also increase the risk.
Effects of Drugs Taken: Such as Cytotoxic Drugs which are toxic to cells, Radiation therapy, Overdose of malaria drugs, etc.
Uterine Abnormalities: Such as Retroverted Uterus, Divided Uterus (Bicornuate) or Fibroids (Submucosal): Noncancerous growths in the uterus affecting implantation.
Trauma: Severe Trauma on the Uterus informs of Impact injuries or falls or Insertion of Instruments or Foreign Bodies into the cervix, Operations Like Myomectomy.
Immunological Factors: Antibodies Crossing the Placenta in maternal blood attacking fetal erythrocytes (rhesus incompatibility).
Acute Emotional Disturbances like Severe Fright or Sudden Bereavement triggering contractions and potential abortions.

Predisposing Factors to Abortion

Unwanted Pregnancy:

Too early (adolescence): Teenage pregnancies are often unplanned and may result in abortion due to lack of resources, support, and education.
Too frequent: Pregnancies that occur too close together may strain a woman’s physical and emotional resources, increasing the risk of abortion.
Too late: Pregnancies that occur later in a woman’s reproductive life may carry increased health risks, leading some women to consider abortion.

Problem of Teenage Sexuality and Pregnancy:

Lack of sex education and access to contraception can contribute to high rates of teenage pregnancy and abortion.
Social and cultural factors may also influence teenage sexual behavior and the likelihood of unplanned pregnancy.

Low Preference Use of Family Planning:

Inconsistent or incorrect use of family planning methods can lead to contraceptive failure and unplanned pregnancy.
Lack of access to affordable and effective contraception can also contribute to unplanned pregnancy and abortion.

Sexual Coercion or Rape:

Unwanted pregnancy resulting from sexual coercion or rape may lead to abortion, as the woman may not have consented to the pregnancy.

Unstable Relationship:

Unstable or abusive relationships may contribute to unplanned pregnancy and abortion, as the woman may feel unsafe or unsupported in continuing the pregnancy.

Financial Constraints:

Financial difficulties may make it difficult for a woman to afford the costs of raising a child, leading her to consider abortion.

Need to Continue with Education or Job:

Some women may choose abortion in order to continue their education or maintain their job, as they may not have the resources or support to balance pregnancy and these other responsibilities.

Unfaithfulness:

In some cases, a woman may choose abortion if she discovers that her partner has been unfaithful, as she may not want to raise a child with someone she no longer trusts.

PREVENTION OF ABORTIONS.

Health educate the community about the dangers of unsafe abortion.
Talk about the importance of family planning to the community.
Provide family planning services to school girls.
The government should strengthen the rule governing unsafe abortion.
Good upbringing of children by the parents.
Strengthening youth friendly services at all health facilities.
Strengthening community based organization to teach the community on the dangers of unsafe abortion.

Types of Abortion

Abortions are broadly classified into spontaneous and induced types.

Spontaneous Abortion

Spontaneous abortion, also known as miscarriage, is the unintentional loss of a pregnancy before 20 weeks of gestation.

It is the most common type of pregnancy loss, occurring in about 10-20% of all pregnancies.

Types of Spontaneous Abortion:

Threatened Abortion: Bleeding occurs in early pregnancy without the opening of the cervix or evacuation of the products of conception (POC). Resolves on its own with no medical intervention.
Inevitable Abortion: The cervix is open and POC are visible indicating an unavoidable termination of pregnancy. The pregnancy will not continue and will proceed to incomplete or complete abortion.
Incomplete Abortion: POC are partially expelled.
Complete Abortion: POC are completely expelled.
Habitual Abortion: Three or more recurrent spontaneous abortions

Induced Abortion

Induced abortion is the intentional termination of a pregnancy before the fetus is viable outside the uterus. It is a legal medical procedure in many countries, but it is illegal in some countries.

Types of Induced Abortion:

Legal or Therapeutic Abortion: This type of abortion is performed to protect the life or health of the mother, or in cases of rape or incest.
Illegal or Criminal Abortion: This type of abortion is performed outside the law and is considered a crime in many countries. Poses serious health risks to the woman due to non-professional and unsafe procedures hence increased likelihood of Septic abortion.

General Nursing Interventions and Actions for Patients with Abortion

1. Helping Patient Through Anxiety and Providing Emotional Support

Assess and Encourage Expression of Feelings:

Assess the client’s anxiety and facilitate the expression of her emotions.
Recognize potential feelings of guilt in both the client and her partner.
Encourage grieving and acknowledge that the process may differ for each individual.

Consider Cultural Beliefs:

Assess the client’s and her partner’s cultural beliefs regarding abortion.
Establish a therapeutic relationship by demonstrating empathy and unconditional positive regard.
Provide compassionate care, acknowledging the significance of the pregnancy.

Provide Psychological Comfort:

Offer psychological and mental support to the client and her partner.
Utilize comfort measures such as breathing and relaxation techniques to reduce anxiety.
Explain procedures, stay with the client, and provide information for informed decision-making.

Support Person and Spiritual Guidance:

Facilitate the presence of a support person, especially during second-trimester procedures.
Explore spiritual support as a resource for coping.
Encourage questions, allowing the client to express fears and concerns.

2. Providing Pain Relief and Comfort:

Assess and Monitor Pain:

Evaluate the severity and location of discomfort, considering variations in pain perception.
Systematically monitor the client for verbal reports and objective cues of pain every two hours.

Educate About Expected Discomfort:

Explain the nature of expected discomfort associated with the termination process.
Provide information about the use of prescription or nonprescription analgesics.

Administer Analgesics and Comfort Measures:

Administer narcotic/non-narcotic analgesics, sedatives, and antiemetics as prescribed.
Offer comfort measures, including relaxation and breathing techniques.
Position the client for comfort and encourage position changes.

Assist with Pain Management Procedures:

Assist with the administration of paracervical block before surgical termination.
Support the client through pain management strategies during the termination process.

3. Promoting Maternal Safety and Preventing Injuries:

Assess and Monitor Methods Used:

Evaluate if the abortion is self-managed and assess for any additional methods used.
Monitor for excessive nausea and vomiting before and after elective termination.

Evaluate Discomfort and Vital Signs:

Assess for dyspnea, wheezing, or agitation, which may indicate complications.
Evaluate the level of discomfort, addressing abdominal pain and tenderness.
Stress the importance of returning for a follow-up examination.

Ensure Proper Procedures and Support:

Determine cervical status before the procedure and assist with the insertion of Laminaria tent or prostaglandin.
Administer RhoGAM to Rh-negative clients after termination.
Assist with additional treatment or procedures to control complications.

4. Preventing Hypovolemic Shock:

Monitor Vital Signs and Blood Loss:

Monitor vital signs, noting increased pulse rate and signs of shock.
Monitor and assess blood loss, counting and weighing peri pads.

Educate and Provide Emergency Contacts:

Educate the client on reporting signs of haemorrhage and adherence to prescribed medications.
Provide emergency contact information for immediate assistance.

Determine Cervical Status and Administer Medications:

Determine cervical status before the procedure and assist with the insertion of Laminaria tent or prostaglandin.
Administer antiemetic agents and draw blood specimens for blood typing and crossmatch.

Administer Oxygen and Intravenous Fluids:

Administer oxygen to increase oxygen tension and intravenous fluids as ordered.
Assist with surgical procedures to mitigate haemorrhage.

5. Preventing Infection:

Monitor and Assess for Signs of Infection:

Monitor for signs of infection, including fever, crampy abdominal pain, and tender uterus.
Regularly assess vital signs, particularly temperature.

Perform Hand Hygiene and Educate on Perineal Hygiene:

Practice hand hygiene before and after each care activity.
Educate the client on proper perineal hygiene to prevent the spread of bacteria.

Encourage Universal STD Screening:

Educate the client about the importance of universal STD screening for sexually active women.
Instruct the client to report any signs or symptoms of infection promptly.

THREATENED ABORTION

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PREMENSTRUAL SYNDROME

Premenstrual syndrome is a group of symptoms both physical and psychological that occur before menstruation.

Symptoms can range from mild to severe and occur during the luteal phase (begin 7-14 days before the onset of menses) and disappear after the onset of menses.

Majority of women experience premenstrual syndrome but it is considered severe if it impairs work, relationships or usual activities.

Causes of Premenstrual Syndrome

The cause of premenstrual syndrome remains unknown/unclear although changes in the hormonal level, Vitamin B6 and calcium deficiency have been suspected.

Signs and symptoms of Premenstrual Syndrome

Premenstrual syndrome presents with both physical and psychological symptoms as outlined below.

Psychological Symptoms: These are emotional and mental aspects affected by PMS, including irritability, depression, tension, anxiety, fatigue, and difficulties in concentration.

Irritability: Feelings of annoyance, impatience, and mood disturbances.
Depression: Persistent feelings of sadness, hopelessness, and despair.
Tension: Increased stress levels and heightened emotional response.
Anxiety: Experiencing nervousness, unease, or a sense of impending doom.
Fatigue: A general feeling of tiredness, weakness, and lack of energy.
Inability to Concentrate: Difficulty focusing, poor attention, and mental fog.

Physical Symptoms: Physical manifestations of PMS, such as abdominal bloating, perceived weight gain, breast swelling, acne, headache, and migraines.

Abdominal Bloating: Swelling or feeling of fullness in the abdominal area.
Feeling of Weight Gain: Perceived increase in body weight, often due to fluid retention.
Swelling of Breasts: Breast tenderness and enlargement due to hormonal changes.
Acne: Skin breakouts and increased oiliness.
Headache: Pain or discomfort in the head.
Migraine: Severe headaches often accompanied by other symptoms like nausea and sensitivity to light.

Management of Premenstrual Syndrome (PMS)

A woman is considered to have PMS if her symptoms interfere with the activities of daily living.

Non-pharmacological Strategies

Diet:

Increase intake of vitamin B6, carbohydrates, fruits, and vegetables, such as legumes and cereals.
Avoid consumption of caffeine.
Refrain from smoking and limit alcohol intake.
Reduce overall salt intake.
Educate patients about the benefits of a diet rich in omega-3 fatty acids and low in saturated fats.
Encourage the consumption of fruits and vegetables.

Physical Exercises:

Engage in regular physical activities, including aerobic exercises and walking.
Encourage exercises to relieve bloating, irritability, and insomnia.

Education and Counseling:

Provide education about the causes, treatment, and prevention of PMS.
Offer counselling to address emotional aspects and coping mechanisms.

Stress Management:

Implement relaxation techniques and mental imagery to manage stress.

General Measures:

Educate the patient about premenstrual syndrome.
Encourage regular exercises to relieve bloating, irritability, and insomnia.
Advise a diet rich in carbohydrates, calcium, omega-3 fatty acids, and low in saturated fats.
Avoid caffeine to reduce breast tenderness and irritability.
Reduce the consumption of sugar, alcohol, and salt.
Restrict salt intake to decrease abdominal bloating and fluid retention.
Encourage the consumption of fruits and vegetables.
Advise patients who smoke to quit.

Pharmacological Strategies

Combined Oral Contraceptives (COCs): Use hormonal contraceptives to regulate hormonal fluctuations.

Antidepressants:

Consider selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (20 mg once daily) or paroxetine (20 mg once daily) if PMS presents with depression and anxiety symptoms.
Start SSRIs at the time of ovulation and stop on the first day of menses.
Monitor for side effects such as insomnia, fatigue, and loss of libido.

Diuretics:

Recommend diuretics, such as furosemide (20-40 mg), for patients with weight gain.
Spironolactone (50-100 mg daily for 7 days) may help reduce fluid retention.

Vitamins:

Consider Vitamin B6 (50-100 mg once daily) and calcium (600 mg twice daily) to reduce physical symptoms.

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DYSFUNCTIONAL UTERINE BLEEDING

Dysfunctional uterine bleeding (DUB) refers to abnormal uterine bleeding that occurs in the absence of organic causes or underlying medical conditions.

It is characterized by irregular, prolonged, or heavy menstrual bleeding. Dysfunctional uterine bleeding also refers to abnormal bleeding resulting from hormonal changes rather than from trauma, inflammation, pregnancy or a tumour.

Associated Causes of Dysfunctional Uterine Bleeding

Although there is no apparent structural or organic cause, the term “dysfunctional” means that the bleeding originates from a dysfunction within the normal hormonal regulation of the menstrual cycle rather than a specific anatomical abnormality.

While these are not direct causes of DUB, they can influence or worsen the condition.

Hormonal Dysfunction: Hormonal imbalances, particularly disruptions in oestrogen and progesterone levels, can interfere with the normal menstrual cycle. These imbalances may result from various factors, including stress, medical conditions, or natural hormonal fluctuations.
Benign and Malignant Tumours: The presence of benign growths (such as uterine fibroids) or malignant tumours (like uterine or cervical cancer) can lead to abnormal bleeding patterns. Tumours affect the uterine structure, impacting the regularity of menstrual cycles.
Use of Some Contraceptives: Certain contraceptives, especially those containing hormones, can influence menstrual patterns. Changes in contraceptive methods or formulations may contribute to dysfunctional bleeding in susceptible individuals.
Coagulation Disorders: Conditions affecting blood clotting, such as thrombocytopenia or leukaemia, can lead to dysfunctional bleeding. Impaired coagulation mechanisms may result in irregular and excessive menstrual flow.
Systemic Diseases – Ovarian Failure: Ovarian failure, characterized by the loss of normal ovarian function, can disrupt hormonal balance and menstrual regularity. Systemic diseases impacting ovarian function contribute to dysfunctional bleeding.
Various Factors Influencing Hormonal Balance:
Immature hypothalamus
Changes in exercise patterns
Impaired follicular stimulation
Malnutrition
Emotional viability/crises
Temporary oestrogen withdrawal at ovulation
Radiation and chemotherapy
Lifestyle changes

Types of Dysfunctional Uterine Bleeding (DUB):

DUB may present in any of the following ways:

Menorrhagia: Menorrhagia involves prolonged or excessive bleeding during regular menstruation.
Metrorrhagia: Metrorrhagia refers to vaginal bleeding occurring between regular menstrual periods.
Oligomenorrhea: Oligomenorrhea is characterized by a significantly reduced menstrual flow, often accompanied by irregular cycles.
Polymenorrhea: Polymenorrhea manifests as frequent menstruation, occurring at intervals of less than three weeks.
Menometrorrhagia: Menometrorrhagia involves excessive bleeding both during the usual menstrual time and at irregular intervals.

Signs and Symptoms of Dysfunctional Uterine Bleeding

Irregular menstrual cycles: Menstrual periods may occur more frequently or infrequently than usual.
Prolonged bleeding: Menstrual bleeding may last longer than the typical duration.
Heavy menstrual bleeding: Excessive or abnormally heavy bleeding during menstrual periods.
Intermenstrual bleeding: Bleeding that occurs between menstrual cycles.
Fatigue or tiredness due to excessive blood loss.
Anaemia symptoms: Weakness, lightheadedness, shortness of breath, or pale skin.

NOTE : A diagnosis of dysfunctional uterine bleeding is made only when all other possibilities of causes of bleeding have been excluded.

Investigations

Dysfunctional uterine bleeding is diagnosed based on patient history and physical examination and laboratory investigations.

Complete blood count (CBC): Helps to detect anaemia
HCG test: It is recommended to rule out pregnancy
Thyroid stimulating hormone (TSH): Elevated levels of TSH may be due to hypothyroidism
Measurement of prolactin levels: Helps to rule out pituitary adenoma
Pelvic ultrasound: Helps to rule out ovarian or uterine causes

MANAGEMENT OF D.U.B

Treatment depends on various factors like age, condition of the uterine lining and the woman’s plans regarding pregnancy.
When the uterine lining is thickened but contains normal cells, heavy bleeding may be treated with a high dose of oral contraceptive oestrogen and progestin(COC) or oestrogen alone usually intravenously, then followed by a progestin given by mouth. Bleeding generally stops within 12-24 hours and then low doses of oral contraceptives may be given in the usual manner for at least 3 months. Women who have lighter bleeding may be given low doses from the start.
If a woman has contraindications to oestrogen-containing drugs, progestin only pills may be given by mouth for 10-14 days each month.
Other medications include;

Class of Drug	Example	Remarks
NSAIDs	Mefenamic acid 500mg	Reduces menstrual blood loss by lowering endometrial prostaglandin concentration.
	Ibuprofen 400-800mg	Should be taken before and during menstruation.
Antifibrinolytics	Tranexamic acid 1g twice daily	Helps prevent blood loss during menstruation.
Hormonal Contraceptives	Combined Oral Contraceptives or IUDs	Controls chronic bleeding by suppressing the endometrium.
Progesterone Therapy	Norethisterone 5mg bd from day 5-26 of menstrual cycle	Helps stop acute bleeding.

Total hysterectomy is indicated if the woman is over 35 years, uterine lining thickened and contains abnormal cells and she does not want to become pregnant.
D&C may be used if response or hormonal therapy proves ineffective.
If a woman wants to become pregnant, clomiphene drugs may be given orally to induce ovulation.

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POLYMENORRHOEA/ EPIMENORRHOEA

Polymenorrhea, also known as epimenorrhoea, is a medical condition characterized by frequent menstrual periods that occur more frequently than the normal menstrual cycle.

Polymenorrhoea also refers to menstruation periods that occur at shorter intervals than usual (14-21 days), but they are frequent and regular.

Causes of Polymenorrhea/Epimenorrhoea:

Hormonal imbalances: Fluctuations in oestrogen and progesterone levels can disrupt the normal menstrual cycle and result in more frequent periods.
Thyroid disorders: Overactive thyroid (hyperthyroidism) or underactive thyroid (hypothyroidism) can affect hormone production and menstrual regularity.
Polycystic ovary syndrome (PCOS): This condition is characterized by hormonal imbalances, enlarged ovaries with cysts, and irregular menstrual cycles.
Uterine abnormalities: Conditions such as uterine fibroids, polyps, or adenomyosis can cause abnormal bleeding and frequent periods.
Stress and lifestyle factors: Chronic stress, excessive exercise, drastic weight changes, and poor nutrition can disrupt the hormonal balance and contribute to polymenorrhea.

Signs and Symptoms of Polymenorrhea/Epimenorrhoea:

Menstrual Cycles Shorter than 21 Days: Defined by the duration between the onset of one period and the beginning of the next, with cycles constantly falling below the normal 21-days.
Frequent Menstrual Periods: Menstrual bleeding occurring every two weeks or at intervals of less than 14 days, indicating increased frequency compared to the standard monthly cycle.
Altered Bleeding Patterns: Variations in blood flow, with episodes of lighter or heavier bleeding than what is considered for the individual.
Increased Menstrual Discomfort: Discomfort or pain associated with menstruation, more than the discomfort experienced during a regular menstrual cycle.
Fatigue or Tiredness: Resulting from more frequent blood loss due to polymenorrhea, leading to a decrease in energy levels and an increased sense of tiredness.
Emotional and Psychological Impact: Potential emotional consequences, including anxiety or mood swings, from the physical and hormonal changes associated with more frequent menstrual cycles.

Investigations for Polymenorrhea/Epimenorrhoea:

Medical history and physical examination: A thorough evaluation of the menstrual patterns, symptoms, and any underlying medical conditions is conducted. A pelvic examination may be performed to assess the reproductive organs.
Hormone level assessment: Blood tests may be done to measure hormone levels, including oestrogen, progesterone, thyroid hormones, and other relevant hormones.
Pelvic ultrasound: This imaging test can provide visual information about the ovaries, uterus, and any structural abnormalities.
Endometrial biopsy: A sample of the uterine lining may be obtained and examined to rule out any abnormalities or cancer.

Medical and Nursing Management of Polymenorrhea/Epimenorrhoea:

Hormonal therapy: Depending on the underlying cause, hormonal medications, such as oral contraceptives or hormone-regulating medications, may be prescribed to regulate the menstrual cycle and reduce the frequency of periods.
Treatment of underlying conditions: If polymenorrhea is caused by conditions such as PCOS or uterine abnormalities, appropriate treatment strategies will be implemented to address the specific cause. Carry out dilatation and curettage (D&C) to remove retained products if its the cause.
Lifestyle modifications: Stress reduction techniques, maintaining a balanced diet, regular exercise, and adequate sleep can help regulate hormonal balance and promote overall well-being.
Supportive care: Nursing management focuses on providing emotional support, educating patients about menstrual hygiene, symptom management, and lifestyle modifications.
Monitoring and follow-up: Monitoring patients’ response to treatment, assessing the effectiveness of interventions, and ensuring appropriate follow-up care should be put into considerations.

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