It is a clinical entity where the process of Abortion (Less than 20 weeks period of gestation) has started but further progression can be averted and pregnancy can be continued.

Clinical Features Symptoms

1)    Amenorrhea depending upon the duration of pregnancy.

2)    Bleeding per vaginum usually slight and bright red in colour. It usually stops spontaneously.

3)    Pain may appear after bleeding. Dull pain in lower abdomen or mild back ache.

Management at level I To Ill

Level 1: Solo Physician Clinic Level 11:6-10 Bedded PHC.

Level Ill: 100 Bedded Community Health Centre.

Per vaginal examination

Gentle p/v is performed to see the state of cervix, uterine size, adenexal tenderness or any mass. The external or is closed in threatened abortion.

Per speculum examination

•           Insped vagina and cervix for amount and source of bleeding.

•           Any local lesion of cervix orvagina.

•           Any product of conception coming out through the external os

•           Any discharge.

General physical examination

•           General condition of patient and her nutritional status should be assessed.

•           Pallor, temperature, pulse, bp should be assessed.

•           Systemic examination for cardiovascular, respiratory or other systems should be done.

•           Per abdominal examination for any distension, mass, tenderness, size of uterus whether corresponding to the period of amenorrhea or not.

Laboratory investigations

•           Urine for pregnancy test - positive

•           Hemoglobin estimation, BT, CT, TLC/DLC

•           HIC, HCV, HBsAg status

•           Blood group - ABO and Rh typing,

•           Serum progesterone levels- option test A level of more than 25ng/ml usually indicates a viable pregnancy.

Ultrasonography

In early pregnancy Transvaginal sonography is better than transabominal sonography. It confirms the diagnosis of pregnancy, localization of pregnancy (Intrauterine I Extrauterine) and cardiac activity depending upon the period of gestation. It demonstrates subchorionic haemorhage if any and position of the placenta. It also rules out molar pregnancy. If cardiac activity and yolk sac present in ultrasound - 98% of cases of pregnancy continue till term.

Differential Diagnosis

1)    Ectopic gestation - In ectopic gestation there may or may not be history of amenorrhea, with occasional attacks of colicky pain in lower abdomen and vaginal bleeding. There is tenderness or a tender mass in adenexa. Ultrasound examination confirms the diagnosis. UPT may be negative or positive.

2)    Ovarian torsion - Here UPT is negative.

3)    In evitable abortion - The as is open.

4)    In incomplete abortion - The os open with products of conception lying in uterine cavity or cervical canal.

5)    Functional menstrual disturbance. UPT is negative bimanual examination reveals absence of signs of pregnancy.

Management

•           Hospitalize the patient.

•           Patient should be counselled that prognosis is excellent with majority of pregnancies i.e. 80-90% cases.

•           Advice rest to patient and limit the activities. Ask the patient to save her pads to know about amount and character of bleeding or any products of conception and clots.

•           Sedation with Injection 25mg promethazine l/M4-6 hourly.

There is no conclusive evidence of the role of progestogenis but they are given on emerica I basis.

1)    Natural Micronized progesterone 200mg BD Oraly OR 1 00m BDvaginaly.

2)    Tab Dydrogestrone 10mg BD.

3)    Tab Allyl Strenol 5mg TDS.

4)    injection 17-alpha hydroxyprogesterone caproate (PROLUTON DEPOT) 250- 500mg I/M weekly for V'half of pregnancy.

5)    Inj. HCG-2000IU l/Mtwiceaweektill3 months.

6)    Anti-D prophylaxis if patient is Rh negative.

In Gestational Age <1 2weeks Inj. Anti-D 50g IM In Gestational Age >1 2weeks ml. Anti-D 300g IM

7)    Hematinics and calcium to be added along with folic acid if gestational age is

>12 weeks.

8)    If there is no bleeding for 48 hours, patient can be discharged with advice to take rest at home.

Advice on discharge and follow up

•           Patient should limit her activities for at least 2 weeks, avoid coitus and heavy work.

•           Follow up after 1 month to assess the growth of fetus by ultrasound.

Late complications

fetal - increased incidence of prematurity, fetal growth restriction and perinatal death in fetus.

Maternal-increased maternal risk of antepartum haemorrhage, manual removal of placenta and placenta previa and caesarean section in women with threatened abortion.

Management of Level IV: 100 or more bedded district hospital.

•           Management of threatened abortion is same as mentioned before Following patients are referred to level - IV Health Institution :-

•           In cases of continued bleeding inspife of giving adequate management of threatened abortion.

•           Inevitable abortion - In complications like inevitable abortion. P/V is done the clots and products can be seen protruding through the cervix along with bleeding.

•           If ultrasonography is not possible at lower levels.

•           Patients complaining of acute colicy pain in lower abdomen and features of shock to rule out ectopic pregnancy.

•           If patients is severely anaemic and needs blood transfusion. Anaemia is corrected with packed red blood cells to a haemoglobin of 8gm/dI.

•           If patient is in state of shock due to excessive haemorrhage. Adequate volume resuscitation should be done. Vasopressors may also be added (e.g. Dopamine and nor epinephrine).