**3. Miscarriage**

**2. Ectopic pregnancy**

34 Contemporary Gynecologic Practice

play here.

stable [8].

salpingectomy are often required [9].

consequences and an increase in case fatality [11, 12].

mortality in the early half of pregnancy [2], [3].

and contraceptive practices of the population studied [5].

tive age bracket presents with a missed period and abdominal pain.

Ectopic pregnancy is one in which the conceptus implants outside the normal endometrial lining of the uterus, with the vast majority, over 95%, occurring in the fallopian tube [1]. It is a life-threatening gynaecological emergency and a leading cause of maternal morbidity and

The incidence of ectopic pregnancy is increasing worldwide [4], and reported incidence varies from 1:60 to 1:250 pregnancies, and is dependent on the incidence of genital tract pathology

Delay in the diagnosis of ectopic pregnancy can be catastrophic because of the associated haemorrhage. Ectopic pregnancy should always be ruled out when a woman in the reproduc‐

There should be a high index of suspicion for early intervention and reduction of morbidity and mortality [6]. The presentation could be acute or chronic. Patients usually present with lower abdominal pain and minimal vaginal bleeding after 5-8 weeks period of amenorrhoea. There could also be shoulder tip pain and fainting spells if intraperitoneal bleeding is massive.

It is mandatory that patients with ectopic pregnancy be managed in a hospital. Sensitive pregnancy test and ultrasonography, preferably a transvaginal scan, aid in initial diagno‐ sis. Laparoscopy may also be used to diagnose ectopic pregnancy, but fails to detect early ectopic pregnancies or those obscured by adhesion. Diagnostic mini-laparotomy comes into

Expectant or medical management of ectopic pregnancy should be considered in selected cases, but they are not widely practiced [7]. Some ectopic pregnancies resolve spontaneously, and this is the basis for expectant management. Methotrexate is employed for medical management in patients with unruptured ectopic pregnancy who are haemodynamically

Surgery remains the mainstay of treatment of ectopic pregnancy. Surgical management is carried out by laparoscopy (Fig. 1) or laparotomy. For tubal pregnancy surgery may be radical (salpingectomy) or conservative (usually salpingostomy). For patients with ruptured ectopic pregnancy, especially those who present late, resuscitation and emergency laparotomy and

Patients managed for ectopic pregnancy require counselling because of the risk of recurrence, which is up to 20.5%, and such cases often give rise to diagnostic dilemma, especially when it occurs in an ipsilateral location [10]. Misdiagnosis of ectopic pregnancy may lead to dire

The World Health Organization (WHO) defined abortion (preferably termed as miscarriage) as the termination of pregnancy prior to 20 weeks of gestation, or the birth of a fetus weighing less than 500g in case the period of gestation is not known. It is noteworthy to state here that a very early miscarriage can sometimes be assumed to be a delayed menstrual period.

There are several types of miscarriages – threatened, inevitable, incomplete, complete, missed, septic, spontaneous, habitual and induced. Miscarriages are a common problem. Approxi‐ mately 75% of all miscarriages occur before 16 weeks of gestation and of these nearly threequarters occur within the first 8 weeks of pregnancy [13].

Abortions, mostly the unsafe, are a leading cause of maternal mortality worldwide, accounting for a global average of 13% of fatalities related to pregnancy [14]. Estimates by the WHO give a global annual total of 42 million induced abortions, with 20 million being unsafe [15, 16]. About 98% of unsafe abortions occur in developing regions [16, 17]. Unsafe abortion generally refers to termination of unwanted pregnancy either by persons lacking the necessary skills or it being performed in an environment lacking the minimal medical standards, or both.

Vaginal bleeding with associated abdominal pain is a common complication in the first half of pregnancy, and most miscarriages present in this manner. There is a psychological impact of early pregnancy loss on women, their partners and families. For some there is need for psychological support.

For the management of miscarriages there is need for proper patient assessment with respect to the history and clinical evaluation, with the need to rule out ectopic gestation. If the vaginal bleeding is moderate to severe and the patient is in some distress or shock, an intravenous line should be set up with a wide bore cannula and crystalloids quickly infused, and blood samples collected for complete blood count and cross-matching of blood for possible transfusion.

Uterine evacuation is the management option for miscarriages, except for threatened miscar‐ riage which requires a conservative approach. Retained products of conception may lead to infection and haemorrhage.

Surgical uterine evacuation is done either by vacuum aspiration or by sharp curettage. The use of the metal curette is not without complications, which invariably includes anaesthetic risk, risk of infection, bleeding, cervical trauma, uterine perforation, long term complications of decreased fertility and abnormal menstruation, including Asherman's syndrome. The suction curettage is safer and easier than the metal/sharp curettage.

Non-surgical management options for miscarriages include expectant management and medical treatment. Expectant management requires an understanding of the course of an abortive process, which includes resorption of early pregnancies to complete abortion. Here, there is a need for close monitoring and early intervention if the need arises. Medical treatment on the other hand involves the use of drugs to achieve uterine evacuation. The medications used here are the prostaglandins and their derivatives like misoprostol, and the antiproges‐ togens like mifepristone.

With expectant and medical treatment, the risks and side effects include unpredictability of the timing until the abortion is completed (with the possibility of significant pain and bleeding requiring an emergent curettage) and retained products of conception requiring surgical intervention. Expectant and medical treatments of abortion assume that prompt medical evaluation and possible intervention are immediately on ground if required, otherwise they should not be considered.

Septic abortion results from any type of miscarriage complicated by infection, especially unsafe abortion, resulting in foul smelling vaginal discharge and/or bleeding, with fever and lower abdominal pain/tenderness. Here, it is advised to cover with appropriate intravenous antibi‐ otics for at least 6 hours prior to evacuation of retained products of conception. The antibiotics should be continued for a total of 14 days.

For missed abortion, there is a need to ripen the cervix before evacuation of retained products of conception after having confirmed the diagnosis by ultrasonography, which is often repeated in cases of very early gestations to ascertain non-viability, and making provisions for management of disseminated intravascular coagulopathy (DIC) if such should arise.

Abortions, mostly the unsafe, are a leading cause of maternal mortality worldwide, accounting for a global average of 13% of fatalities related to pregnancy [14]. Estimates by the WHO give a global annual total of 42 million induced abortions, with 20 million being unsafe [15, 16]. About 98% of unsafe abortions occur in developing regions [16, 17]. Unsafe abortion generally refers to termination of unwanted pregnancy either by persons lacking the necessary skills or it being performed in an environment lacking the minimal medical standards, or both.

Vaginal bleeding with associated abdominal pain is a common complication in the first half of pregnancy, and most miscarriages present in this manner. There is a psychological impact of early pregnancy loss on women, their partners and families. For some there is need for

For the management of miscarriages there is need for proper patient assessment with respect to the history and clinical evaluation, with the need to rule out ectopic gestation. If the vaginal bleeding is moderate to severe and the patient is in some distress or shock, an intravenous line should be set up with a wide bore cannula and crystalloids quickly infused, and blood samples collected for complete blood count and cross-matching of blood for possible transfusion.

Uterine evacuation is the management option for miscarriages, except for threatened miscar‐ riage which requires a conservative approach. Retained products of conception may lead to

Surgical uterine evacuation is done either by vacuum aspiration or by sharp curettage. The use of the metal curette is not without complications, which invariably includes anaesthetic risk, risk of infection, bleeding, cervical trauma, uterine perforation, long term complications of decreased fertility and abnormal menstruation, including Asherman's syndrome. The

Non-surgical management options for miscarriages include expectant management and medical treatment. Expectant management requires an understanding of the course of an abortive process, which includes resorption of early pregnancies to complete abortion. Here, there is a need for close monitoring and early intervention if the need arises. Medical treatment on the other hand involves the use of drugs to achieve uterine evacuation. The medications used here are the prostaglandins and their derivatives like misoprostol, and the antiproges‐

With expectant and medical treatment, the risks and side effects include unpredictability of the timing until the abortion is completed (with the possibility of significant pain and bleeding requiring an emergent curettage) and retained products of conception requiring surgical intervention. Expectant and medical treatments of abortion assume that prompt medical evaluation and possible intervention are immediately on ground if required, otherwise they

Septic abortion results from any type of miscarriage complicated by infection, especially unsafe abortion, resulting in foul smelling vaginal discharge and/or bleeding, with fever and lower abdominal pain/tenderness. Here, it is advised to cover with appropriate intravenous antibi‐ otics for at least 6 hours prior to evacuation of retained products of conception. The antibiotics

suction curettage is safer and easier than the metal/sharp curettage.

psychological support.

36 Contemporary Gynecologic Practice

infection and haemorrhage.

togens like mifepristone.

should not be considered.

should be continued for a total of 14 days.

Habitual abortions, which entail at least three consecutive miscarriages, would require screening of patients before they embark on future pregnancy, but most turn out negative. Only a few, those positive for antiphospholipid antibodies (APA), can be treated with anticlotting agents, like aspirin, enoxaparin (clexane) and heparin, to improve outcome. For those with cervical incompetence resulting in second trimester miscarriages or early preterm births, cervical cerclage procedures may need to be performed between 14-16 weeks of gestation. Most of those with habitual abortion still have a successful pregnancy.

The complications of abortions, mostly haemorrhage and infection, and iatrogenic injuries like perforated uterus (Fig. 2) and gut injuries [18, 19, 20] cut across the different types of abortions, especially if the secondary care given for cases of spontaneous incomplete abortion is less than optimal. Laparoscopy, and/or laparotomy, is indicated to determine the extent of injury and to properly manage.

**Figure 2.** Perforation on the anterior uterine wall following instrumentation demonstrated at laparotomy.

Most healthcare systems expend far more resources treating complications of unsafe abortion than they would to provide safe abortion services [21, 22]. These costs are mostly on beds, antibiotics, blood transfusions services, surgeries and management of subsequent long term complications like ectopic pregnancy and infertility.

There is the need to send the specimen obtained from uterine evacuation for pathological analysis and for cervical/vaginal cultures to be obtained in cases of infection. Histopathological study may also exclude gestational trophoblastic diseases which can present in a similar manner to the miscarriages, may require suction evacuation of the uterus, but also do require a specific follow up plan, which may indicate the need for further treatment.
